A Global Perspective

A Global Perspective

The gravest health threats facing developing

countries are not viral outbreaks or parasites, but

chronic conditions such as heart disease and cancer.

Professor Collins O. Airhihenbuwa has pioneered a

culturally informed approach to confront the global

spread of these diseases.

BY TONY REHAGEN | PHOTOS BY STEVEN THACKSTON

Collins O. Airhihenbuwa was a graduate student studying health planning and administration in Tennessee when he first realized there was a problem. When his professors talked about health issues facing developing countries, they focused on the income, formal education, nutrition and other resources that these places lacked — and the impact those deficiencies had on the health of the people. But to Airhihenbuwa’s mind, the well-meaning instructors were only painting half the picture.

Airhihenbuwa knew the full scope of life in many of these countries because he had lived it. He had grown up in Benin City, Nigeria, in the 1960s, the son of subsistence farmers. By the standards he was being taught by Western researchers, his parents — who did not work for wages — would have appeared poor, but they farmed their own land and traded for everything they couldn’t grow or make. Scientists might have seen no meat on young Airhihenbuwa’s plate and declared his diet unbalanced, yet his seasonal plant-based diet conferred all the nutritional benefits he needed. Some might have declared his parents uneducated because they lacked formal schooling, without taking into account their organic and practical knowledge and life wisdom, which had been passed down through the culture and community. “Hearing the way my parents’ generation and the people I grew up with were described left me wondering why the focus was on what was missing,” says

Airhihenbuwa. “Instead, I felt we needed to address what was there.”

That realization has informed the past four decades of Airhihenbuwa’s research in global health management and policy. While today the phrases “social justice” and “social determinants of health” are routinely used to describe a way of looking at how a community’s economic and social conditions shape individual physical and mental health, Airhihenbuwa has long been a pioneer in this more holistic approach. He has studied everything from HIV in South Africa to nutrition among African Americans here in the U.S. He has developed a cultural model, known as the PEN-3, that is used in several countries to develop public health programs and address health inequality.

“In public health right now, there are three concepts that are en vogue: health disparities, culture of health and the cultural determinants of health,” says Michael

Eriksen, interim vice president for research and economic development and founding dean of the university’s School of Public Health. “Airhihenbuwa’s work deals with the intersection of these concepts because he’s focused his career on looking at things like poverty and race and education level and their impacts on health. Not just the behaviors, but the root causes that determine that behavior.”

That’s why Eriksen brought Airhihenbuwa to Georgia State, where he will lead a new interdisciplinary team known as the Global Research Against NonCommunicable Disease (GRAND) Initiative. Part of the university’s Next Generation research program, meant to build strength around innovative research that addresses some of the world’s most pressing issues, the GRAND Initiative will look at ways to combat chronic conditions such as heart disease, stroke, cancer, diabetes, obesity, respiratory disease, mental illness and drug abuse and alcoholism — collectively the leading causes of mortality on Earth — through the wider lens of social, structural and cultural determinacy. He and his colleague Nida I. Shaikh, assistant professor of nutrition in the Byrdine F. Lewis College of Nursing and Health Professions, will examine the structures and systems behind individual behaviors that contribute to these widespread diseases, from eating certain foods to failing to seek preventative treatment, and try to better understand them.

“Understanding the social determinants of health is so crucial in understanding global health disparities,” says Airhihenbuwa. “This is the way we’re going to close the gap of inequity.”

Airhihenbuwa first switched his focus from business to healthcare as an undergraduate at Tennessee State University because he thought he wanted to work at the macro level managing healthcare facilities. But as he delved into micro aspects of the field, he found he was more curious about the people behind the numbers.

“I wanted to understand why people die and why they are sick,” he says. “To make sense out of people and their agency.”

Central to Airhihenbuwa’s research is the difference between addressing health disparity and addressing health equity. A popular metaphor imagines a group of fans watching a football game from behind a fence. Some are tall enough to see over the fence, others cannot. Equality means bringing a bench for all to stand on, but though it elevates everyone, some may be still too short. Equity means looking at individuals, sizing up their situation and providing each a riser that allows them to see the game. Researchers like Airhihenbuwa look deeper, to the roots of the structural inequity, and ask: Why do you need the fence? This is the social justice question.

For Airhihenbuwa, the answers always revolve around

cultural context. In the late 1990s, while teaching at Pennsylvania State University, Airhihenbuwa studied the high mortality rate from diet-related diseases among African Americans. Traditional social science rested on the perceived connection between socioeconomic status and the overwhelming availability of cheap and unhealthy fast food in the poorer communities in which many African Americans live. In short, they ate diets high in fat, saturated fat and salt because that’s all that was offered to them.

Airhihenbuwa felt that wasn’t the complete picture. He and his research team began studying African Americans’ eating practices, and found that the participants

How Culture Impacts Health

Airhihenbuwa’s PEN-3 cultural model consists of three domains, each of which include three key factors that form the acronym PEN. The domains are Cultural Identity (Person, Extended Family and Neighborhood); Relationships and Expectations (Perceptions, Enablers and Nurturers); and Cultural Empowerment (Positive, Existential and Negative).

Cultural Identity looks at the potential points of entry for intervention, such as family members, healthcare workers or communities as a whole. Relationships and Expectations evaluates local attitudes toward health problems, including healthcare services, but also the influence of family and friends in nurturing decisions about health. Cultural Empowerment takes into account local beliefs and practices.

PEN-3 CULTURAL MODEL

Cultural Identity

Relationships & Expectations

• Person • Extendend Family • Neighborhood

• Perceptions • Enablers • Nurturers

• Positive • Existential • Negative

Cultural Empowerment

themselves agreed their diets were largely independent of their socioeconomic status. Yes, there was often a dearth of healthy options in urban neighborhoods, but there was also food culture that included nutritious dishes like green vegetables. (Less healthy dishes like chitterlings and pot liquor — or “potlikker,” the liquid in which meat, fish and vegetables has been cooked — are also associated with African American food culture, but these were consumed infrequently.) The study concluded that the structural changes in food availability and accessibility would have to occur in concert with culturally informed individual choices of what to eat.

But cultures are complex webs of customs, beliefs and social institutions that continually evolve, conflict and overlap with one another. How can a researcher decipher the key components that affect an individual’s health? Airhihenbuwa himself was faced with this challenge early on. In 1989, while studying the impact of HIV and AIDS in Africa, he developed a framework to help simplify the process, a model that has helped countless researchers over the past 30 years.

Airhihenbuwa’s PEN-3 cultural model puts culture at the core of the development, implementation and evaluation of public health interventions. (See sidebar.) Since its inception, the model has been applied by scientists in the study of HIV, cancer, hypertension, diabetes, malaria, nutrition and even cigarette smoking. The model is used to provide context, highlighting not only the aspects of a culture that are harmful to health, but those that are positive to health, including the people, structures and traditions that are benign or beneficial in unconventional ways.

“It helps me set aside my own biases and, at the same time, not be overwhelmed by the fact that I have biases,” says Chandra Ford, a professor at the University of California – Los Angeles Center for Health Equity, who studied and collaborated with Airhihenbuwa at Penn State. “PEN-3 helps us address our own fallacies. It helps us realize that even when we show up meaning to do good, we bring assumptions that can harm communities. It’s almost radical in public health. We usually view everything through the lens of the problem. But the first ‘P’ in PEN is not ‘Problem,’ it’s ‘Positive.’”

“You can’t just go into a culture and look at the negative and ignore everything else,” says Airhihenbuwa. “When public health practitioners work with a population that has been studied heavily, they need to be mindful that although there might be an expectation to provide a solution, every individual, family and community has something beneficial going on, something unique. If we can work through the process and identify the positive qualities, we’ll be more likely to get positive results.”

Chronic diseases such as cancer and heart disease have claimed the majority of lives in affluent countries like the U.S. for decades, but they are rising fast in developing

By 2030, more people in the developing world will die from chronic conditions than from infectious diseases.

Source: World Health Organization

countries — and striking younger populations. Almost three quarters of all deaths from non-communicable diseases (NCDs), and the majority of premature deaths, now occur in low- and middle-income countries, according to the World Health Organization (WHO). Some of the reasons behind the global rise of NCDs are positive: people are living longer thanks to improved sanitation, wider access to vaccines and progress in fighting infectious diseases like malaria. Others are less so: Urbanization often leads to increased air pollution and more sedentary lifestyles. The diseases also tend to produce worse outcomes in poorer parts of the world. A 2014 report from the Council on Foreign Relations notes that NCDs that are preventable or treatable in developed countries are often death sentences in developing countries. As a result, there’s an urgent need for public health interventions that can be effective across cultures. The GRAND initiative will work to develop a thorough and holistic approach to reducing the global impact of chronic diseases. It’s easy to see why Georgia State tapped Airhihenbuwa, who was previously dean of the College for Public Health at Saint Louis University, to head up the initiative. In addition to the invention of the PEN-3 model, he’s had stints as a visiting scholar to United Nations agencies like the WHO and has served on the board of Scientific Counselors for the Centers for Disease Control and Prevention.

“Across the globe, our major health problems have shifted from infectious diseases to chronic diseases,” says Eriksen. “Yet at the same time, places like Africa are still dealing with infectious diseases like malaria and Ebola. We need to work upstream to affect behaviors, and that’s the area where Airhihenbuwa has a unique ability to contribute because of his understanding of place and culture as determinants of that behavior.”

While the School of Public Health will lead this initiative, faculty from Georgia State’s Andrew Young School of Policy Studies, Byrdine F. Lewis College of Nursing and Health Professions and the College of Arts and Sciences will collaborate and offer expertise. “Chronic diseases are expressions of inequities in society,” says Airhihenbuwa. “What we want to do in GRAND is to focus on the sources of those inequities by examining issues of structural racism and cultural contexts. That way, we can design and sustain interventions that work at the local and global levels.”