In the United States, the large, white, middle class is the major cultural influence, and subcultures include African American, Latino, Asian American, Native American, and Middle Eastern American. Because cultural groups vary in their health beliefs and practices, this diversity poses important challenges for physicians. For example, schizophrenia is seen to about the same extent in all cultures (see Chapter 12), but the presentation of its symptoms (e.g., delusions of persecution) typically differs by culture. For example, although a white patient may fear that the FBI is after her, an Asian-American patient may believe that the ghost of a dead relative is torturing her, and an African-American patient may believe that someone has put a curse on her (Westermeyer, 1988).

Most folk beliefs and remedies are benign and can be included in the patient’s medical treatment plan. For example, a patient who believes that his illness can be cured by eating a certain food should be helped to get the food. Similarly, if the patient believes that an outside influence like a hex or a curse imposed by the anger of another person caused her illness, the doctor should ask the patient who can help to remove the curse and then involve that individual in the patient’s treatment. When a folk remedy is potentially harmful or medically contraindicated, the doctor can explain the danger and substitute a similar but safe remedy that harmonizes with the patient’s belief system. Whatever the plan, patients tend to be more satisfied with their care and to comply with treatment recommendations when their physicians acknowledge and have a nonjudgmental attitude toward their cultural and religious beliefs and practices.

Adult patients are addressed using their correct titles, such as Mr., Ms., or Dr., and family names. Using first or given names to address patients is not appropriate. However, the correct title and family name may not be obvious. For example, in people from certain parts of India, what appears to be the last or family name is actually the given name. Among the Chinese, the family name commonly comes first and is followed by the given name. For example, for someone named Yang Lin Lin, Yang is the family name. Sikh patients are likely to have three names, the first, the religious (typically Singh for men and Kaur for women), and the family name. If it is not clear, the doctor should ask the patient what the family name is and how the patient would like to be addressed.

No matter what the ethnicity or culture, it is essential that the physician speak directly to the patient. For non-English-speaking patients, a professional interpreter should be used to facilitate communication. Using a child or adult child for this role is not appropriate (Salas-Lopez et al., 2002).

Culture shock is a strong emotional response related to geographic relocation and the need to adapt to unfamiliar social and cultural surroundings. It is reduced when immigrants of a particular culture gather in the same geographic area. Young immigrant men appear to be at higher risk of culture shock, including psychiatric symptoms such as paranoia and depression, than women and other age groups. This increased risk has been attributed to at least two factors. First, young men lose the most status on leaving their culture of origin. In addition, unlike others in the cultural group who can stay at home among familiar people, young men often must venture out into the new culture, learn the new language, and earn a living.

Certain racial and ethnic minorities in the United States face significant obstacles to obtaining quality health care. These difficulties lead to higher mortality rates in these groups from some common disorders (LeCook et al., 2009). For example, African Americans and Latinos have less access to physical and mental health care services than other Americans and, when they do receive care, it is often of poorer quality. These disparities are not caused solely by economic factors or lack of physical access to care. They exist even when incomes and health care insurance are equal. Communication difficulties, overt bias (Flores, 2000), and physician-held negative racial stereotypes about African Americans and Latinos ( Smedley et al., 2002) contribute to the poorer health care for these groups. Other elements contributing to ethnic disparities in health care include the typically shorter-term relationships between minority patients and primary care physicians and the relative scarcity of minority physicians.

There are approximately 37 million African Americans, 12.4% of the total U.S. population. The average income of African-American families is only about half that of white families. Coupled with other health care disparities (see previous text), financial factors result in decreased access to health care services and increased health risks. When compared with white Americans, African Americans have shorter life expectancies (see Fig. 4-1) and higher rates of infant mortality (see Table 1-4), hypertension, heart disease, stroke, obesity, asthma, tuberculosis, diabetes, prostate cancer, and AIDS. In fact, African-American men and women are 15 times and 5 times more likely to have AIDS than white men and women, respectively. African Americans also have higher death rates from heart disease and all forms of cancer. Although the higher cancer mortality rates among African Americans compared with white Americans had been attributed mainly to biological differences between the races, recent studies suggest that this difference is more likely to result from economic factors and coexisting medical conditions affecting African Americans than from genetic factors (Bach et al., 2002). As evidence for this, African-American women under the age of 50 years have lower breast cancer survival rates than do white women of the same age. However, African-American women and white women aged 65 years and older (who all have Medicare benefits; see Chapter 27) have equivalent survival rates (see Chapter 27) (Chu, 2003). Genetics, however, may be an important factor in the increased rate of hypertension in African Americans. When compared with white Americans, African Americans appear to be more salt sensitive and to respond better to diuretics (with or without concurrent angiotensin-converting enzyme [ACE] inhibitors) than to therapy with ACE inhibitors alone (Lopes, 2002).

America’s long and destructive history of racism, fueled by tragic events like the Tuskegee Institute Study, in which African-American men with syphilis were given a placebo instead of an effective medication, has resulted in a general distrust among some African Americans of the white-dominated health care system. This has resulted in low participation in organ donation programs and clinical trials, as well as reluctance to seek routine preventive care for diseases like HIV (Thomas & Quinn, 1991).