Discussion 1:
According to the assigned article, "Health Disparity and Structural Violence: How Fear
Undermines Health Among Immigrants at Risk for Diabetes," narratives tell the story of the
interconnectedness between fear and health. Thematically, the issue of fear is a dominant
feature that affects how an individual approaches day-to-day living and health. Explain the
relationship between fear and health identified by the researchers in the article. Do you agree
that structural violence perpetuates health disparity?
Discussion 2:
Diversity among individuals, as well as cultures, provides a challenge for nurses when it
comes to delivering meaningful health promotion and illness prevention-based
education. How do teaching principles, varied learning styles (for both nurses and
patients), and teaching methodologies impact the approach to education? How do
health care providers overcome differing points of view regarding health promotion and
disease prevention? Provide an example.
30 Health Disparity and Structural Violence- Page-Reeves, et al.
Journal of Health Disparities Research and Practice
Volume 6, Issue 2, Summer 2013, pp. 30-48
© 2011 Center for Health Disparities Research
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 health models have improved our
conceptualization of how certain contexts and environments influence an individual's ability
to make healthy choices, a structural violence framework transcends traditional unidimensional analysis. Thus, a structural violence approach is capable of revealing dynamics
of social practices that operate across multiple dimensions of people’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 simultaneously directly
inhibit access to appropriate healthcare services and create fear 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 we conducted this study
participant narratives discussed fear and health as interconnected.
Keywords: Structural Violence, Health Disparities, Diabetes, Immigrants
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
31 Health Disparity and Structural Violence- Page-Reeves, et al.
“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 most 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, Gregg, 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 Prevention 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 prevalence 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. There are significant
disparities associated with diabetes based on race and ethnicity. Minority 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). Hispanics 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, diabetes 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 research found that
the prevalence of diabetes and pre-diabetes among those sampled was 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, Bertin, and Schull 1991;
Samet, Coultas, Howard, Skipper, and Hanis 1988), research has demonstrated a broad range of
factors influences diabetes risk. Moreover, the findings of an Institute of Medicine report,
(2002) identify the complicity of “policies and practices of health care systems…[with]…racial
bias, discrimination, stereotyping and clinical uncertainty” (Smedley 2012, p. 993) as core
factors in the creation and maintenance of disease and disparity. The 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 treating it from a purely
biomedical perspective is rarely effective; but without a comprehension of the relationship
between health and broader social forces that produce disparity, efforts to improve health are not
likely to result in meaningful change.
Despite research regarding broader factors involved in disease and disparity, 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 physical activity (Diabetes
Prevention Program Research Group 2002) or to be “compliant” with prescribed actions and
medications for diabetes maintenance (Bahati, Guy, and Gwadry-Sridhar 2012). Expanding the
focus to include more expansive factors like historical and structural racism, changing
relationships in the international economy that affect employment, housing policy that defines
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
32 Health Disparity and Structural Violence- Page-Reeves, et al.
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 adequate than a focus on
individual behavior for addressing diabetes (Fisher, Chesla, Mullan, Skaff, and Kanter 2001;
Peyrot, McMurry Jr, and Kruger 1999; Schulz, Zenk, Odoms-Young, Hollis-Neely, Nwankwo,
Lockett, Ridella, and Kannan 2005). Groundbreaking research on social determinants 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. For example, the
impact of chronic stress (Cohen, Doyle, and Baum 2006; Kopp, Skrabski, Szé kely, Stauder, and
Williams 2007) and the fact that individuals from low-income communities are exposed to
higher levels of stress are now recognized as significant and cumulative influences on health and
health disparities (Davey Smith 2003; Evans and Schamberg 2009; Raphael, Anstice, Raine,
McGannon, Rizvi, and Yu 2003). The social determinants approach acknowledges that
health behavior reflects more than individual desire or intention to change (Caban and Walker
2006; Cabassa, Hansen, Palinkas, and Ell 2008; Mendenhall, Seligman, Fernandez, and Jacobs
2010).
The extent to which individual action is embedded in contexts external to
individual authority and structured by institutionalized relations, environments, and
policies is now well-documented in the social determinants literature (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 alarming rise in diabetes will require a
more nuanced understanding of the broader social determinants of health if 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 many 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 relationship between social
determinants, chronic disease and health disparity (Chaufan, Constantino, and Davis 2011;
Coleman 2011, p. 13). The move toward a perspective on social determinants of health has
necessitated a broader conceptualization of factors influencing health, 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 colleagues (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 fails to go beyond the
specifics of what people say or do to developing a coherent interpretation exploring “the
meanings and processes associated with the categories of behavior observed” (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 that public
health frameworks tend to be under-theorized, and that by expanding our theoretical repertoire to
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
33 Health Disparity and Structural Violence- Page-Reeves, et al.
include conceptual approaches from social theory, we can not only illuminate dynamics
underpinning the production of health disparity that are poorly understood in the public health
literature, but can offer new perspectives to expand our ability to prevent and reduce health
disparity.
Using data collected with a Hispanic, immigrant population in Albuquerque, 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 disease, 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, whether current or past, is
produced by historical processes that create inequitable relationships, environments, and policies,
influencing and often governing individual experience. The multi-dimensional nature of social
inequality means that its influence in people’s lives is cross-cutting; 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 structural 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, liberation
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 Latin 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 resulting “Puebla document”
identified structural forces that allow the “rich [to] get richer 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 result 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., family, ethnicity, religion)
systematically perpetrate and reproduce a lack of actualized potential for some individuals while
expanding the actualized potential of others (often beyond that suggested by their own innate
skill and capacity), the “violence” becomes ensconced in people’s everyday lives as disparity.
Although disparity can take many forms, health disparities can be understood as one of the most
concrete manifestations of inequity, often determining who will live and who will die—with the
poor and immigrants suffering disproportionately. In this context, Farmer, 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 is in this context that
Farmer (2005), playing on the language of liberation theologians in their argument regarding the
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
34 Health Disparity and Structural Violence- Page-Reeves, et al.
proper perspective and relationship of the clergy and the church to social 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 contexts, biology
and the environment are not treated as independent variables (Singer 2001). From this
perspective, we can understand that individual health behavior is circumscribed by structured
and institutionalized inequality that limits the ability of individuals to make choices. Limited
options then directly affect health outcomes. Individual agency is limited by and contained
within the options that are realistically available. In many cases, health-promoting choices are
not an option, or they may not represent the most valuable strategy for an individual in the
context of other limiting factors—regardless of whether other options are healthy or not. Maar,
et al. (2011) used a structural violence approach focusing on the circumstances in which
Aboriginal people live to understand barriers to diabetes maintenance and treatment. They
suggest that “it is important to look beyond the surface and identify the root causes of nonadherence, to prevent the unjustifiable blaming of socio-politically disadvantaged 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-based diabetes
care, ultimately increasing the risk of rapid onset of complications…The determinants of
poor diabetic management uncovered in this research are inseparable from the structural
violence exhibited in colonial history resulting in persistent disempowerment, poverty,
stress and marginalization of First Nations communities and their health.” (p. 13)
Using a structural violence framework to understand health disparities in Albuquerque, New
Mexico, we explore how structural forces and institutionalized inequality 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 the 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 Albuquerque that primarily
serves Hispanic immigrants. The issue of diabetes was identified 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 reflected a community-engaged
approach. The analysis presented here uses data gathered through key community member
interviews and focus groups, contextualized by geocoding and data mapping of secondary data
sets. The larger study, discussed elsewhere (Mishra et al, 2012; Page-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 miles 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 recently been
recognized by some as an asset, the ID is also an area of the city with a reputation for its high
levels of poverty (U.S. Census Bureau, 2010), transience (U.S. Census Bureau, 2010), and low
educational attainment (U.S. Census Bureau, 2010). In addition, residence in 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 that
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
35 Health Disparity and Structural Violence- Page-Reeves, et al.
75% of individuals surveyed have a family member with diabetes and 56% of people tested for
blood glucose levels were in the range for uncontrolled diabetes/pre-diabetes. Of those, 29%
were not aware of their condition.
ECM, our partner for the research, is a non-profit, faith-based community 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. Besides
developing a Community Food Co-op, which addresses some of the food-based needs 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 quality 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 community. 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 wellbeing. 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 data to
create maps of the County in terms of multiple dimensions (e.g., demographics, school BMI,
pedestrian accidents, violent crime, food outlets, diabetes-related death, 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 was 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 Study 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 eighteen people to participate in
focus groups. Three focus groups were held in two sessions each. Interviews and focus groups
were conducted at the One Hope facility. Participants received a $20 merchandise card to a local
business for each interview or focus group session to remunerate them 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 conducted in Spanish by the
Study Coordinator with support from one of the researchers who also took notes on a laptop
computer. Interviews and focus groups used questions from a semi-structured 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 emphasized understanding
people’s perceptions of the problem of diabetes, challenges to living a healthy lifestyle, 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 barriers to diabetes
prevention in much broader terms than merely thinking about diet and levels of physical activity.
Our analysis of the data revealed opinions and experiences related to people’s ability to live a
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
36 Health Disparity and Structural Violence- Page-Reeves, et al.
healthy lifestyle that would prevent diabetes in terms of six themes: (a) Money and cost; (b)
Stress and fear; (c) Being physically active is challenging; (d) People 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 interviews with the key
community members, as well as in focus group sessions, we identified three main dimensions of
fear in participant discussion of diabetes and health: (a) Cost; (b) Language, Discrimination and
Immigration Status; and (c) Cultural Disconnect. Here we use these dimensions to further
conceptualize and explore the theme of fear in relation to diabetes and health disparities.
DISCUSSION
Cost as a Dimension of Fear
As described above, the ID has high levels of poverty with a median household income
that is well below national and county average (U.S. Census Bureau, 2010). This disparity can
be seen geographically. Our data mapping demonstrates sharp income disparity between the ID
and its surrounding neighborhoods. Moreover, the maps show this same geographic pattern for a
number of other negative social indicators, including low education attainment, high levels of
transience, housing vacancies. This suggests that poverty is tied with many other socioeconomic aspects of the community. The same geographic pattern emerges for health issues.
Furthermore, our data maps demonstrate that low economic status correlates with high uninsured
rates. Because of the economic insecurity, one of the prominent dimensions of fear to emerge
during interviews and focus groups was in relation to the financial burden associated with illness.
Participants reported that people in this community fear seeking assistance 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 visits,
but does not have the capacity to come anywhere close to meeting the healthcare need in the
community.
Currently, debate is raging in the U.S. about the sustainability of the healthcare system
(Berwick and Hackbarth 2012; Song and Landon 2012). One of the biggest barriers 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 insurance, or one in six who
are not receiving adequate healthcare (Wolf 2010). In our study, participants discussed how cost
limits access. In the ID, people do not go to the doctor because given their 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 without 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 ironically, more
expensive.
Participants also described how parents put their children’s health 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 precedence 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 homeless 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 all types of healthcare.
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
37 Health Disparity and Structural Violence- Page-Reeves, et al.
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 English 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 concern over
what unpleasantness may be entailed in a particular treatment. Among families living in poverty,
the cost of healthcare causes a level of stress that people described 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 and 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 undocumented)…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 particular to an
immigrant community. The ID is so-named because it is one of the most diverse neighborhoods
in the state (Childress, 2009). The data maps we created revealed a high percentage of foreignborn 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 associated 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 as an asset, but challenging
mainstream views of the neighborhood has been difficult and stereotypical negative discourse
and attitudes remain common.
Participants in our study expressed strong sentiments regarding discrimination that
immigrants face on multiple levels on a daily basis. They feel that people with a Spanish accent
or who lack English-speaking skills are discriminated against in institutions 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 translation 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 that 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 speak 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.
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
38 Health Disparity and Structural Violence- Page-Reeves, et al.
She argues that this influences social practices through what she defines as “powerful
‘subjectivation’ effects” that are both psychological and political, influencing and shaping the
behavior of immigrants and institutional actors in a dynamic of hierarchy. This process, in turn,
contributes to the construction of immigrants as undesirables.
Although hospitals have policy regarding the provision of professional interpreters,
participants said that they are still made to feel guilty—as if it is somehow their fault that they
need this service. At the same time, participants reported a dearth in bilingual support at clinics.
This is especially problematic in a state with such a large Spanish-speaking population. One of
the interviewees, who also has a job as an interpreter at a large hospital, indicated that the
interpretation provided is often very poor. In one example from a psychiatric out-patient 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 they 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 medical interpreters are
generally disinterested and not fully-invested in what they do—further reflecting 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 incompetent, and people who
cannot speak English are afraid of finding themselves in a situation where they cannot
communicate their symptoms, or understand what people are saying or what 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 fear reported in relation
to discrimination is more than merely a concern over language proficiency. Many of the
immigrant households in the ID have members with problematic immigration 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 people 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 they are bad people.
One participant expressed how this difference in treatment is perceived, saying “These people,
even when in the hospital or the waiting room, there’s a big sign that says we’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 access in the system.” Another, in a
more pointed description said,
“and I hate to say it, but we’re a racist, xenophobic society that refuses 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 quit 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 can 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 their needs with the realities of
discriminatory environments and exclusionary institutional policy.
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
39 Health Disparity and Structural Violence- Page-Reeves, et al.
The fear around illegality expressed by participants is partially an abstract concern with
the discriminatory treatment involved, but for individuals who lack documents 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 the other dimensions of fear,
becomes virtually paralyzing for many people in terms of seeking assistance 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 lacking 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 Naturalization Service]
may be looking over the bill collector’s … shoulder… people are really fearful.” Participants
described a local medical provider’s aggressive questioning of patients (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 inappropriate in a medical
environment. Knowledge of encounters like this, especially with physicians who are proverbial
“gatekeepers” in the system, spreads like wildfire throughout the community. People become
afraid that at best, the doctor may be making erroneous assumptions about their immigration
status, or at worst, be trying to sniff out and report immigrants without documents.
Discrimination against immigrants and minorities is a deeply rooted 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 times 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 country 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 access to healthcare for immigrants,
while ensconcing fear into people’s daily lives. Larchanche (2012) describes how immigrants
exist within a “climate of fear [that is] tangible” (p. 862), extending even to those who provide
services and help to the undocumented. Viruell-Fuentes, Mirand and Abdulrahim (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 dimensions 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 with 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, including diabetes. Walton (2009)
describes this type of conflict between patients and providers regarding 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 alternatives 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 recounted the story of a man
who was selling a type of “bark” from Mexico to cure diabetes that people could take in the
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
40 Health Disparity and Structural Violence- Page-Reeves, et al.
form of a tea. The price he was charging for the bark was extremely expensive, but many
people bought it. Not surprisingly, taking the tea did not have the desired effect, and participants
reported that people ultimately felt swindled by a charlatan. Participants 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 healthcare setting.
Doctors trained in a bio-medical model often have little patience for or a
misunderstanding of alternative medicine (Farmer, 1999; Farmer, 2005; Poss, Jezewski, and
Stuart, 2003; Singer, 2004; Walton, 2009). Yet in many cultures, including that of many
Mexican immigrants, alternative medicine can have important cultural dimensions, and at the
same time, supplement medical treatment (Astin, 1998; Niforatos, 2012; Poss, Jezewski, and
Stuart, 2003; Rivera, Ortiz, Lawson, and Verma, 2002). Participants in 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 medication (Poss, Jezewski, and,
Stuart 2003; Rivera, Ortiz, Lawson, and Verma, 2002). They also discussed 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 routinely hide their use
of alternative remedies and treatments from their provider. Patients often feel, either from
previous experience or from the experience of others, that their physician will “scold” or ridicule
them for using alternative treatments that the provider believes to be irrational. As a result, many
do not tell their healthcare provider that they are using alternatives to prescribed treatment. (Poss,
Jezewski, and Stuart, 2003; Rivera, Ortiz, Lawson, and Verma, 2002). One participant 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, so 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 which the reaction of
others spoils normal identity” (p. 3). The potential negative reaction of the healthcare provider
towards a patient in relation to the causes of and cures for disease, or the providers’ questioning
of the rationality of alternative treatments can “spoil the normal 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 influencing 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 provider notified Child
Protective Services because of marks on a child’s arms. As a result, the child was removed from
the home. Although temporary, this experience was traumatic for the child, 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 application 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 literature on health disparities
(Betancourt, Green, Carrillo, and Ananeh-Firempong, 2003; Betancourt, Green, Carrillo, 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 understanding of the realities of
the lives of their patients, as in the example given above. Farmer (1999; 2005) and Singer (2001;
2004) highlight how important it is for providers to understand the history, political economy,
and culture of the population that they serve. In one poignant example, it was common for
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
41 Health Disparity and Structural Violence- Page-Reeves, et al.
patients on the central plateau of rural Haiti not to finish a full-course of tuberculosis (TB)
treatment. Practitioners attributed this to local beliefs related 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 the etiology of disease had no
impact on whether a patient finished the full-course of TB treatment; rather, access to the TB
medicine and having support from community health workers to monitor patients were the key
determinants of whether the patients were “compliant.” Elsewhere, Farmer and colleagues
(2005) observe that “those least likely to comply are usually those least 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. Moreover, the culture-asproblem framework for understanding health disparity often merely serves to legitimize and
underscore narratives that devalue the poor and communities of color as irrational and therefore
deserving of what they get.
The fear experienced by Hispanic immigrants in the ID related to cultural disconnect is a
reflection of larger inequities within the system. In the ID, provider 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 results from cultural disconnect reduces
a patient’s ability to receive proper medical treatment and further puts the patient as risk when
they do seek care. When patients hide their use of or belief in alternatives 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 physician. 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 reactions 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 Hispanics are at particular risk. While
we know how to prevent diabetes through a healthy diet and regular physical activity, and how
to maintain the health of people with diabetes through a regimen of care from a provider, we
have not been able to develop meaningful strategies to encourage prevention 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 continue to lack a more integrated
understanding of the nature of social practices that impact health 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 understanding diabetes
health disparities in a Hispanic immigrant community in Albuquerque would provide significant
insights into the processes that produce and encourage disparity. A structural violence
framework takes into consideration the extent to which people’s lives are affected by
institutionalized inequality, influencing and often governing individual experience. Political,
economic, and social inequalities limit the personal agency of an individual to live a healthy life
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
42 Health Disparity and Structural Violence- Page-Reeves, et al.
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 services and create fear
among immigrants in Albuquerque, acting to further undermine health and nurture disparity.
Although fear is not normally directly associated with diabetes health 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 residents of the ID, fear is
both a psychological barrier for those seeking access to healthcare services 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 requirements, 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 inequalities and health,
namely, that structural forces create the social, emotional, and 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 multidimensionality 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-anthropologist Arthur Kleinman
(2006a) observes that a limit in personal agency causes an “enervating anxiety…[an] 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 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 ultimately 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 frameworks from social theory,
we are able to reveal dynamics underpinning health disparity in an immigrant 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 ID, 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 convenient ignorance of the
structural forces that institutionalize inequality and produce and maintain 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 extent to which
the dynamics of disparity are structured by broader political, economic and social forces. Deeper
theorizing allows us to activate our conceptualization of how the social determinants of health
operate rather than merely acknowledging that they exist.
Like the IOM report (2002) on racial and ethnic disparities in health care, the data from
our study demonstrate that effective diabetes prevention in communities like the ID requires that
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
43 Health Disparity and Structural Violence- Page-Reeves, et al.
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 causes. 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. Those of us who attempt to
approach the work of public health from a broader perspective are routinely instructed that such
a focus is the purview of other disciplines, too far afield from health-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 project 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 central 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 legitimately espouse an interest
in addressing health disparity through environmental and policy change or “community
empowerment” while generally being unwilling to think about non-health related factors and
dynamics that generate disparity. Of course, this shift is extremely challenging given the
epistemological tendency in public health to narrow the focus of research 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 participation 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 Report of the
Commission on Social Determinants of Health from the World Health Organization (CSDH,
2008) will not be possible. Incorporating social theory (such as the structural violence
framework utilized in the analysis presented here) into the way that we conceptualize public
health contexts and the way that we view the purpose and focus of our own 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 disparities 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 Research Resources and the
National Center for Advancing Translational Sciences of the National Institutes of Health
through Grant Number UL1 TR000041. The content is solely the responsibility 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 treatment compliance of patients
with diabetes." Knowledge Representation for Health-Care:108-116.
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
44 Health Disparity and Structural Violence- Page-Reeves, et al.
Belliveau, M. 2011. "Gendered Matters: Undocumented Mexican mothers in the 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 benefits 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. "Projection of the year
2050 burden of diabetes in the US adult population: Dynamic modeling of incidence,
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 nervios: explanatory
models and treatment experiences of Hispanics with diabetes and depression." 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 fact 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 USA."
Chavez, L.R. 2008. The Latino threat: Constructing immigrants, citizens, and the nation / Leo
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 Prevention 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 Determinants of
Health." World Health Organization, Geneva.
Davey Smith, G. 2003. Inequalities in Health: Life Course Perspectives. Bristol, UK: Policy
Press.
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
45 Health Disparity and Structural Violence- Page-Reeves, et al.
Diabetes Prevention Program Research Group. 2002a. "Reduction in the Incidence 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 health 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. "Contributors to
depression in Latino and European-American patients with type 2 diabetes." 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. "Origins 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 Getting 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 Enforcement." 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 Danger.
New York: Oxford University Press.
Konrad, W. 2011. "For those with diabetes, older drugs are often best." in The New York Times.
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
46 Health Disparity and Structural Violence- Page-Reeves, et al.
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 stigmatization, structural
violence, and fear among undocumented immigrants in France." Social Science &
Medicine.
Maar, A., D. Manitowabi, D. Gzik, L. McGregor, and C. Corbiere. 2011. "Serious complications
for patients, care providers and policy makers: Tackling the structural 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 diabetes
prevention initiative with East Central Ministries.” University of New Mexico.
Nelson, A. 2002. "Unequal treatment: Confronting racial and ethnic disparities in health care."
Journal of the National Medical Association 94:666.
New Mexico Department of Health. 2009. "New Mexico selected health 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 Amazon:
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 community
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 diabetes 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. "Evaluation of the use of
complementary and alternative medicine in the largest United States-Mexico border city."
Pharmacotherapy 22:256-64.
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
47 Health Disparity and Structural Violence- Page-Reeves, et al.
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. "Diabetes,
gallbladder disease, obesity, and hypertension among Hispanics in New 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. Lockett, W. Ridella,
and S. Kannan. 2005. "Healthy eating and exercising to reduce diabetes: Exploring the
potential of social determinants of health frameworks within the context of communitybased participatory diabetes prevention." Journal Information 95(4):645-651.
Singer, M. 2001. "Toward a bio-cultural and political economic integration 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 69:919.
Smedley, B.D. 2012. "The lived experience of race and its health consequences." American
Journal of Public Health 102(5):933-5.
Song, Z. and B.E. Landon. 2012. "Controlling health care spending—The Massachusetts
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 interventions 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 immigration."
KSEN5.com San Antonio.
Wolf, R. 2010, September 17. "Number of uninsured Americans rises to 50.7 million." USA
Today.
Journal of Health Disparities Research and Practice, Volume 6, Issue 2, Summer 2013
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