When Dr. Kathie Culhane-Pera started caring for Vietnamese immigrants in the 1990s, she found built-in trust from patients — who called her “Bác si” and followed her guidance on diet, exercise and medication for chronic diseases such as diabetes.
That wasn’t the case as Hmong refugees arrived in Minnesota, despite the fact that she can speak one Hmong dialect and understands the history of the mountain-dwelling people who were persecuted after the Vietnam War for supporting the Americans.
Her diabetic patients would nod when she prescribed insulin and encouraged them to change their high-carbohydrate, rice-based diet. But many elderly Hmong patients weren’t following her orders.
“Those of us who are working really hard to reach the elderly Hmong have kind of a fatalist sense for some of them,” said Culhane-Pera, a doctor with Westside Community Health Services in St. Paul. “We’re doing all we can to support them, but we’re not on the same road.”
The doctor’s experience reflects a disparity in the health of minority groups in Minnesota — particularly among its “New American” immigrant populations — that has only been guessed at until now. A report released last week by MN Community Measurement went beyond the prior comparisons of whites, blacks, Hispanics and other minority groups, and instead looked at health outcomes for patients based on their national origins and preferred languages.
Doctors agreed over the past three years to ask patients about their national and ethnic origins and input the data into electronic medical records. The nonprofit Community Measurement organization found some unexpected trends there.
One was that 52 percent of Vietnamese-speaking diabetics were in optimal health — meaning they didn’t smoke, they took daily aspirin, and their blood sugar and blood pressure levels were under control. By comparison, only 39 percent of their English-speaking peers were at optimal health.
Among diabetics who prefer to speak Hmong, only 26 percent were at optimal health.
The gap between the Vietnamese and Hmong populations surprised some health care officials, but Culhane-Pera said there are important differences between the two Asian immigrant populations that help explain it.
The Hmong came from more of a rural, agricultural lifestyle with an oral tradition of storytelling rather than the written word. Some older Hmong patients had very limited “numerical literacy,” she added, which can make it challenging when explaining that they have blood sugar levels of 13 milligrams per deciliter and need to get them down to 7.
The notion of taking medication, even when feeling healthy, can be foreign as well, said Mollie O’Brien, program manager for health equity at Allina Health. “In their worldview, there isn’t sort of a concept of chronic illness, that they’re taking a medication for life.”
May Yia Yang ignored her diabetes diagnosis, made shortly after her arrival in the U.S. in 1976, but her health deteriorated over time and she left her job in medical assembly one day in 1999 because she was so sick.
“When I lived in Laos, we didn’t have a doctor,” she said through an interpreter. “I really didn’t understand what diabetes was. That’s why I didn’t believe it.”
Minnesota has long been known for its top health, but also as a state with one of the widest gaps between the health of its white majority and minority populations. Signs of change — or at least attempts at change — are emerging.
In a test program last year, Allina eliminated a racial disparity in colorectal cancer screening at its Plymouth clinic by sending home stool test kits to patients from minority groups that have typically refrained from invasive medical screening procedures.
Side effects of inequities
In annual reports and legislative testimony, state health officials have argued that white, healthy Minnesotans should care about health inequities because they affect the vitality of the state’s workforce and the amount of health insurance premiums and state taxes that they pay.
“It’s an essential challenge for Minnesota as a whole if we are going to continue to be a healthy and prosperous state,” Dr. Ed Ehlinger, state health commissioner, said in testimony Wednesday to the Senate Health, Human Services and Housing Committee. “Everybody should have the opportunity to be healthy, regardless of your ZIP code, your race, your ethnicity, your language, your sexual preference.”
The Community Measurement data could present opportunities for improvement by identifying successful minority groups. For instance, Vietnamese-speakers with vascular disease also were among the healthiest.
Vietnamese Social Services of Minnesota provides regular forums for diabetics on healthy eating tips, such as reducing rice intake or substituting healthier wild rice in recipes, said Dung Pham, health program manager for the St. Paul-based organization.
“We ask people to eat more fruits and vegetables. Lots of Vietnamese and Karen people [from Myanmar] are unfamiliar with American fruit,” Pham said.
If community supports make a difference, efforts in the Hmong community also should be working. Westside Community Health now employs a Hmong doctor and Hmong educators for monthly diabetes classes. Information on diabetes has been converted to audio and video to respect the Hmong oral communication tradition.
Limits of the study
Culhane-Pera said the Community Measurement report is limited. Two populations with the worst health outcomes are the Hmong and Somalis, who also happen to have higher rates of poverty. It’s possible the poor outcomes are less about cultural resistance to health care and more about the struggle to afford insurance premiums and copays for prescriptions and office visits.
Diabetics who prefer to speak native languages are probably older, first-generation immigrants, Culhane-Pera added. The disparity in health outcomes might not look as severe when comparing the second and third generations. Some have entered health care professions, which might make their elders more comfortable with American medical care.
Dr. Nam Ho was born in 1976, the year after his Vietnamese parents arrived in the U.S. Now many Vietnamese patients seek his care.
“I was born here and know Vietnamese and can understand what they’re saying,” said Ho, who works in Fairview’s Brooklyn Park Clinic. But he still uses a translator for Vietnamese-speaking patients to make sure they understand their health information.
May Yia Yang, 72, has lived with diabetes for 40 years since her diagnosis. Some of her friends have remained in denial about the dangers of the disease, and some have died prematurely. She says she feels a responsibility to stick with her meds and daily walks outside or on a treadmill, and to encourage friends to face up to the disease.
“I believe that they know and they understand what diabetes is,” she said, “but they just refuse to take the medication. I try to convince them every time we have group meetings or when I seem them. I always share my experience, that, in the past, I didn’t believe it either.”