Winkleby Lab In the Prevention Research Center

Copyright 1998 The Philadelphia Inquirer 
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AUGUST 10, 1998 Monday SF EDITION



Susan Shinagawa's surgeon was confident.

The lump in her right breast was not cancer, he told her. The biopsy she was requesting made no sense. At 34, she was too young for cancer. She had no family history of it, and the mammogram was negative.

Then came the clincher: "He told me that Asian women don't get breast cancer and I had nothing to worry about."

Those words still haunt her. Because the doctor was wrong, both about her and about Asian American women.

In the seven years since that day, Shinagawa, a third-generation Japanese American who lives near San Diego, has endured a mastectomy and chemotherapy. A recurrence of cancer in another part of her body required radiation and more chemo.

Now an activist for cancer patients, she has learned the facts: Women in Asia are less likely to get breast cancer, but studies show that U.S.-born granddaughters of immigrants, like her, have a cancer rate approaching that of whites.

Health researchers have come up with a remarkable and troubling finding: Long-term immigrants from Asian and Latin countries gradually lose many of the health advantages they bring to American shores.

The longer you live somewhere, the more your health resembles that of people who were already living there - for better and worse.

Americanization isn't all bad. U.S. medicine offers powerful drugs to treat the infectious diseases common in Latin and Asian countries. And studies show that smoking among Asian men declines with the degree of Americanization. Moreover, all immigrants can benefit from the American emphasis on regular checkups and preventive care.

But if you move to this country, you will face a higher risk of cancer than in Mexico or China, more heart disease than in Japan.

"Acculturation is a danger to your health," said Aida Giachello, director of the Midwest Latino Health Research, Training and Policy Center at the University of Illinois in Chicago. "We seem to get worse the longer we stay."

Among Hispanics, researchers have found that Americanization leads to increases in cancer, infant mortality, high blood pressure and mental health problems.

The reasons are not completely understood, and probably vary.

For some, such as Puerto Ricans living in poverty in big American cities, harsh living conditions take a toll. And overall, Hispanics are more likely to lack health insurance than any other group.

Many epidemiologists believe that the protective benefits of Latino and Asian cultures are weakened as traditional diets are abandoned and immigrants ease into America's couch-potato lifestyle.

"The traditional diet in our culture did not have all this fat in it," said Linda Hernandez, a nurse working with the federally sponsored Diabetes Prevention Program at the University of Texas Health Science Center in San Antonio.

"People who come from Mexico eat corn tortillas, which are made with cornmeal, water and lime, and have half a gram to 1 gram of fat per tortilla," Hernandez said. "Mexican Americans eat flour tortillas, which are made with lard and have 3 to 6 grams of fat."

Nutrition researcher Marilyn Winkleby of Stanford University has found that lower-educated Hispanics in California appear to slowly exchange their native diet for a high-fat diet preferred by lower-educated whites.

Among Latinos and Asian Americans, the spread of cancer and other chronic diseases has serious consequences. These are the fastest-growing ethnic groups in the United States, and their share of the population will rise from 15 percent to about 30 percent in the next 50 years.

Efforts to understand and address Hispanic and Asian health concerns are hampered by an information gap that is dangerous to life and well-being. It's like a puzzle with many missing pieces.

For decades, the government has collected statistics on rates of death and disease for whites and African Americans, but serious data-gathering on Latinos, Asians and Pacific Islander Americans only began in the 1980s.

The very categories of "Hispanic" and "Asian/Pacific" create distortions, because they combine data on recent immigrants and longtime citizens, on Latinos of every hue and nationality, and on Asians from more than 50 distinct groups. The numbers fail to distinguish people by income and social status, variables that are perhaps the most powerful predictors of health.

"Data grouped for all Hispanics, in my opinion, is not very useful," Boston University professor Hortensia Amaro said. "It hides the true rates and causes of disease for the different major Latino groups."

For instance, infant-mortality data only for "Hispanics" do not reveal that the death rate for Puerto Rican babies is 50 percent higher than for Mexican Americans.

Moon Chen, a public-health professor at Ohio State University in Columbus, said the information gap led doctors to shortchange patients.

"Physicians are least likely to counsel Asians about smoking, because they are perceived as a model minority who have good health," Chen said.

One study found that 50 percent of all patients - but just 33 percent of Asian patients - said they had been advised by their doctors about the dangers of smoking. Yet smoking rates are high among some Asian Americans, such as Vietnamese men and recent immigrants.

At the patient's level, lack of English skills and cultural misunderstandings can scramble communication with doctors, an information gap with potentially tragic results.

For example, the high rates of cervical cancer among Vietnamese women could be reduced with better preventive care. But many Vietnamese women are unaware of the importance of regular Pap tests.

"In Vietnam, we rarely go to the doctor until we get very sick," said Thoa Nguyen, a community-health worker in Oakland and San Francisco. "If there are no symptoms, it's very embarrassing for a woman to talk about having a Pap test. Women are afraid to ask the doctor, because the doctor is an authority figure."

San Antonio nurse Linda Hernandez became a diabetes educator because she saw how her patients were hurt by the information gap. High rates of adult-onset diabetes are a serious problem for Hispanics, particularly Mexican Americans, Puerto Ricans and older Cuban Americans.

"I was working in a children's hospital and we would get a lot of juvenile diabetics in crisis," Hernandez recalled. "We'd get them stabilized and then they'd go home to the same bad diets. It was a constant cycle of the same people over and over. The parents did not understand."

Hernandez knows what her patients go through because she faces a daily struggle to manage her own diabetes.

"There is a refusal to accept that it is the fat," she said. "People become defensive. They say, 'This is the way I have always eaten. This is our culture.' I tell them no, your ancestors didn't eat all the meats and processed foods, and the big portions we eat. My dad packed two tacos for lunch and that was it, because they only had $13 a week for groceries."

For cancer survivor Susan Shinagawa, now 41, the realization that myths about ethnicity create medical misfortunes ultimately led her to become a crusader.

When her first surgeon refused to do a biopsy of the lump in her breast, Shinagawa insisted on a second opinion. The second doctor was also certain she did not have breast cancer, partly because of her Japanese ancestry. He was shocked when the pathology report came back positive.

Shinagawa entrusted her mastectomy to the first surgeon. He did the operation, without ever saying a word to indicate that his assumption about Japanese American women and cancer had been wrong.

"I thought I was some kind of freak, a statistical anomaly," she said. "My mother - and this still makes me feel so bad - thought it was something that she did."

About a year later, as she was getting involved in advocacy work, Shinagawa began to discover the research that shows a markedly higher cancer risk for Asian American women - as opposed to women who stay in Asia.

It was then that she felt anger and found another doctor for her follow-up care.

Shinagawa decided not to hold her anger in. She became a speaker on cancer, and she serves an adviser to a government research program, spreading the word that Asian women do get the disease. Once, she persuaded her first doctor to do a free diagnostic biopsy for a young woman who was uninsured.

"I don't think my original surgeon was negligent," she said. "But he certainly was not well-informed."


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