The COVID-19 pandemic has highlighted longstanding disparities and inequities in healthcare access and outcomes, specifically for minority groups in the United States. Dr Jean Balestrery is an interdisciplinary scholar–practitioner advocating for healthcare equity amongst culturally diverse groups, particularly among American Indian/Alaskan Native peoples and LGBTQ+ communities. Through extensive ethnographic research, Dr Balestrery highlights the conflicts, pains and tensions emergent upon historical traumas and structural inequities that create poor health outcomes. The research understandings offer hope for a new perspective on overcoming health disparities through a collective commitment to cultural humility, structural competency and intersectional alliances in finding solutions to health crises.
Dr Jean Balestrery’s career as an applied anthropologist and behavioural health clinician has spanned research, teaching, practice, and advocacy for equitable healthcare amongst culturally diverse groups. She has worked extensively with American Indian/Alaska Native (AIAN) peoples and LGBTQ+ communities along her career journey, which has led to identifying significant healthcare inequities. These inequities have far-reaching implications for access to life-preserving healthcare on an ongoing basis and within crisis-emergency situations, particularly on Indigenous tribal lands. Against the backdrop of these longstanding inequities, the arrival of the COVID-19 pandemic on the global emergency health stage has served to further highlight and accentuate these inequities and the need for urgent change.
Healthcare access
Balestrery personally experienced the lack of emergency healthcare services on the AIAN tribal lands in the Grand Canyon after suffering a hiking accident that resulted in the near loss of her foot. Within the Grand Canyon lies an eight-mile hiking trail to the Hasavu Falls set on the Havasupai tribal lands. This destination annually attracts 25,000 tourists and generates millions of dollars in revenue. Yet, Balestrery endured gaps in care including no emergency protocol, inadequate medical attention, and missing social worker support at this site. The realisation of these gaps while waiting for an emergency medical evacuation reinforced Balestrery’s awareness of the longstanding and enduring inequities in access to healthcare among AIAN peoples on tribal lands with whom she has worked for many years.
JJava Designs/Shutterstock.com
Zooming in on health inequities
The COVID-19 crisis hit people and nations globally in 2020, prompting not only a public health emergency but also an economic and mental health crisis for many peoples across the world. Balestrery explains that nowhere was this more profound than for groups already at a disadvantage on the healthcare and economic terrain. Many of these people did not have the option of staying home and staying safe.
How does it happen that people remain without direct access to emergency health and economic funding, despite revenues and funding flowing around them? To understand this, we first need to acknowledge the roots of structural determinants that impact everyday individual and social lives and result in poor health outcomes across the lifespan. Structural determinants of health are often embedded in governance systems that inflict historical traumas on groups of people and continue to impact intergenerational health. The study of intergeneration trauma has become an increasing area of specialisation in social work, with the emergent understanding of these linkages enabling a trauma-informed approach. This approach illuminates the systems or structures that give rise to health disparities and result in poor health outcomes. For the AN peoples, these health outcome disparities include higher death rates compared to the US White population for nine out of 10 of the leading causes of death in the US, namely pneumonia/influenza, cancer, heart disease, chronic obstructive pulmonary disease, chronic liver disease, unintentional injury, alcohol abuse and suicide. Institutional policies, procedures and resource allocation, including those of tribal governments, continue to impact economic development and access to economic and healthcare resources.
“These health outcome disparities include higher death rates for nine out of 10 of the leading causes of death in the US.”
Balestrery has conducted extensive ethnographic studies in Alaska amongst the major Indigenous cultural groups, which include the Inupiaq, Athabascan, Yup’ik and Chup’il, Aleut and Alutiiq. Each of these groups is culturally unique in their languages, practices and histories. The AN tribes make up close to half of the 567 federally recognised tribes in the US. The researcher says that the work undertaken with her collaborators has revealed several factors relevant to understanding persistent health disparities among AN peoples. These factors include emergent cultural disjunctures across all levels of intervention, which influence interpersonal communications and relationships within care-service settings. Cultural oppression and severance of social support networks as sources of care have also impacted the emergence of social and mental health issues, including domestic violence and substance use. The enduring impact of these circumstances for many diverse cultural groups continues to place many people at risk for poor health outcomes, even though the US has made it a priority to eliminate health disparities.
Braided rivers symbolise the integration of diverse knowledge systems, for example to support intercultural healthcare. melissamn/Shutterstock.com
Collective effort
As nations tackle the health and economic crises and consequences of the COVID-19 pandemic, Balestrery points out that effective solutions to the public health crisis and achieving health equity requires collective effort. Balestrery states that as collective humanity, we have come to recognise through the pandemic that we are interdependent. Consequently, we all need to be part of the solution.
She proposes that overcoming poor health outcomes rooted in trauma requires establishing collective alliances that overcome divisions among diverse cultural groups. She points out that this requires ‘building bridges across lines of difference’, which in itself requires ‘courage, commitment and collaboration’. Without this, the resilience needed to overcome the challenges facing humanity as a collective will remain weakened. This extends not only to physical disease outcomes, but also concomitant mental health outcomes associated with crises and traumas.
The pandemic has highlighted constraints in access to healthcare and healthcare resources. AIAN peoples have for a long time faced these challenges, made obvious by the fact that the need for health and social care among Indigenous peoples and communities has far exceeded the Indigenous care service resources available. These resource constraints have included not only emergency medical care services but also AIAN services geared to meeting the mental health needs of Indigenous communities. As a result, care services on offer are often constituted by diverse perspectives and paradigms, both in relation to the actual care service and the broader organisational operating procedures of the care service. Arthimedes/Shutterstock.com
This cultural diversity within care services takes place alongside the globalisation evident in the changing geographic and socio-political context of AIAN peoples. Balestrery points out that geographically, AIAN tribal lands comprise mixed populations with a large proportion of non-native outsiders living in Alaska native villages and on American Indian tribal lands and reservations. Additionally, about 78% of AIAN peoples live outside these areas. For those seeking care services across these diverse contexts, inevitably the services accessed are culturally pluralistic.
These culturally pluralistic settings contribute to a range of emotions such as pain, confusion, and hope, linked to generational pain, prejudices, relational wounding, value systems clashes, and different healthcare models. Balestrery, however, also sees within this blending of diverse cultures in care settings an opportunity for healing a legacy of colonial histories that impact health outcomes. According to Balestrery, this requires collective effort that moves at the speed of listening and co-learning; it will occur by rethinking, reimagining, and restructuring care services. Expanding our perspectives and integrating diverse knowledge contributes to a vision for the creation of a collective future of equitable health determinants and outcomes.
What cultural values inhibit and support the building of equitable health services?
There are some value differences between diverse cultural groups and mainstream health and human services in the US. These include differences associated with scale and scope: the typical unit of focus and what constitutes health. For example, while many cultural groups have a collectivist worldview, mainstream health and human services in the US have an individualistic worldview. These worldviews are correlated with different explanatory models of the illness experience. For example, Western biomedicine can produce a dichotomy between disease as biology and illness as culture. This differs from a more holistic view of health. Developing intercultural health and human services that integrate multiple knowledge systems supports the building of equitable services.
Balestrery, JE, Going, H, Pacheco, R, (2020) Tribal Leadership and Care Services: ‘‘Overcoming These Divisions That Keep Us Apart’. Health and Social Work. doi.org/10.1093/hsw/hlaa018
Balestrery, JE, (2016) Indigenous Elder Insights About Conventional Care Services in Alaska: Culturally Charged Spaces, Journal of Gerontological Social Work.doi.org/10.1080/01634372.2016.1206649
Balestrery, JE, (2017) History of the LGBTQ Movement and Community. In MP Dentato (ed), Social Work Practice with the LGBTQ+ Community: The Intersection of History, Health, Mental Health and Policy Factors. New York: Oxford University Press [2nd edition forthcoming] bit.ly/30TRKuR
Balestrery, JE, (2012) Intersecting Discourses on Race and Sexuality: Compounded Colonization among LGBTTQ American Indians/Alaska Natives. The Journal of Homosexuality. doi.org/10.1080/00918369.2012.673901
Dr Balestrery studies the impact of cultural, social, and structural determinants on care services and health outcomes across the life course relevant to equity-seeking groups.
Funding
Dr Balestrery’s research has been funded by community foundations and university grant mechanisms.
Collaborators
Equity-seeking communities
Bio
Dr Balestrery is an interdisciplinary scholar–practitioner in social work and anthropology with years of clinical practice experience. She collaborates with equity-seeking groups to improve care services and health outcomes across the life course. Dr Balestrery is a Spirit of Eagles Hampton Faculty Fellow and has national committee appointments advocating for LGBTQ+ rights.
