Discussion Question week 2 429VN

30 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013 Journal of Health Disparities Research and Practice

Volume 6, Issue 2, Summer 2013, pp. 30-48

School of Community Health Sciences

University of Nevada, Las Vegas

Health Disparity and Structural Violence: How Fear Undermines

Health Among Immigrants at Risk for Diabetes Janet Page-Reeves, University of New Mexico

Joshua Niforatos, University of New Mexico

Shiraz Mishra, University of New Mexico

Lidia Regino, One Hope Centro de Vida Health Center

Andrew Gingrich, University of New Mexico

John Bulten, One Hope Centro de Vida Health Center

ABSTRACT Diabetes is a national health problem, and the burden of the disease and its consequences

particularly affect Hispanics. While social determinants of he alth models have improved our

conceptualization of how certain contexts and environments influence an indi vidual's ability

to make healthy choices, a structural violence framework trans cends traditional uni-

dimensional analysis. Thus, a structural violence approach is capable of revealing dynamics

of social practices that operate across multiple dimensions of pe ople’s lives in ways that may

not immediately appear related to health. Working with a Hispanic immigrant community in

Albuquerque, New Mexico, we demonstrate how structural forces simul taneously directly

inhibit access to appropriate healthcare services and create fea r among immigrants, acting to

further undermine health and nurture disparity. Although fear is not normally directly

associated with diabetes health outcomes, in the community where w e conducted this study

participant narratives discussed fear and health as interconnected.

Keywords: Structural Violence, Health Disparities, Diabetes, Immigrants

31 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

“There is a powerful, enervating anxiety created by the limits of our

control over our small worlds and even over our inner selves. This is the

existential fear that wakes us at 3 a.m. with night sweats and a dreaded inner

voice that has us gnawing our lip, because of the threats to what matters m ost to

us” (Kleinman 2006b, p. 6)

“… it has long been clear that medical and public health interventions will fail if

we are unable to understand the social determinants of disease”

(Farmer, Nizeye, Stulac, and Keshavjee 2006, p. 1686)

INTRODUCTION

Diabetes has become an epidemic problem in the U.S. (Boyle, Thompson, Gr egg, Barker,

and Williamson 2010; Centers for Disease Control and Prevention 2011). Approximately 8.3%

of the population (or 25.8 million people) suffer from diabetes in the U. S., with the majority

(nearly 95%) having type-2 diabetes (Centers for Disease Control and P revention 2011). In

addition, nearly one-fourth of the population has been diagnosed as pre-diabetic (Centers for

Disease Control and Prevention 2008) and trends suggest that diabetes preva lence may increase

to as many as 1-in-3 adults by 2050 (Boyle et al. 2010) . These data demonstrate that diabetes is

a compelling national problem, but the risk of diabetes is not uniform. T here are significant

disparities associated with diabetes based on race and ethnicity. Mi nority populations have a

higher prevalence of diabetes as compared to non-Hispanic whites ( Centers for Disease Control

and Prevention 2011; Community Preventive Services Task Force 2011). His panics are 66%

more likely, and Mexican Americans are 87% more likely to be diagnosed with diabetes (Centers

for Disease Control and Prevention 2011). In Albuquerque, New Mexico, diabete s is the sixth

leading cause of mortality (New Mexico Health Policy Comission 2009). In the Hispanic

immigrant neighborhood where this study was conducted, our preliminary researc h found that

the prevalence of diabetes and pre-diabetes among those sampled wa s 56%, with 29% of those

undiagnosed and unaware of their compromised health status (Mishra et al. 2012).

Although ethnicity is one risk factor (Hanis, Hewett-Emmett, Bert in, and Schull 1991;

Samet, Coultas, Howard, Skipper, and Hanis 1988), research has demonstr ated a broad range of

factors influences diabetes risk. Moreover, the findings of an Inst itute of Medicine report,

(2002) identify the complicity of “policies and practices of health care systems…[with]…rac ial

bias, discrimination, stereotyping and clinical uncertainty” (Smedley 2012, p. 993) as core

factors in the creation and maintenance of disease and disparity. T he etiology of diabetes, then,

involves the complex intersection of multiple risk factors, some of which are not traditionally the

focus of public health research. This reality has implications for prevention and treatment.

Since the cause of diabetes is multidimensional, preventing it or t reating it from a purely

biomedical perspective is rarely effective; but without a comprehens ion of the relationship

between health and broader social forces that produce disparity, ef forts to improve health are not

likely to result in meaningful change.

Despite research regarding broader factors involved in disease and dis parity, the public

health model for diabetes prevention and treatment has tended to continue to focus on getting

individuals to change their behavior in terms of diet and levels of physic al activity (Diabetes

Prevention Program Research Group 2002) or to be “compliant” with prescr ibed actions and

medications for diabetes maintenance (Bahati, Guy, and Gwadry-Sridha r 2012). Expanding the

focus to include more expansive factors like historical and structur al racism, changing

relationships in the international economy that affect employment, housing pol icy that defines 32 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

neighborhood residence, immigration policy, or government subsidies to industrial

agriculture, is

generally considered to be beyond the scope of study and therefore avoided in public health

research. Increasingly though, because of the growing diabetes “epidemic” (Lam and LeRoith

2012) a social determinants of health perspective is seen as more a dequate than a focus on

individual behavior for addressing diabetes (Fisher, Chesla, Mullan, Ska ff, and Kanter 2001;

Peyrot, McMurry Jr, and Kruger 1999; Schulz, Zenk, Odoms-Young, Hollis-Neely, N wankwo,

Lockett, Ridella, and Kannan 2005). Groundbreaking research on social dete rminants of health

(e.g., Kawachi and Bruce 2006; Marmot and Bell 2009; Syme and Frohlich 2002) and how

“social factors ‘get into the body’ to cause disease (Syme 2005) helped to focus on disease

mechanisms that had not previously been well understood or even imagined. F or example, the

impact of chronic stress (Cohen, Doyle, and Baum 2006; Kopp, Skrabski, Szé ke ly, Stauder, and

Williams 2007) and the fact that individuals from low-income communiti es are exposed to

higher levels of stress are now recognized as significant and cumula tive influences on health and

health disparities (Davey Smith 2003; Evans and Schamberg 2009; Raphael, A nstice, Raine,

McGannon, Rizvi, and Yu 2003). The social determinants approach acknowledges that

health behavior reflects more than individual desire or intention to cha nge (Caban and Walker

2006; Cabassa, Hansen, Palinkas, and Ell 2008; Mendenhall, Seligman, Fernandez, a nd Jacobs

2010). The extent to which individual action is embedded in contexts externa l to

individual authority and structured by institutionalized relations, environments , and

policies is now well-documented in the social determinants literat ure (CSDH 2008). This

has translated into a growing interest in environmental and policy change (e.g.,

http://www.cdc.gov/prc/about-prc-program/contributions/environment.htm , &

http://www.rwjf.org/applications/solicited/ cfp.jsp?ID=20804 ) and the need to promote

“community empowerment” (Brennan Ramirez, Baker, and Metzler 2008) to overcome social

determinants as “upstream” strategies for improving diabetes health outcomes.

However, understanding of the social dynamics involved in the mechanisms and

pathways of chronic disease continues to lag (Potvin, Gendron, Bilodeau, and Chabot 2005;

Trickett 2009). It has become clear that curtailing the alar ming rise in diabetes will require a

more nuanced understanding of the broader social determinants of health i f evidence-guided

strategies for individuals at high risk for developing the disease are to be effective. Yet,

conceptual frameworks from public health theory, while enlightening in ma ny respects, have not

sufficiently embraced the true vision of social determinants thinking ( Kawachi and Bruce 2006;

Marmot and Bell 2009; Syme 2005; Syme and Frohlich 2002). Current approaches tend to be

insufficient for revealing the multi-dimensionality of the relation ship between social

determinants, chronic disease and health disparity (Chaufan, Constantino, a nd Davis 2011;

Coleman 2011, p. 13). The move toward a perspective on social determinants of health has

necessitated a broader conceptualization of factors influencing heal th, but rarely does research

seek to go beyond identifying immediate barriers and promoters of disease to explore or address

the inequitable power dynamics and the root causes involved. Potvin and coll eagues (2005)

argue that public health operates from this incomplete knowledge base because there is an “acute

need for theoretical innovation” (p. 591). Moira (2010) similarly suggests that because theory is

not sufficiently incorporated into public health research, the focus fail s to go beyond the

specifics of what people say or do to developing a coherent interpretat ion exploring “the

meanings and processes associated with the categories of behavior obs erved” (p. 287)—in other

words, an interpretation of the data. As such, we have yet to develop a more complete and

integrated understanding of the way that health and illness are “produced as a social

phenomenon.” Like Potvin and colleagues (2005) and Moira (2010), we believe tha t public

health frameworks tend to be under-theorized, and that by expanding our theor etical repertoire to 33 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

include conceptual approaches from social theory, we can not only illum

inate dynamics

underpinning the production of health disparity that are poorly understood in the publ ic health

literature, but can offer new perspectives to expand our ability to pr event and reduce health

disparity.

Using data collected with a Hispanic, immigrant population in Albuquer que, New

Mexico, we apply a structural violence framework (Bourgois 2002; Farmer, Nizeye, Stulac, and

Keshavjee 2006; Galtung 1969; Scheper-Hughes 1992; Singer 2004) to develop the concepts

presented in this article. When analyzing processes related to di sease, a structural violence

framework takes into consideration the extent to which people’s lives are embedded in, reflect,

and are limited by institutionalized inequality. Social inequality, wh ether current or past, is

produced by historical processes that create inequitable relationships, environment s, and policies,

influencing and often governing individual experience. The multi-dimensional natur e of social

inequality means that its influence in people’s lives is cross-cutt ing; institutionalized inequality

affecting one realm of a person’s life ( e.g., low educational attainment) spills over into other

dimensions ( e.g., health status) (Eide and Showalter 2011; Ross and Wu 1995). Although not

commonly employed in public health, a theoretical framework based on s tructural violence

offers a useful tool for analyzing this spill over. Using this approach can provide insights for

understanding the landscape of diabetes disparities.

Theory: A Structural Violence Framework

Farmer (2005) attributes the term “ structural violence” to the writings of Latin American

Liberation theologians and Johan Galtung (1969; 1990). In the 1960’s and 70’s, libera tion

theology gained ascendency in Latin America as Catholic clergy working in impoverished

communities throughout the Americas questioned traditional orthodoxy in terms of the role of

the church. Liberation theologians espoused a moral imperative for the church to go beyond

merely ministering to the needs of the poor to actively undermine and challenge social and

economic inequality, and to promote social justice. Catholic bishops in L atin America convened

in Medellín (1968) and in Puebla (1978) to “denounce the political and economic forces that

immiserate so many Latin Americans” (Farmer 2005 p. 141). The re sulting “Puebla document”

identified structural forces that allow the “rich [to] get ric her at the expense of the poor, who get

even poorer” ( ibid.) (Boff and Boff 1987; Farmer 2005) as the underlying root of social

inequality. This is the primary tenet of a structural violence lens.

Academic conceptualization of institutionalized inequality as “ structural violence” was

originally developed in Gultang’s (1969) seminal essay Violence, Peace, and Peace Research

where he identified as violent, processes, actions or causes that r esult in certain individuals being

unable to live according to their own innate skill and capacity-- for their actual lifetime

“realizations” to be “ below their potential realizations” (Galtung 1969, p. 168). When power

relations (e.g., class, gender, race), and social institutions (e.g., fam ily, ethnicity, religion)

systematically perpetrate and reproduce a lack of actualized pote ntial for some individuals while

expanding the actualized potential of others (often beyond that suggested by t heir own innate

skill and capacity), the “violence” becomes ensconced in people’s ever yday lives as disparity.

Although disparity can take many forms, health disparities can be und erstood as one of the most

concrete manifestations of inequity, often determining who will live a nd who will die—with the

poor and immigrants suffering disproportionately. In this context, Farme r, et al . (2006) explain

that these dynamics “are structural because they are embedded in the political and economic

organization of our social world; they are violent because they cause injury to people (typically,

not those responsible for perpetuating such inequalities)” (p. 1686). It i s in this context that

Farmer (2005), playing on the language of liberation theologians in their a rgument regarding the 34 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

proper perspective and relationship of the clergy and the church to soc

ial injustice, suggests that

diseases like diabetes have “a preferential option for the poor” (p. 140).

When using a structural violence framework to consider public health cont exts, biology

and the environment are not treated as independent variables (Singer 2001). From this

perspective, we can understand that individual health behavior is ci rcumscribed by structured

and institutionalized inequality that limits the ability of individuals to make choices. Limited

options then directly affect health outcomes. Individual agency is limit ed by and contained

within the options that are realistically available. In many ca ses, health-promoting choices are

not an option, or they may not represent the most valuable strategy for an i ndividual in the

context of other limiting factors—regardless of whether other options ar e healthy or not. Maar,

et al. (2011) used a structural violence approach focusing on the circumst ances in which

Aboriginal people live to understand barriers to diabetes maintenance a nd treatment. They

suggest that “it is important to look beyond the surface and identify the r oot causes of non-

adherence, to prevent the unjustifiable blaming of socio-politically disa dvantaged and vulnerable

patients for deteriorating their health” (p. 13). Their findings are “compelling” (p. 13). They

show that barriers created by social and political marginalization

“put people with diabetes in harm’s way by interfering with evidence-ba sed diabetes

care, ultimately increasing the risk of rapid onset of complications…T he determinants of

poor diabetic management uncovered in this research are inseparabl e from the structural

violence exhibited in colonial history resulting in persistent disempower ment, poverty,

stress and marginalization of First Nations communities and their health.” (p. 13)

Using a structural violence framework to understand health dispariti es in Albuquerque, New

Mexico, we explore how structural forces and institutionalized inequal ity similarly create the

social, emotional, and physical condition that invite and sustain diabetes in a Hispanic immigrant

community.

METHODS

Research for this article was conducted by investigators from t he University of New

Mexico (UNM) in collaboration with community partners at East Central Ministries (ECM), a

faith-based and social justice-oriented nonprofit organization in A lbuquerque that primarily

serves Hispanic immigrants. The issue of diabetes was identifie d as a health priority by

members of the community who requested assistance in understanding and addressing diabetes

as a threat to the health of their families, and study design re flected a community-engaged

approach. The analysis presented here uses data gathered through key com munity member

interviews and focus groups, contextualized by geocoding and data mapping of se condary data

sets. The larger study, discussed elsewhere (Mishra et al, 2012; Pa ge-Reeves et al, n.d.) also

included a survey and blood analysis based assessment of diabetic status with 100 people.

Study Setting and Population

The site for this research was the International District (ID) in southeast Albuquerque,

home to a significant Hispanic immigrant population. Located a few mi les from the University

of New Mexico, the ID is the one of the most diverse neighborhoods in the state, has a large

Hispanic population (Childress, 2009), and is the most densely populated sector of the city (U.S.

Census Bureau, 2010). Although the cultural diversity of the neighborhood has rec ently been

recognized by some as an asset, the ID is also an area of the cit y with a reputation for its high

levels of poverty (U.S. Census Bureau, 2010), transience (U.S. Census Bur eau, 2010), and low

educational attainment (U.S. Census Bureau, 2010). In addition, residence i n the ID is

associated with high levels of diabetes-related hospitalizations and mortality, and childhood

obesity. Our preliminary research with ECM in the neighborhood (Mishra et al, 2012) found t hat 35 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

75% of individuals surveyed have a family member with diabetes and 56% of pe

ople tested for

blood glucose levels were in the range for uncontrolled diabetes/pre-dia betes. Of those, 29%

were not aware of their condition.

ECM, our partner for the research, is a non-profit, faith-based comm unity organization

operating in the ID. ECM focuses on community, youth, and economic development in the

neighborhood with an emphasis on the large Hispanic immigrant population. B esides

developing a Community Food Co-op, which addresses some of the food-based nee ds of

individuals in the ID, ECM opened One Hope Centro De Vida Health Center in September 2006

to address a community-identified need for better access to qual ity affordable healthcare. One

Hope is a low/no-cost clinic providing access to affordable healthcare for people regardless of

their health insurance status, and is operated and managed by the communit y. All of the doctors

and medical staff are volunteers, and many are doctors or residents from the UNM School of

Medicine . One Hope is more than just a clinic as it values the holistic health of the community

in terms of mental, physical, spiritual, emotional, and social wellbe ing. Diabetes care and

prevention have been identified as strategic community priorities for 2012 and beyond.

Data Collection & Analysis

Working with the Office for Community Assessment, Planning and Evaluation at the New

Mexico Department of Health , we conducted a secondary analysis of archived data sets including

information obtained from the U.S. Census, the New Mexico Department of Health , Albuquerque

Public Schools , the New Mexico Department of Transportation , Bernalillo County , the City

of Albuquerque , and hospitalization and death records. We geocoded and mapped these dat a to

create maps of the County in terms of multiple dimensions (e.g., demo graphics, school BMI,

pedestrian accidents, violent crime, food outlets, diabetes-related dea th, health insurance

coverage, graduation rates, etc.). We used these maps to contextualize our understanding of risk

factors for diabetes and factors that would affect people’s food and physical activity behaviors

(Mishra,et al, 2012).

Data was also collected through interviews and focus groups. Approval w as obtained

from the UNM Human Research Protections Office prior to the conduct of the research and all

participants provided signed informed consent. With the help of the St udy Coordinator, who is

the Director of One Hope and lives in the neighborhood, we identified and recruited six key

community leaders in the ID to participate in interviews and e ighteen people to participate in

focus groups. Three focus groups were held in two sessions each. Interv iews and focus groups

were conducted at the One Hope facility. Participants received a $20 merchandise card to a loca l

business for each interview or focus group session to remunerate th em for their time. Interviews

were conducted in English by an intern research assistant who took notes by hand. The

interview sessions were also audio recorded. Focus groups were conduct ed in Spanish by the

Study Coordinator with support from one of the researchers who also took note s on a laptop

computer. Interviews and focus groups used questions from a semi-struct ured guide that was

developed from a review of the literature pertaining to diabetes in Hispanic communities (e.g.,

Personal Diabetes Questionnaire; Stetson et al., 2011). Questions em phasized understanding

people’s perceptions of the problem of diabetes, challenges to living a healthy lifes tyle, and ideas

for diabetes prevention. Questions were open-ended in order to allow participant input to define

the direction of the questioning.

RESULTS

In interviews and focus groups, participant narratives conceptualized ba rriers to diabetes

prevention in much broader terms than merely thinking about diet and leve ls of physical activity.

Our analysis of the data revealed opinions and experiences related to people’s ability to live a 36 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

healthy lifestyle that would prevent diabetes in terms of six theme

s: (a) Money and cost; (b)

Stress and fear; (c) Being physically active is challenging; (d) P eople eat unhealthy food; (e)

Food as social practice; and, (f) People’s lack of information (Page -Reeves et al., n.d.). Using a

structural violence framework, the issue of fear stood out as an important cross-cutting factor

that affects how an individual approaches day-to-day living. In intervi ews with the key

community members, as well as in focus group sessions, we identified t hree main dimensions of

fear in participant discussion of diabetes and health: (a) Cost; (b) La nguage, Discrimination and

Immigration Status; and (c) Cultural Disconnect. Here we use thes e dimensions to further

conceptualize and explore the theme of fear in relation to diabetes and health dispari ties.

DISCUSSION

Cost as a Dimension of Fear

As described above, the ID has high levels of poverty with a median hous ehold income

that is well below national and county average (U.S. Census Bureau, 2010). T his disparity can

be seen geographically. Our data mapping demonstrates sharp income dispar ity between the ID

and its surrounding neighborhoods. Moreover, the maps show this same geographic pat tern for a

number of other negative social indicators, including low education atta inment, high levels of

transience, housing vacancies. This suggests that poverty is tied with m any other socio-

economic aspects of the community. The same geographic pattern emer ges for health issues.

Furthermore, our data maps demonstrate that low economic status corre lates with high uninsured

rates. Because of the economic insecurity, one of the prominent dimension s of fear to emerge

during interviews and focus groups was in relation to the financial burden associate d with illness.

Participants reported that people in this community fear seeking assi stance with health concerns

or getting sick because of the cost involved, saying “ People are afraid to go to the doctor…they

can’t afford the bills, can’t make the payment…they are scared, afraid” and “People are afraid

of debt.” One Hope provides health care services on a $15.00 donation basis for doctor’s visit s,

but does not have the capacity to come anywhere close to meeting the hea lthcare need in the

community.

Currently, debate is raging in the U.S. about the sustainability of the h ealthcare system

(Berwick and Hackbarth 2012; Song and Landon 2012). One of the biggest barrier s to

improving health being discussed on a national level is cost (Harrop 2012; Hensley 2012).

There are currently more than 50 million Americans without health i nsurance, or one in six who

are not receiving adequate healthcare (Wolf 2010). In our study, participant s discussed how cost

limits access. In the ID, people do not go to the doctor because given the ir limited income,

individuals are forced to choose between paying the doctor (whether through co -pay if they have

insurance or more likely, by paying out-of-pocket for services if they do not) or paying essential

bills for food, electricity, water, gas and rent. Moreover, individuals w ithout health insurance

will often wait until “ the last minute,” before going to the doctor. The result is that health

problems go untreated and undiagnosed, and tend to become more acute, and ironicall y, more

expensive.

Participants also described how parents put their children’s healt h first when they neglect

their own medical concerns in order to be able to afford to pay for milk, bread, clothing, and

shelter. All of these expenses sustain a family and take precede nce over individual potential

health problems. “ Although diabetes may kill you someday, it’s not going to kill you today ,” one

community member stated. While the consequences of uncontrolled diabetes may not be

imminent, the potential consequences of not paying the rent and becoming home less is an

immediate possibility. Because few people have a medical home with an established primary

care provider, the emergency room becomes a default “clinic” for al l types of healthcare. 37 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

Emergency room visits are expensive, and people are often unable to pay

their bills. Interest

accrued on unpaid bills can quickly become more than the original expense. In addition,

participants reported that is common for bills to be sent in Englis h and people who do not read or

speak English are not able to understand what the bill is about or what they need to do to settle it.

As such, the fear of going to the doctor is much more complicated than c oncern over

what unpleasantness may be entailed in a particular treatment. Among famili es living in poverty,

the cost of healthcare causes a level of stress that people des cribed as a fear. This fear is created,

not by the illness of diabetes itself, but by the structural relations defining the economic

condition of a low-income, immigrant community that intersect with the incidence of chronic

disease. Without resources, people are unable to obtain the healthcare they need to treat or

prevent diabetes. This disparity is then exacerbated by the stress a nd often debilitating fear

caused by the financial burden associated with illness or with trying to stay well. The fear itself

then nurtures and encourages further health disparity nicely captured in the comment by one

participant that, “ That’s why there’s a lot of depression in this community…they don’t have the

resources to pay for the basic needs (especially if you’re undocumente d)…it’s difficult asking for

help .” The fear of cost can be understood as a form of violence that is not something

experienced by people who have health insurance or sufficient resources . Like chronic disease,

certain dimensions of fear can be seen to have a “ preferential option for the poor” (Farmer 2005,

p. 140).

Language, Discrimination & Immigration Status as Dimensions of Fear

Another prominent dimension of fear reported by participants was part icular to an

immigrant community. The ID is so-named because it is one of the m ost diverse neighborhoods

in the state (Childress, 2009). The data maps we created revea led a high percentage of foreign-

born residents in the International District, and a statistically significant number of which are not

U.S. citizens, and that a high percentage of Spanish speakers in the ID do not speak English very

well (U.S Census Bureau, 2010). In the past, this diversity was assoc iated with negative social

and economic conditions and the neighborhood and was viewed through a lens of blight. Over

the past few years, this diversity has come to be recognized by some a s an asset, but challenging

mainstream views of the neighborhood has been difficult and stereotypic al negative discourse

and attitudes remain common.

Participants in our study expressed strong sentiments regarding disc rimination that

immigrants face on multiple levels on a daily basis. They feel tha t people with a Spanish accent

or who lack English-speaking skills are discriminated against in inst itutions like doctor’s offices,

clinics and hospitals. ECM’s One Hope clinic caters to the needs of the immigrant community

and attempts to address these concerns by providing professional transla tion in the clinical

setting. In addition, patients all receive an “exit interview” (“ salida”) by a Spanish-speaking

community health worker who goes over instructions and health information tha t the patient has

received from the provider. However, care at One Hope is not the norm in Albuquerque.

Participants described, in detail, the discrimination that they commonly experience .

Discrimination often takes the form of tacit disapproval on the part of the receptionist in

healthcare settings who makes people feel that they are a burden or that they should be ashamed

of their inability to communicate. Almost all of those interviewed reported numerous instances

when receptionists at various health clinics in Albuquerque refused to s peak Spanish to patients,

often literally telling them to speak English because “ you’re in America now.” One participant

said, “ …they feel that discrimination…why do you need help, you aren’t supposed to be in this

country…so they are afraid and don’t ask [for help].” The attitudes of institutional actors in

healthcare settings can become what Larchancé (2011, p. 859) called “ intangible mechanisms of

creating or reproducing population hierarchy” in relation to immigrants and ethnic difference. 38 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

She argues that this influences social practices through what she def

ines as “powerful

‘ subjectivation’ effects” that are both psychological and political, influencing and shaping the

behavior of immigrants and institutional actors in a dynamic of hierarc hy. This process, in turn,

contributes to the construction of immigrants as undesirables.

Although hospitals have policy regarding the provision of professional interpre ters,

participants said that they are still made to feel guilty—as i f it is somehow their fault that they

need this service. At the same time, participants reported a dea rth in bilingual support at clinics.

This is especially problematic in a state with such a large Spa nish-speaking population. One of

the interviewees, who also has a job as an interpreter at a larg e hospital, indicated that the

interpretation provided is often very poor. In one example from a psychiatric out-patie nt clinic, a

psychiatrist asked the patient if they had been unable to concentrate recently. The interpreter, a

native Spanish speaker and fluent in English, asked the patient if they had been constipated

recently. The patient responded that they had not been constipated, although t hey had been

suffering from an inability to concentrate. This would be funny if it were not so tragic. The

explanation for this critical mistake given by the interviewee was that the medi cal interpreters are

generally disinterested and not fully-invested in what they do—further r eflecting structured

inequality in employment options for individuals who while they may be bi-lingual are not

credited with other skills meriting a higher salary. For good reason then, people who have an

accent when they speak English fear being made to feel stupid or in competent, and people who

cannot speak English are afraid of finding themselves in a situation whe re they cannot

communicate their symptoms, or understand what people are saying or wha t they are being told

to do. These language/discrimination-based fears are often enough to make people refuse to go

out to seek assistance until their health problems become acute.

People’s language-related fears are a reflection of experience, but fea r reported in relation

to discrimination is more than merely a concern over language profici ency. Many of the

immigrant households in the ID have members with problematic immigr ation status. The

number of individuals in the ID who do not have immigration documents (“ undocumented”) is

high. Participants felt that this fact tinges the experience of pe ople who have an accent or

difficulty speaking or understanding English. They reported that the level of care and treatment

that Spanish-speakers receive is different from that of people who are presumed to be citizens.

As a result, people fear being singled-out for different treatment or being treated as if they are

illegal , whether they are or not. By definition, being illegal implies that the y are bad people.

One participant expressed how this difference in treatment is p erceived, saying “These people,

even when in the hospital or the waiting room, there’s a big sign that says w e’re not going to

discriminate anybody or whatever…[but] the immigrant people…I’ve seen so many, many

differences in the way that they treat them, especially with ac cess in the system.” Another, in a

more pointed description said,

“and I hate to say it, but we’re a racist, xenophobic society that refuse s to deal with

immigrants…we can’t manage to provide healthcare for everyone that is a citizen, let

alone those that are not …until [the hospital system]really decides to qui t discriminating

against immigrants and indigent folks in general in our community…it’s going to be a

huge barrier .”

Lechanche (2012) reports that because of these dynamics, immigrants ca n feel a sense of

intimidation and fear in institutional health contexts that can lead them to adopt strategies

downplaying their real health-related needs and concerns in an attempt to make themselves seem

more “ deserving ” of assistance (p. 861). Belliveau (2011, p. 41), calls these behaviors,

“strategies of acquiescence” that immigrants use to balance the ir needs with the realities of

discriminatory environments and exclusionary institutional policy. 39 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

The fear around

illegality expressed by participants is partially an abstract concern with

the discriminatory treatment involved, but for individuals who lack document s or have family

members without documentation, the fear is more concretely about being discovered.

Deportation is an ever-present reality for people living in the shadows because they lack legal

immigration status. This threat, especially when combined with t he other dimensions of fear,

becomes virtually paralyzing for many people in terms of seeking assi stance with health

problems. Many of those who lack documents do not feel comfortable or safe going to a clinic

or to the emergency room. Discussing the fear associated with lac king documents and

demonstrating the cross-cutting nature of fear, one participant who works for an agency that

serves immigrants said, “ Our clientele run on fear because of their documentation status…if a

bill collector is bugging them, then they fear INS [Immigration and Naturaliz ation Service]

may be looking over the bill collector’s … shoulder… people are really fearful.” Participants

described a local medical provider’s aggressive questioning of patie nts (or, in this case, it was

referred to as “ interrogation”). It was reported that this physician routinely asks patients about

their legal status. If the patient is an illegal resident, the physician asks to know how the patient

entered the country (e.g., via a “ coyote”), how much it cost the patient and who they paid. This

line of questioning is viewed by participants as intrusive and inappropriat e in a medical

environment. Knowledge of encounters like this, especially with physicians who are proverbial

“gatekeepers” in the system, spreads like wildfire throughout the commu nity. People become

afraid that at best, the doctor may be making erroneous assumptions a bout their immigration

status, or at worst, be trying to sniff out and report immigrants without documents.

Discrimination against immigrants and minorities is a deeply root ed social construct that

is embedded in American political and social discourse (Chavez, 2008). Combating such

embedded discourse in a medical context is difficult, especially in t imes of economic downturn

when immigrants become convenient scapegoats for a variety of social ills. The economic and

social burden of “ criminal aliens” is a common theme in the media, while others portray

immigrants as an economic and social danger (Jordan, 2010; Willson, 2010; Wolf, 2010). In

caricaturing all immigrants as illegal or potentially illegal, and by conveniently ignoring the fact

that the vast majority of immigrants without documents come to this c ountry to work (and

generally they work “hard”) rather than to rape and pillage, mainstream images portray

immigrants as a danger to society (Anderson, 2006; Chavez, 2008). This dynamic effectively

institutionalizes discriminatory treatment and disparities in acc ess to healthcare for immigrants,

while ensconcing fear into people’s daily lives. Larchanche (2012) desc ribes how immigrants

exist within a “climate of fear [that is] tangible” (p. 862), ext ending even to those who provide

services and help to the undocumented. Viruell-Fuentes, Mirand and Abdulrahi m (2012) suggest

that understanding how complex factors such as these influence immigrant health requires

shifting the focus away from the individual to an analysis of multiple di mensions of inequality

and how they intersect to produce health disparities.

Cultural Disconnect as a Dimension of Fear

The third dimension of fear we identified in participant narratives has to do w ith concerns

described by participants about their inability to discuss the fact that they use “traditional”

remedies to cure or treat some of their health problems, includi ng diabetes. Walton (2009)

describes this type of conflict between patients and providers rega rding non-medical or

alternative medicine as “ cultural disconnect.” Many of the participants reported that it is

common for people to use a variety of medicinal herbs or other alt ernatives to prescription

medication to treat their health problems. For diabetes, it is not unusual for people to use herbs

or particular foods to lower blood sugar. A number of participants recount ed the story of a man

who was selling a type of “bark” from Mexico to cure diabetes th at people could take in the 40 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

form of a tea. The price he was charging for the bark was extre

mely expensive, but many

people bought it. Not surprisingly, taking the tea did not have the desired ef fect, and participants

reported that people ultimately felt swindled by a charlatan. Parti cipants said that people are

hesitant to tell their provider about the fact that they take or use these products or that they

would like to know more about the effects of taking them. This cultural disconnect over the use

of these alternative medicines is a common experience for immigrants in a hea lthcare setting.

Doctors trained in a bio-medical model often have little patience for or a

misunderstanding of alternative medicine (Farmer, 1999; Farmer, 2005; P oss, Jezewski, and

Stuart, 2003; Singer, 2004; Walton, 2009). Yet in many cultures, including that of many

Mexican immigrants, alternative medicine can have important cultur al dimensions, and at the

same time, supplement medical treatment (Astin, 1998; Niforatos, 201 2; Poss, Jezewski, and

Stuart, 2003; Rivera, Ortiz, Lawson, and Verma, 2002). Participants i n our study described their

own conviction that these remedies and alternative treatments are effective, more trustworthy

and less likely to have damaging side effects than prescription medi cation (Poss, Jezewski, and,

Stuart 2003; Rivera, Ortiz, Lawson, and Verma, 2002). They also discusse d the social obligation

they feel to try a remedy if a relative or close friend recommends it.

At the same time, individuals who use alternative medicine routine ly hide their use

of alternative remedies and treatments from their provider. Pat ients often feel, either from

previous experience or from the experience of others, that their physic ian will “scold” or ridicule

them for using alternative treatments that the provider believes to be irrat ional. As a result, many

do not tell their healthcare provider that they are using alternatives to prescribe d treatment. (Poss,

Jezewski, and Stuart, 2003; Rivera, Ortiz, Lawson, and Verma, 2002). One par ticipant said, “A

lot of our community members are afraid to tell their providers that they take tea (alternative

medicine) because of problems that have happened in the past…people don’t know, s o they are

afraid of what [their provider] will say.” The perceived ethnocentrism on the part of the

healthcare provider creates a stigma for patients who may have a different worldview.

Sociologist Erving Goffman (1963,) defined stigma as “the process by w hich the reaction of

others spoils normal identity” (p. 3). The potential negative reacti on of the healthcare provider

towards a patient in relation to the causes of and cures for dise ase, or the providers’ questioning

of the rationality of alternative treatments can “spoil the nor mal identity” of the patient. In other

words, this cultural disconnect can make them feel that something they value is seen as wrong,

silly or irrational by others. This stigma produces a (sub-)conscious fear on the part of the

patient regarding their relationship with their provider, negatively i nfluencing the care they

receive. Yet, the consequences of cultural disconnect can be more dire than fear of social

stigma. One participant reported an instance when a healthcare provide r notified Child

Protective Services because of marks on a child’s arms. As a re sult, the child was removed from

the home. Although temporary, this experience was traumatic for the c hild, the parents, and the

community. A cursory knowledge of the community could have prevented an event like this

from occurring; the marks on the child’s arm were from the applicat ion of a traditional remedy

to treat the child’s sickness rather than the child abuse that was alleged. Seen in this light, there

may be good reason to hide the use of alternatives to biomedical treatment.

Cultural competency is a well-documented issue in the literat ure on health disparities

(Betancourt, Green, Carrillo, and Ananeh-Firempong, 2003; Betancourt, Green, C arrillo, and

Park, 2005; Farmer, 1999; Hirsch, 2003; Ikemoto, 2003; Kleinman and Benson, 2006).

However, it is common for providers to be unaware of or to lack unders tanding of the realities of

the lives of their patients, as in the example given above. Farmer (1999; 2005) and Si nger (2001;

2004) highlight how important it is for providers to understand the history, politi cal economy,

and culture of the population that they serve. In one poignant example, it wa s common for 41 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

patients on the central plateau of rural Haiti not to finish a full

-course of tuberculosis (TB)

treatment. Practitioners attributed this to local beliefs rel ated to alternative medicine held by

followers of Voodoo. Farmer and colleagues (1999) conducted a study to determine if this was

the case. What they discovered was that non-biomedical beliefs of t he etiology of disease had no

impact on whether a patient finished the full-course of TB tr eatment; rather, access to the TB

medicine and having support from community health workers to monitor patient s were the key

determinants of whether the patients were “compliant.” Elsewhe re, Farmer and colleagues

(2005) observe that “those least likely to comply are usually those lea st able to comply.”

Understanding the history, political economy, and culture of Haiti allowed the Harvard -affiliated,

non-profit health and social justice organization, Partners in Health, to subsequently effectively

treat TB. It is common for providers to blame noncompliant behavior on cultural dictates that

are unintelligible to them as outsiders (e.g., Voodoo), but this approach under-appreciates both

cultural dynamics at work and the influence of contextual factors. Mor eover, the culture-as-

problem framework for understanding health disparity often merely serve s to legitimize and

underscore narratives that devalue the poor and communities of color a s irrational and therefore

deserving of what they get .

The fear experienced by Hispanic immigrants in the ID relate d to cultural disconnect is a

reflection of larger inequities within the system. In the ID, provi der cultural incompetence and

the resulting cultural disconnect have the effect of making patients fear discussing alternative

treatments, whether they take them or not. The fear that resul ts from cultural disconnect reduces

a patient’s ability to receive proper medical treatment and furthe r puts the patient as risk when

they do seek care. When patients hide their use of or belief in alt ernatives to provider-based

medicine and do not tell their healthcare provider what alternative treatments they are using,

they risk having a reaction with pharmaceuticals prescribed by the physi cian. The violence

perpetrated upon individuals with alternative beliefs and behaviors in terms of stress, lack of

attention to medical problems and the potential for serious drug reacti ons reflects structural

inequality, and reproduces and accentuates existing health disparity.

CONCLUSION

Structural Violence and Fear

Although diabetes is a national health problem, the burden of the disease and its

consequences are not shared equally. Statistics show that Hispanic s are at particular risk. While

we know how to prevent diabetes through a healthy diet and regular physical ac tivity, and how

to maintain the health of people with diabetes through a regimen of c are from a provider, we

have not been able to develop meaningful strategies to encourage pre vention or “compliance”,

especially in contexts of disparity. Although the social determinants of health approach for

understanding chronic disease has improved our conceptualization of how individuals are

embedded in contexts and environments that influence their ability to make healthy choices, live

a healthy lifestyle, and seek or have access to healthcare, we cont inue to lack a more integrated

understanding of the nature of social practices that impact heal th and how social determinants

operate to produce health disparities. Unpacking the dynamics of this process requires further

expanding our theoretical repertoire.

We proposed that applying a structural violence framework to understandi ng diabetes

health disparities in a Hispanic immigrant community in Albuquerque would provide significant

insights into the processes that produce and encourage disparity. A struc tural violence

framework takes into consideration the extent to which people’s lives are affected by

institutionalized inequality, influencing and often governing individual experienc e. Political,

economic, and social inequalities limit the personal agency of an individu al to live a healthy life 42 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

or to seek care. Attention to this type of cross-cutting factor

is not commonly employed in more

theoretically shallow public health analyses of barriers and promoters of disease. This study

highlights the importance of moving beyond uni-dimensional approaches to be able to capture

the dynamics of social practices that operate across multiple dimensions of people’s lives in

ways that may not immediately appear related to health. We demonstrate how structural forces

simultaneously directly inhibit access to appropriate healthcare ser vices and create fear

among immigrants in Albuquerque, acting to further undermine health and nurture disparity.

Although fear is not normally directly associated with diabetes he alth outcomes, in the

community where we conducted this study participant narratives discussed fear and health as

interconnected. People’s everyday lives are framed by fear. For res idents of the ID, fear is

both a psychological barrier for those seeking access to healthcare se rvices and a further burden

of stress that negatively affects their health. Institutional and social inequalities, poverty,

discrimination, immigration status issues, and cultural bias, create an experiential landscape that

generates fear. People are afraid because they recognize their inability to deal effectively

with costs, language barriers, immigration documentation requirement s, and the cultural

incompetence of others that makes people feel inadequate. Fear is pervasive and

multidimensional.

Our study corroborates what Singer (2001) observed of social inequaliti es and health,

namely, that structural forces create the social, emotional, a nd physical conditions that invite and

sustain disease. Among Hispanic immigrants in the ID, fear is one of these conditions. Using a

structural violence framework to conceptualize the multidimensionalit y of this fear, we can see

how structural violence operates to further limit the personal agency of individuals already

significantly constrained by structural inequality. Physician-anthropologi st Arthur Kleinman

(2006a) observes that a limit in personal agency causes an “enerva ting anxiety…[an] existential

fear that wakes us at 3 a.m. with night sweats and a drea ded inner voice, that has us gnawing

our lip, because of the threats to what matters most to us.” This type of existential fear is

palpable in the ID, dramatically undermining the opportunity for immigrants at risk for diabetes

to be healthy. Given the consequences of diabetes, the result is ult imately a matter of life and

death.

In this study, we aim to use our research to “ask questions about the assumptions built

into public health studies…as a way to understand [the] embodied reality” (Coleman 2011, p. 13 )

of inequality. By expanding our theoretical repertoire to include fram eworks from social theory,

we are able to reveal dynamics underpinning health disparity in an immi grant community that

are not commonly the focus of attention in public health research or interventions . As part of our

analysis of structural violence in the landscape of diabetes in the I D, we identify the

multidimensionality of fear. We give voice to what matters to individuals who have been made

to seem invisible by a “regime of disappearance” (Goode and Maskovsky 2001, p. 17) created

through a paradigm of research that tends to ignore and maintain a convenie nt ignorance of the

structural forces that institutionalize inequality and produce and ma intain health disparity. This

“regime” makes health disparity appear as an unavoidable consequence of the natural order of

things, reflecting risk factors internal to or specific to individuals , and allows the silo-ing of

health from other dimensions of life. In this regard, the structural violence lens helps to

reintegrate our understanding of health by illuminating and emphasizing the e xtent to which

the dynamics of disparity are structured by broader political, economic and socia l forces. Deeper

theorizing allows us to activate our conceptualization of how the socia l determinants of health

operate rather than merely acknowledging that they exist.

Like the IOM report (2002) on racial and ethnic disparities in hea lth care, the data from

our study demonstrate that effective diabetes prevention in communities like the ID requires that 43 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

we move beyond the focus on

barriers and promoters that is common in public health research;

if we are to reduce or eliminate diabetes health disparities, we must address factors previously

assumed to be beyond the focus of public health, such as fear and its multiple root caus es. Yet

this means moving outside of the comfort zone created by the positioning of health research as

separate from or above the need to address structural inequality. Thos e of us who attempt to

approach the work of public health from a broader perspective are rout inely instructed that such

a focus is the purview of other disciplines, too far afield from h ealth-related concerns, or too

political . The perspective common in public health research is nicely summed -up in the

experience of one of the authors who was told by a colleague leading a pr oject that it was not

possible or appropriate to think about or investigate poverty in relation to the public health issue

that was the focus of the research, despite the fact that the community of study was characterized

by significant levels of poverty and health disparity that had provided the c entral rationale for the

research. Given the need to address the health disparities that are destroying lives in the ID and

similar communities, public health as a discipline can no longer legi timately espouse an interest

in addressing health disparity through environmental and policy change or “comm unity

empowerment” while generally being unwilling to think about non-health relat ed factors and

dynamics that generate disparity. Of course, this shift is extreme ly challenging given the

epistemological tendency in public health to narrow the focus of res earch in order to improve the

scientific quality of the variables, the concern that funders will find a broader focus distasteful ,

and the discomfort that many researchers (and Americans in general ) feel about discussing

structural inequality, its roots and our own potential complicity or parti cipation in the creation

and maintenance of privilege and disparity. Without this paradigm shift, however, we fear that

hoped for improvements in health equity delineated clearly in the Final R eport of the

Commission on Social Determinants of Health from the World Healt h Organization (CSDH,

2008) will not be possible. Incorporating social theory (such as the struct ural violence

framework utilized in the analysis presented here) into the way t hat we conceptualize public

health contexts and the way that we view the purpose and focus of our ow n research helps to

move us toward embracing a new research paradigm challenging the status quo. This shift

improves the potential for our work to meaningfully reduce and eliminate di sparities such as

those experienced in relation to diabetes by immigrants in the ID.

ACKNOWLEDGEMENTS This project was supported in part by the National Center for Res earch Resources and the

National Center for Advancing Translational Sciences of the Nat ional Institutes of Health

through Grant Number UL1 TR000041. The content is solely the responsibilit y of the authors

and does not necessarily represent the official views of the NIH.

REFERENCES

American Diabetes Association. 2008. "Economic costs of diabetes in the U.S. in 2007."

Diabetes Care ,31:596-615.

Anderson, B. 2006. Imagined Communities: Reflections on the Origin and Spread of

Nationalism . New York: Verso.

Astin, J.A. 1998. "Why patients use alternative medicine." JAMA: The Journal of the American

Medical Association 279:1548-1553.

Bahati, R., S. Guy, and F. Gwadry-Sridhar. 2012. "Analysis of treatme nt compliance of patients

with diabetes." Knowledge Representation for Health-Care :108-116. 44 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

Belliveau, M. 2011. "Gendered Matters: Undocumented Mexican mothers in t

he current policy

context." Affilia 26:32-46.

Berwick, D.M. and A.D. Hackbarth. 2012. "Eliminating waste in US health care." JAMA: The

Journal of the American Medical Association 307:1513-1516.

Betancourt, J.R., A.R. Green, J.E. Carrillo, and O. Ananeh-Firempong. 2003. "Defining cultural

competence: A practical framework for addressing racial/ ethnic disparities in health and

health care." Public Health Reports 118:293.

Betancourt, J.R., A.R. Green, J.E. Carrillo, and E.R. Park. 2005. "Cultural competence and

health care disparities: Key perspectives and trends." Health Affairs 24:499-505.

Boff, L. and C. Boff. 1987. Introducing Liberation Theology . Maryknoll, N.Y.: Orbis Books.

Boren, S.A., K.A. Fitzner, P.S. Panhalkar, and J.E. Specker. 2009. "Costs and benef its associated

with diabetes education." The Diabetes Educator 35:72-96.

Bourgois, P. 2002. "The violence of moral binaries." Ethnography 3:221-231.

Boyle, J, Thompson, T., Greggk E., Barker, L., and Williamson, D. 2010. "Project ion of the year

2050 burden of diabetes in the US adult population: Dynamic modeling of incide nce,

mortality, and prediabetes prevalence." Population Health Metrics 8:29.

Brennan Ramirez, L.K., E.A. Baker, and M. Metzler. 2008. "Promoting health equity: A resource

to help communities address social determinants of health." Atlanta: US Department of

Health and Human Services, Centers for Disease Control and Prevention .

Caban, A. and E.A. Walker. 2006. "A systematic review of research on culturally relevant issues

for Hispanics with diabetes." The Diabetes Educator 32:584-595.

Cabassa, L.J., M.C. Hansen, L.A. Palinkas, and K. Ell. 2008. "Azucar y ner vios: explanatory

models and treatment experiences of Hispanics with diabetes and depr ession." Social

Science & Medicine 66:2413-2424.

Centers for Disease Control and Prevention. 2008. "National diabetes fact sheet: General

information and national estimates on diabetes in the United States, 2007." Atlanta.

Centers for Disease Control and Prevention. 2011. "National diabetes f act sheet: National

estimates and general information on diabetes and prediabetes in the United States,

2011.", Atlanta.

Chaufan, C., S. Constantino, and M. Davis. 2011. "‘It's a full time job being poor’:

Understanding barriers to diabetes prevention in immigrant communities in the U SA."

Chavez, L.R. 2008. The Latino threat: Constructing immigrants, citizens, and the nation / Le o

R. Chavez : Stanford, Calif: Stanford University Press.

Childress, M. 2009. "Say Hello to the Albuquerque International District ." The New Mexico

Independent .

Cohen, S., WJ. Doyle, and A. Baum. 2006. "Socioeconomic status is associated with stress

hormones." Psychosomatic Medicine 68:414-420.

Coleman, L. 2011. "Introduction," in Food: Ethnographic Encounters, edited by L. Coleman.

New York: Berg. Pp. 1-16.

Community Preventive Services Task Force. 2011. "Diabetes Prevent ion and Control: Disease

Management Programs."

CSDH. 2008. "Closing the gap in a generation: Health equity through action on the social

determinants of health. Final Report of the Commission on Social Det erminants of

Health." World Health Organization, Geneva.

Davey Smith, G. 2003. Inequalities in Health: Life Course Perspectives . Bristol, UK: Policy

Press. 45 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

Diabetes Prevention Program Research Group. 2002a. "Reduction in the Inc

idence of Type 2

Diabetes with Lifestyle Intervention or Metformin." New England Journal of Medicine

346: 393-403.

Eide, E.R. and M.H. Showalter. 2011. "Estimating the relation between hea lth and education:

What do we know and what do we need to know?" Economics of Education Review

30:778-791.

Evans, G.W and M.A. Schamberg. 2009. "Childhood poverty, chronic stress, and adult working

memory." Proceedings of the National Academy of Sciences 106:6545-6549.

Farmer, P.E., B. Nizeye, S. Stulac, and S. Keshavjee. 2006. "Structural violence and clinical

medicine." PLoS Med 3:e449.

Farmer, P.E. 1999. Infections and Inequalities: The Modern Plagues . Berkeley: University of

California Press.

Farmer, P.E. 2005. Pathologies of Power: Health, Human Rights, and the New War on the Poor .

Berkeley: University of California Press.

Fisher, L., C.A. Chesla, J.T. Mullan, M.M. Skaff, and R.A. Kanter. 2001. "C ontributors to

depression in Latino and European-American patients with type 2 diabe tes." Diabetes

Care 24:1751-1757.

Galtung, J. 1969. "Violence, peace, and peace research." Journal of Peace Research 6:167-191.

Galtung, J. 1990. "Cultural violence." Journal of Peace Research 27:291-305.

Goffman, E. 1963. Stigma; Notes on the Management of Spoiled Identity . Englewood Cliffs,

N.J.,: Prentice-Hall.

Goode, J. and J. Maskovsky. 2001. "Introduction." In The New Poverty Studies: The

Ethnography of Power, Politics and Impoverished People in the United States , pp. 1-37,

edited by J. G. J. Maskovsky. New York: New York University Press.

Haffner, S.M. 1998. "Epidemiology of type 2 diabetes: risk factors." Diabetes Care 21:C3-C6.

Hanis, C.L., D. Hewett-Emmett, T.K. Bertin, and W.J. Schull. 1991. "Ori gins of US Hispanics:

implications for diabetes." Diabetes Care 14:618-627.

Harrop, F. 2012. "Why American's Need Universal Health Care." in Real Clear Politics.

Hensley, S. 2012. "More Americans Are Checking Prices Before Get ting Health Care." in NPR's

Health Blog .

Hirsch, J. 2003. "Anthropologists, Migrants, and Health Research: Confronting Cultural

Appropriateness." In American Arrivals: Anthropology Engages the New Immigration ,

pp. 229-257 edited by N. Foner. Santa Fe: School of American Research Press.

Ikemoto, L.C. 2003. "Racial disparities in health care and cultural competency." Louis ULJ

48:75.

Jordan, M. 2010. "Arizona Sheriff, U.S. in Standoff Over Immigration Enforce ment." in Wall

Street Journal .

Kawachi, I. and B. Kennedy. 2006. The Health Of Nations: Why Inequality Is Harmful To Your

Health Author . New York: New Press.

Kelly, M. 2010. "The role of theory in qualitative health research." Family Practice 27:285-290.

Kleinman, A. and P. Benson. 2006a. "Anthropology in the clinic: The problem of cultural

competency and how to fix it." PLoS medicine 3:e294.

Kleinman, A. 2006b. What Really Matters: Living a Moral Life Amidst Uncertainty and D anger.

New York: Oxford University Press.

Konrad, W. 2011. "For those with diabetes, older drugs are often best." in The New York Times. 46 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

Kopp, M.S., Á Skrabski, A. Szé kely, A. Stauder, and R. Williams. 2007. "Chronic

stress and

social changes: Socioeconomic determination of chronic stress." Annals of the New York

Academy of Sciences 1113:325-338.

Lam, D.W. and D. LeRoith. 2012. "The worldwide diabetes epidemic." Current Opinion in

Endocrinology, Diabetes and Obesity 19:93.

Larchanché, S. 2011. "Intangible obstacles: Health implications of sti gmatization, structural

violence, and fear among undocumented immigrants in France." Social Science &

Medicine .

Maar, A., D. Manitowabi, D. Gzik, L. McGregor, and C. Corbiere. 2011. "Ser ious complications

for patients, care providers and policy makers: Tackling the stru ctural violence of First

Nations people living with diabetes in Canada." The International Indigenous Policy

Journal 2:6.

Marmot, M.G. and R. Bell. 2009. "Action on health disparities in the United States: Commission

on Social Determinants of Health." Journal of the American Medical Association

301:1169-1171.

Mendenhall, E., R. A. Seligman, A. Fernandez, and E. A. Jacobs. 2010. "Speaking through

diabetes: Rethinking the significance of lay discourses on diabetes ." Medical

Anthropology Quarterly 24:220-39.

Mishra, S., J. Page-Reeves, L. Regino, A. Gingrich, J. Niforatos & R . Bulten. 2012.

“ Community report: Results from a CTSC-funded planning project to develop a di abetes

prevention initiative with East Central Ministries .” University of New Mexico.

Nelson, A. 2002. "Unequal treatment: Confronting racial and ethnic dispa rities in health care."

Journal of the National Medical Association 94:666.

New Mexico Department of Health. 2009. "New Mexico selected heal th statistics: Annual report

2009." Albuquerque.

New Mexico Health Policy Comission. 2009. "2008 Hospital inpatient discharge data."

Niforatos, J., Marquis, R., Mousavi, A., Pogzeba, A. 2012. "Ethnomedicine in the Am azon:

Importance and endangerment." International Journal of Traditional and Natural

Medicines , 1: 20-40.

Page-Reeves, J., S. Mishra, J. Niforatos, L. Regino, A. Gingrich & R. Bulten. N.d. “An

integrated approach to diabetes prevention: Anthropology, public health and comm unity

engagement.” Unpublished manuscript .

Peyrot, M., J.F. McMurry Jr, and D.F. Kruger. 1999. "A biopsychosocial model of glycemic

control in diabetes: Stress, coping and regimen adherence." Journal of Health and Social

Behavior :141-158.

Poss, J. E., M. A. Jezewski, and A. G. Stuart. 2003. "Home remedies for type 2 diabetes used by

Mexican Americans in El Paso, Texas." Clinical Nursing Research 12:304-23.

Potvin, L., S. Gendron, A. Bilodeau, and P. Chabot. 2005. "Integrating social theory into public

health practice." Journal Information 95(4):591-595.

Raphael, D., S. Anstice, K. Raine, K.R. McGannon, S. Kamil Rizvi, and V . Yu. 2003. "The

social determinants of the incidence and management of type 2 dia betes mellitus: Are we

prepared to rethink our questions and redirect our research activities ?" Leadership in

Health Services 16:10-20.

Rivera, J. O., M. Ortiz, M. E. Lawson, and K. M. Verma. 2002. "Evaluati on of the use of

complementary and alternative medicine in the largest United States-Me xico border city."

Pharmacotherapy 22:256-64. 47 Health Disparity and Structural Violence- Page-Ree

ves, et al.

Journal of Health Disparities Research and Practice , Volume 6, Issue 2, Summer 2013

Ross, C.E. and C. Wu. 1995. "The links between education and health."

American Sociological

Review :719-745.

Samet, J.M., D.B. Coultas, C.A. Howard, B.J. Skipper, and C.L. Hanis. 1988. "Di abetes,

gallbladder disease, obesity, and hypertension among Hispanics in N ew Mexico."

American Journal of Epidemiology 128:1302-1311.

Scheper-Hughes, N. 1992. Death without Weeping: The Violence of Everyday Life in Brazil .

Berkeley: University of California Press.

Schulz, A.J., S. Zenk, A. Odoms-Young, T. Hollis-Neely, R. Nwankwo, M. L ockett, W. Ridella,

and S. Kannan. 2005. "Healthy eating and exercising to reduce diabetes : Exploring the

potential of social determinants of health frameworks within the cont ext of community-

based participatory diabetes prevention." Journal Information 95(4):645-651.

Singer, M. 2001. "Toward a bio-cultural and political economic integrat ion of alcohol, tobacco

and drug studies in the coming century." Social Science Medicine 53:199-213.

Singer, M. 2004. "The social origins and expressions of illness." British Medical Bulletin 69:9-

19.

Smedley, B.D. 2012. "The lived experience of race and its health consequenc es." American

Journal of Public Health 102(5):933-5.

Song, Z. and B.E. Landon. 2012. "Controlling health care spending—The Massachuset ts

experiment." New England Journal of Medicine 366:1560-1561.

Syme, S.L. 2005. "Historical Perspective: The social determinants of disease: Some roots of the

movement." Epidemiologic Perspectives & Innovations 2:2.

Syme, S.L. and K.L. Frohlich. 2002. "The contribution of social epidemiology: Ten new books."

Epidemiology 13:110-112.

Trickett, E.J. 2009. "Multilevel community-based culturally situated int erventions and

community impact: An ecological perspective." American Journal of Community

Psychology 43:257-266.

U.S. Census Bureau. 2010. "2006-2010 American Community Survey."

Viruell-Fuentes, E.A., P.Y. Miranda, and S. Abdulrahim. 2012. "More than culture: Structural

racism, intersectionality theory, and immigrant health." Social Science & Medicine

75(12):2099-2106.

Walton, F. 2009. Community Health Leaders Address Health and Health Care for Immigrants

and Their Families . Princeton.

Willson, S. 2010. February 10. "Governor Perry, speak out against illegal i mmigration."

KSEN5.com San Antonio .

Wolf, R. 2010, September 17. "Number of uninsured Americans rises to 50.7 m illion." USA

Today .

ofJournal ofHealth Disparities Research&Practice isthe property ofMichelle

Chino,

Ph.D.anditscontent maynotbecopied oremailed tomultiple sitesorposted toa

listserv

without thecopyright holder'sexpresswrittenpermission. However,usersmayprint,

download,

oremail articles forindividual use.