A Fatal Miscommunication

On early Friday morning, June 15, 2012, Mai Vo Bor, 37, and her elderly Vietnamese American parents were in a car heading west on the I-10 near Tonopah, about 50 miles west of downtown Phoenix. They were returning from a vacation in California. For some reason, they exited the freeway at 411th Avenue and were involved in a single-car accident about a half-mile off the freeway. The accident resulted in minor injuries to the parents and disabled the vehicle. Ms. Bor left her parents with the vehicle and went to seek help. Tragically, her body was found a mile from the accident scene later that same day. The Maricopa County Sheriff’s Office is still trying to determine if her death was due to exposure, injuries sustained during the accident, or perhaps foul play. Results of an autopsy are pending.

Myself, I don’t need to see a copy of the autopsy report to know the real cause of her death. It was not exposure, accident-related injuries, or foul play. I believe that Mai Vo Bor died due to a language barrier. Sheriff’s officers admit that they could not communicate with her parents because they spoke Vietnamese only. Had they been able to communicate with Mai’s parents, the officers would have almost certainly learned that Mai was on foot somewhere in the vicinity seeking help. Instead, the officers cleaned up debris from the crash, cleared away the disabled vehicle and transported Mai’s parents to the hospital, leaving the 37-year-old woman alone in the desolate area.

It was only later that day around 3 pm that an interpreter at the hospital learned from Mai’s parents that Mai had also been involved in the accident and was still missing. A search team found her naked body a few hours later.

Now, there are many unanswered questions related to this tragedy. Why did the family pull off of I-10 at Tonopah? What caused the single-vehicle accident? What was her time of death? Why was she found unclothed? There are probably a dozen other questions of interest to the investigation. However, I would argue that the most important question is this: Why did the officers not communicate with the parents at the scene of the accident? Do officers have access to remote telephonic language interpretation services? If not, then why not? If so, why did the officers choose not to utilize the system to interview the parents?

This is not to place blame on the Maricopa County Sheriff’s Office. But it is important to emphasize that Asian Americans are the fastest growing racial/ethnic group in Arizona, and 40% are of limited English proficiency. Language access is critically important in the kind of emergency situations faced by our public safety officers on a daily basis. Personally, I hope that Ms. Bor’s death will not be in vain and that the Sheriff’s Office and other government agencies will review their policies, protocols and systems around language access to ensure that all Arizona residents, regardless of language spoken, have equal and expedient access to high quality public services.  It can be the difference between life and death.

- Doug Hirano, MPH, APCA Executive Director

The Loudest Duck Gets Shot: Why Asian Americans are Dying in Silence

A few weeks ago, I had a chance to make a presentation at the Arizona Department of Health Services regarding Asian American health disparities. Thank you to the Arizona Health Disparities Center for inviting me to speak and for coordinating this series of workshops around social and racial/ethnic inequalities in health.

I titled my workshop “The Loudest Duck Gets Shot: Why Asian Americans are Dying in Silence.”  My contention is that a “perfect storm” of factors continues to compromise the political effectiveness of Asian Americans in this country and that the result in at least one case (chronic hepatitis B infection and liver disease, which disproportionately impact Asian Americans) is that Asian Americans are dying unnecessarily.

The “perfect storm” begins with a cultural disinclination to make waves (“the loudest duck get shot” is a Chinese proverb) and a proclivity towards “face-saving” (keeping problems within the family). In my mind, these tendencies continue to allow the “model minority” to also be the “invisible minority”.  Elected officials and government don’t hear from their Asian American constituents, and not surprisingly, little gets done to address a preventable health problem like hepatitis B infection, which is killing Asian Americans on a daily basis.  

Another factor has an historical context. Asian Americans, like other people of color in this country, have a longstanding history of being oppressed and disempowered. For Asian Americans, this marginalization began not long after their entry into this country – beginning with the 1892 Chinese Exclusion Act and culminating in the 1924 Asian Exclusion Act, which for 40 years essentially halted all Asian immigration into the United States. To this day, many American-born Asian Americans are asked, “Where are you really from?” as if we are less than real Americans. Dr. Frank Yu coined the term “perpetual foreigner” to describe this state of marginal Americanism. It’s harder to impact the outcome of a game if you’ve been relegated to the sidelines. 

There are other important factors. Asian Americans are a very diverse group, constituting peoples from the Far East, Southeast Asia and South Asia – many of whom literally don’t speak the same language and some of whom are historically bitter enemies. Building political solidarity among such diverse groups can be challenging at best.

My point is that Asian Americans need to be better organized and more vocal to address their own policy and systems related needs. In this country, “the loudest duck gets fed.” So, again using hepatitis B as an example, in addition to fighting the good fight and trying to scrape together resources to conduct hepatitis B education and screening among Asian Americans (working within the system), we also need to put a spotlight on and work to redress the inequities in overall hepatitis B funding (working the system). HIV/AIDS advocates learned this lesson decades ago, and that is largely why federal HIV/AIDS funding dwarfs viral hepatitis funding (even though far more Americans are infected with hepatitis B and hepatitis C, and far more die from these infections). I would venture to suggest that their advocacy, which resulted in a steep increase in federal investment in terms of HIV/AIDS prevention, screening, treatment and research, has saved hundreds of thousands of lives in the meantime. Asian Americans with hepatitis B infection deserve no less – but we must organize and speak up.

I’ve placed my workshop slides here on our website if you would like to view the full presentation.


- Doug Hirano, MPH, APCA Executive Director

The Weight of the Nation

On May 14th, HBO will be premiering a new a series called the “Weight of the Nation”. The focus of this series is on the epidemic of overweight and obesity in this country.

One of the key themes in this series is that the physical and social environment in which people live has a lot to do with their risk of becoming overweight or obese. This is counter to the idea which suggests that obesity is largely an individual problem related to discipline, willpower and personal responsibility.  

In anticipation of the series premiere, the Washington Post has published a brief interview with one of the series’ primary contributors, Marlene Schwartz, Deputy Director of the Rudd Center for Food Policy and Obesity and Yale University. I’m providing a link to this interview because I think Dr. Schwartz provides a simple, clear-eyed and compelling rationale for focusing efforts on the systems, policies and environments that predispose individuals and communities towards obesity, as opposed for instance to a purely educational approach.
  
I hope that this new series spurs much more dialogue on the matter.

- Doug Hirano, MPH, APCA Executive Director

Asian American Health Research: What Community Agencies on the Front Lines Need to Know

In response to a call for papers on Asian American and Pacific Islander health research, I put some thoughts on paper as to the type of research I think is needed for community agencies like APCA to more effective in its work. The paper, entitled “Asian American Health Research: What Community Agencies on the Front Lines Need to Know,” was accepted last year and has now made its way to print in the Spring 2012 issue of Progress in Community Health Partnerships: Research, Education, and Action. In this issue, I’m proud to be published alongside such friends and colleagues as Dr. Marguerite Ro, Dr. Winston Tseng, and Dr. Simona Kwon, among many others. I was also privileged to do an accompanying podcast related to my article. The transcript of the podcast is also published in this issue. To access copies of articles in this issue, click here.

Doug Hirano, MPH, APCA Executive Director

Reminiscing About the Coming Plague

I recently attended a meeting at the Maricopa County Department of Public Health – ostensibly to review health status data and offer my opinion about the most pressing health issues confronting Maricopa County residents. However, within the course of discussion, I was surprised to learn that dengue fever and malaria are moving northward through Mexico, and both diseases will eventually be taking a toll on Arizona residents. The mere mention of these diseases brought back fond memories and youthful dreams.

As a callow graduate student in public health at UCLA, I had yearned for a career overseas investigating vector-borne diseases like dengue fever and malaria. My professors peppered their epidemiology lectures with stories of their own exploits in exotic foreign lands (one professor, Dr. Telford Work, helped discover West Nile Virus back in the late 1950s), and I imagined myself following in their footsteps.

Indeed, while working in the CDC STD Program, I had the opportunity to interview for a dengue fever epidemiology position in Puerto Rico. I was just certain that this position would jumpstart my brilliant career in global health, and that I would spend a good bit of the rest of my life finding adventure in foreign lands. Unfortunately, I was not selected for the position. I therefore find it ironic that while I never did make it overseas, exotic infectious diseases like dengue fever and malaria are – after all these years – making their way to me.

However, from my perch at APCA, I don’t anticipate playing any role in the fight against either dengue fever or malaria. So, sadly, it would seem that I never will achieve my dream of global health work. Well, not so fast.

The vast majority of people that our agency serves are in fact foreign born and bring to this country a health profile with diverse, global risks. Infectious diseases like tuberculosis and chronic hepatitis B infection are relatively common among new immigrants. So, too, are nutritional deficiencies such as rickets. Immigrants also bring to this country their indigenous conceptions of health. Our understanding of their disease risks, beliefs and behaviors is critical towards effectively working with them on health improvement strategies. As such, our work is partially ethnographic in nature, and we are in a sense cultural brokers of good health. To this end, we often find ourselves thinking globally and acting locally.

So, I’ve come to realize that my dream of global health work is being fulfilled right here in the Phoenix area, and I’m grateful every day for the opportunity to perform this work. And who knows, some day I might just dust off my barely used passport and spend a few weeks volunteering with an international health organization in some far off country. You never know, they might just learn a thing or two from an old global health hand like me.

-Doug Hirano, MPH, APCA Executive Director

A Chance Encounter With a Public Health Icon

This past Saturday morning, our home doorbell rang, and I sprang up with the expectation of greeting someone interested in trimming our mesquite trees or painting our house (both of which do need to be done). However, to my surprise, I found myself greeting Dr. Leland Fairbanks. Dr. Fairbanks is a retired physician well known in Arizona for his tireless work in tobacco control. Indeed, he is a public health icon and one of my local heroes.

He handed me a set of campaign brochures for various candidates for Tempe City Council and patiently explained why he supported each candidate. I listened to him for a bit, thanked him for his information, and assured him that I would be voting in the upcoming election.

We had actually met at an Arizona Public Health Association meeting many years ago, but I don’t believe he remembered me. So, before he walked off, I felt compelled to express my admiration for his past work. But before I could utter anything, he noticed the name on our door (“Casa de Hirano”) and commented that a woman with the last name of “Hirano” used to work on tobacco control with the state health department. I confirmed that my wife Rosalie had directed the state tobacco control program in the late 1990s. He smiled and said to say “hello” and then ambled off to visit with my neighbors.

I recount this story not as a chance encounter with a public health icon, but because I was so inspired that a man in his early 80s was going door to door on a Saturday morning advocating for things in which he believes. If anyone has earned a leisurely Saturday morning, it is he. I promised myself that on Monday morning I would make a few phone calls in support of a hepatitis B funding bill currently under consideration by Congress. Please consider taking a moment in the upcoming week to advocate for something you believe in.

- Doug Hirano, MPH, APCA Executive Director

Suicide among Bhutanese Refugees in United States

What are the risk factors that may be linked to suicidal ideation and/or attempted suicide among Bhutanese refugees to the United States from 2008 to the present?

Since last week, our Nepali speaking interpreters have been busy in helping Center for Disease Control and Prevention (CDC) find an answer to the above question. Since 2008 approximately 35,000 Bhutanese refugees have been resettled in the United State. 16 suicide cases in 10 states have been reported to the Office of Refugee Resettlement (ORR). As our interpreters were undergoing two days training session with the CDC staff, another suicide had been reported to ORR. Considering the pattern in which suicide cases are increasing among the newly resettled Bhutanese refugee population, CDC is conducting “Epi-aid” study in collaboration with Office of Refugee Resettlement and Refugee Health Technical Assistance Center at the Massachusetts Department of Public Health.

A random sample of Bhutanese refugees from four states – Georgia, Arizona, New York, and Texas were selected from which a total of 579 Bhutanese refugees, age 18 and older will be interviewed using a set of pre-designed questionnaire which is about 90 minutes long. After two days of intense training on research ethics, informed consent, questionnaire, addressing difficult situations, distressed respondent guidelines, and role play sessions, our Nepali speaking interpreters are ready to assist in face-to-face interviews with Bhutanese refugees. The study findings will help better understand the underlying causes and associated risk factors for suicide in the Bhutanese community, provide evidence-based guidance on prevention of suicide and reducing emotional distress among Bhutanese refugees, and raise awareness of suicide risk factors and mental health resources to Bhutanese refugees in the United States.

There is definitely the need for linguistically competent and culturally appropriate mental health programs in Arizona to address the issues of Bhutanese refugees and also other individuals who have Limited English Proficiency. With the use of our professionally trained interpreters, Bridging Cultures is in a unique position to help bridge the gap between mental health patients and medical professionals/facilities. Our interpreters, some of who are former refugees, found Bhutanese Suicide Prevention study with CDC very meaningful. We are very positive about the outcomes of this study and enthusiastic about the changes it will follow. Please check back with us for more progress on this topic.

Kamana Khadka, Program Manager, Bridging Cultures