Our KIs explained, and our GKs and CWs illustrated through descriptions of daily life from their respective vantage points, that transculturation among U.S. Latinas and Filipinas is a dynamic mixture of past and present, homeland and United States. This mixture was evident in various realms of their lives, including their experiences with the U.S. health care system, public schools, religious and spiritual practices, and health and wellness practices. These converged under five transculturation and transmigration themes: (a) colonialism, (b) immigration dislocation and disorientation, (c) immigration status, (d) discrimination, and (e) therapeutic engagement. We use the following additional abbreviations to indicate type of respondent: KI (key informant), GK (gatekeeper), and CW (community woman). A number (e.g., KI5, GK2, CW4) indicates the specific interview participant, with a 2 preceding the number for Filipina CWs (e.g., CW27).
Our concept of culture not only allows for but also expects the intermingling of influences from long ago with those of the here and now. Transcultural processes may begin with experiences of the United States in the home country, through collective memories of conquest and other historical encounters, the influence of colonialism and neocolonialism on education and health systems, the economy, popular culture, and the stories and remittances immigrants send back home.
Colonialism is a form of cross-cultural contact and cultural change (transculturation) in which direct political, economic, and sociocultural power is imposed by one population, usually a nation-state, on another. The exploitative relationship of colonial rule has complex and profound effects on the colonized, including economic underdevelopment, political instability, religious syncretism, the undervaluing of local mores and practices, and internalized oppression.
So you have an entire generation of Filipinos that were raised to believe that we are the little brown sisters, because the narrative of Manifest Destiny. And benevolent assimilation is very damaging … the psychic and epistemic consequences of this colonial relationship, it's what really defines the Filipino experience. At least for this generation. (KI4)
A history of colonialism (and neocolonialism, where power is wielded indirectly rather than through direct rule) is familiar to many immigrants and people of color in the United States. The Filipina anthropologist Espiritu (2003)
wrote, “The relationship between the Philippines and the United States has its origins in a history of conquest, occupation and exploitation. A study of Filipino migration to the United States must begin with this history” (p. 1). Like the Philippines, Latin America was first colonized by the Spanish and then came under U.S. influence. Although the Philippines were directly colonized, Latinos in the United States are primarily from countries where the United States has wielded extensive influence, especially political and economic influence, often characterized as neocolonial. For Filipinas as well as Latinas, as this KI explained, (neo)colonization imbues a “less than” status.
Part of the psychology of being colonized is knowing deep within your soul that you're not really inferior … but you've been told, and you've been oppressed and your life and economic and social conditions have been structured so that it really almost convinces you that maybe you are indeed inferior. (KI4)
Experiences of colonization are integral to the challenges of immigration and discrimination experiences that may lead to unwillingness to encounter the health care system and distrust of those who operate it.
I'm trying to think of other things that might prevent desire to access the system … but I think the big thing is really just being intimidated because you don't have the knowledge because you don't have the connection, you don't have the confidence, and perhaps the feeling of, you know feeling inferior is part of it. Of not being good enough and maybe that's even the biggest problem. (KI4)
Immigration: Dislocation, Disorientation, and Disruption
Immigration involves profound experiences of dislocation, disorientation, and social isolation. Immigration of a colonized people both compounds and is compounded by such experiences. Experiences of dislocation, disorientation, and social isolation can limit knowledge of and access to the health care system and, in conjunction with the struggles created by colonialism, can create deep senses of illegitimacy, not belonging, and not being welcomed in many spheres of life, including health care.
Even in just the most basic ways—like you get on the bus and people will—people will contort into every position to not touch a stranger. … And I think there's that real loss of physical contact and just kind of feeling always being “off” on social cues and just not knowing what to do when you meet someone. (GK10)
This sense of being “off” on social cues reflects outwardly subtle but profoundly meaningful cultural differences that can be hard to name and therefore even harder to negotiate and that can discourage people from dealing with a new and potentially unwelcoming medical system.
[We] land in San Francisco … we don't even know the subway system here … there's no such thing in the Philippines … to even master how to get around. … And we're talking about [the] health field … where do you find doctors that could understand you? … In the Philippines, we were all schooled in the English language … but … over here … the accent is so different … so, we're not really being understood. (KI8)
“The reality of the accent,” as she put it, was an abrupt and unexpected recognition of difference. Although many Filipinos speak English—it was made a national language as a result of U.S. colonization—communication can still be difficult.
And you're trying to speaking in English, and you cannot do it fast enough, you can't do it simultaneously to [mentally translate], and you're surrounded by people that talk very fast … and talk very loudly and they're taller than you [laughter] … so I think part of our discomfort with the system is the overwhelming Whiteness of it and also the influence of norms, how different they are. (KI4)
As a result of such differences and discomfort, some of the women in our study chose to get their medical care in their home country. Travel back and forth and the maintenance of relationships in both countries (transmigration) made accessing care in the home country possible, and in some cases preferable.
Over there, they have access to health insurance and over here, they don't … they have in some cases, but they'd rather go over there. And maybe not only the access but the language … they will be more comfortable going to a doctor that speaks their own language. Or, if they have to pay, I think it's almost cheaper. Services are cheaper than here. I also have talked to some women that are from El Salvador and she … this woman was telling me, “Well, I go to El Salvador every year and I get all my screening over there.” Or some women just go to Tijuana. (GK1)
For one woman who routinely received care when visiting family in Mexico, the benefits of seeking mammography screening in the United States were not sufficient in light of the costs of learning the system and her lack of access. Her long-term relationship with her doctor in Mexico, along with the familiarity and comfort of getting care there, might have encouraged her to seek a mammogram there where she also obtained regular Pap tests. Another Latina woman, however, explained that, over time, her fear and intimidation gave way to confidence and, with that, the ability to seek health care in the United States and advocate for herself (Burke, Bird, et al., 2009
An unfamiliar situation, activity, person, setting, or, in more general terms, context gives rise to great fear or anxiety. Two KIs commented, “Not knowing what to expect is a terrifying thing” (KI7) and “Familiarity is a very important part in making the Filipino patient comfortable in any clinical situation. It's not a familiar procedure … machines, gas, medications were not in hinterland Philippines … medications are seen suspiciously … they'd rather go for their arbularyos (healers) with herbal therapies and prayers” (KI8).
Lack of familiarity also affects receptivity to health information. To be effective, the source must be familiar to the person being instructed and the information must resonate with their values. Two participants explained,
Because, if they're not familiar [with the system] … even if you tell them it's for the good of the family, it won't fly … and for somebody who … doesn't even know it can be done … they give up easily. (KI8)
The information has to be familiar … somewhere, you know, they need to be able to recognize it … decode stuff that you're throwing at them. It has to be proximate … real close in to their life space. (KI9)
Thus, the legitimacy or validity—and, hence, the influence—of information provided in or by this unwelcoming context may be drowned out by unfamiliarity. As Pasick, Barker, et al. (2009)
note, “The messenger can be far more important than the message” (p. 102S).
The literature (e.g., Echeverria & Carrasquillo, 2006
) and our findings document how the political and legal distinctions made with regard to immigrants in the United States—as legal or illegal, documented or undocumented residents—affect health-seeking behavior. One undocumented Filipina described, for example, the fear of being reported to the immigration authorities and being deported and the sense of shame and inferiority that comes from constantly having to respond to questions about one's immigration status. At times, this outweighed the perception of benefits of a recommended health behavior.
Interviewer: So is the reason why you don't go to the doctor because … [pause] … you don't have time? Are there other reasons why?
Participant: Because in the first place, I don't have insurance. They will ask, “Your—do you have insurance? Do you have, are you le– [legal].” Sometimes they ask your Social Security [number] and everything. And I don't have that. So I, I know some hospital will refuse to check you. So I'm afraid of that. …
Interviewer: If, if someone were to tell you that, “Oh, you can go and get a mammogram,” in the next 12 months, would you go?
Participant: Yeah. As long as they will not ask lots of question about my, you know … [immigration status]. Yeah. I, I love to, because … that's for, you know … for my health. (CW213)
This woman perceived the benefits of mammography for her health but not in isolation from her social context—her immigration status, her understanding of how that affected her access to health care, and its implicit impact on her family.
Discrimination: “And Then You Deal With Discrimination … That's Real.” (KI8)
Closely connected to immigration status, but also independent of it, women in our study recounted disturbing tales of their vulnerability to discrimination and abuse as immigrants, ethnic minorities, non-English speakers, or those unfamiliar with the medical system. In various cases, medical providers were revealed as being ignorant, insensitive, and disrespectful.
I was desperate for them to give [my daughter] something for the pain, that he would say something, that he would produce a solution for that pain. And the conversation was, “Oh, Brenda. Why Brenda and not Lupe, Maria? … Where are you from?” I told him that we were from Mexico. … And he continued “Brenda? And why not Lupe or Maria or Juanita?” That is what the doctor said to me. I was desperate about my daughter and he was talking about why I hadn't named my daughter another name. (CW5)
Several women told stories that revealed their vulnerability as women to sexual abuse and manipulation by health care providers.
The doctor asked me to lie down on the table. … He wanted me to take off my clothes, and he locked the door from the inside. So I told him that I had to come back with someone because that did not seem right to me. … I had to get out of there, and it was a horrible experience because I think that he wanted to sexually abuse me. (CW9)
Women also reported discrimination on the basis of insurance status and income. One uninsured recent immigrant felt she was treated disrespectfully—not even given the information about her diagnosis or referred for affordable care—because her doctor made the assumption she could not pay for the treatment she needed. The doctor told her,
“I've already found your problem. But you can't pay. You can't pay. The medicine is very expensive and you can't pay.” I felt so bad. I left that office crying, crying, crying. I never went back to see that doctor. … He didn't tell me or guide me. … There are so many hospitals. … He could have said, “I cannot help you but you can go to such and such a place.” Now I know that there are other places, but when I first got here I didn't know. (CW13)
Fortunately, this woman figured out how to get care without the help of this physician, but it is likely that others in such situations do not. Thus, even women who feel susceptible to breast cancer and/or understand the potential benefits of a screening mammogram may not be getting mammograms to avoid feeling belittled or mistreated.
Known as “medical pluralism” in medical anthropology, the combining of different traditions of therapeutic practices by one person or in one system is common through-out the world. Ideas and practices that combine elements of biomedicine and traditional or alternative health practices took many forms among our participants. Some respondents mentioned practices that were explicitly connected to their religious and spiritual identity, whereas others were based on home country practices (e.g., taking herbs or drinking teas) or complementary and alternative practices common in the San Francisco Bay area. In the context of this variety of healing practices, the PB of biomedicine is limited, good for some things, but not all. One participant, in discussing her expectations of doctors, articulated a division of labor between biomedicine and alternative practices: going to the doctor is good for diagnosis but not necessarily for treatment.
It's important to get [biomedical] tests and exams, to know what you have. If you don't want to take the medicine that the doctor prescribes, you can help yourself. … Natural medicine helps to fortify the parts of your body that are deteriorating. The doctor's medicine is killing the virus or the infection. They do their jobs differently. (CW11)
The mixed use of biomedical and alternative healing practices among our participants suggests that perceptions of susceptibility to illness and benefits of biomedical prevention practices such as mammography are complex manifestations of transcultural processes. The context of colonialism and immigration is, for many of our participants, woven tightly with a religious or spiritual orientation to the world, profoundly influencing the meanings of illness, life, death, and one's relationship to these processes. The integration of religious and spiritual orientations and practices that involved healing infused highly variable meanings into perceptions of susceptibility and benefits among our participants. Although biomedicine typically focuses on the individual body as the locus of disease (and hence locates susceptibility and benefits in behaviors that affect the body), other worldviews frame health and illness in terms of more transcendent or metaphysical phenomena such as balance (hot-cold, yin-yang) and social harmony (G. Becker, 2003
; Kleinman, 1981
). People with such orientations might locate the cause of illness (and hence susceptibility to illness) in relationships that are out of balance or disharmonious (see Pasick, Barker, et al., 2009
) or in retribution for bad deeds or immoral behavior. Religious and spiritual orientations among our respondents—in part beliefs and in part an unconscious way of understanding the world—were not usually exclusive of beliefs in biomedicine. Recalling her reaction to being diagnosed with breast cancer, one Mexican American woman told us,
I'm a spiritual person. I'm a strong believer in a higher power, and in prayer. And I knew that I had no control. That was out of my hands. I was in the hands of good doctors, but they were also in the hands of a greater power. You know, of the Teacher, so … I gave in. I said, “I'm in your hands,” and the only thing I could do was have a positive attitude and take care of myself. (CW4)
In contrast to the “fatalism” so often discussed in public health and social science literature, this woman's religious orientation incorporated and was consistent with her use of biomedical interventions. Some of our KIs regarded the construct of “fatalism” as flawed precisely because it fails to account for structural circumstances such as poverty and colonialism.
Somehow the idea is that Latinos can't think about tomorrow because you know, God gave us today and that's it. … I think that the experiences of being poor in Latin America don't give you much option in life … if you're well off, you have access to good medical care, if you don't—the other 90%—you're pretty much gonna be a fatalist [laughs]. (KI2)
The belief in “God's will”—as it appears on a survey—might reflect a lack of control over health caused by scant resources or minimal access to health care. Under such conditions, “folk” or home remedies (e.g., chicken soup and herbal tea) or denial are viable, practical, and even protective options (Kagawa-Singer & Kassim-Lakha, 2003
). Another KI explained how the context of colonialism contributed to “fatalism”:
There is a negative connotation attached to fatalism, and the Tagalog word is bahala na, but the anthropologists and social psychologists that have studied this, they said that this attitude is really a product of again, colonization. When you know that you are not in control of your circumstances, and so you kind of do everything you can and then you ask God to do the rest. Bahala na: you know, it's up to God. But whatever outcome he wants. I've already done what I need to do and there's nothing more I can do before I surrender it. (KI4)
Fatalism is giving up without really trying, but these respondents make clear that is not what is happening here. Rather the exact opposite occurs: “You kind of do every-thing you can [within your often limited means] and then you ask God to do the rest.” This Filipina KI also suggested that the acceptance of death as “just a part of life” put a different spin on medicine than in the United States.
So it's more about faith, faith that there is something bigger than medicine, there is some-thing bigger than you know, uh, surgery, but that also comes from the fact that we will accept death, uh, very well. That death is just a part of life. So it's not a death denying culture as much as it is in the U.S. (KI4)
Thus, understanding the combination of the historical context of colonialism, the meaning of poverty in everyday life, and culturally specific ideas about control, faith, and death affords quite a different reality than what is often described negatively and simply as fatalism. These observations are consistent with those of Trostle (2005)
, who wrote,
Anthropologists have long said that non-Western cultures explain misfortune partly through magic and witchcraft. Anthropologist E. E. Evans-Pritchard wrote in his classic book Witchcraft, Oracles and Magic among the Azande that his African village informants were perfectly capable of explaining that a raised granary collapsed because termites had eaten through the supports (Evans-Pritchard, 1937). But witchcraft explained why that particular granary collapsed just when that particular individual was seated underneath it enjoying the shade. (p. 163)
Biomedicine that diagnoses a woman's breast cancer is equivalent to talking about termites; spiritual belief, however, answers her questions about “Why me?” “Why now?” “Why this cancer?” just as it explains who was affected and why when a granary collapsed.