News of the patient who died at Montefiore’s Family Health Center in the Bronx — and whose body wasn’t discovered until five days later, as POLITICO reported last week — shocked New Yorkers and national audiences alike. The body of 57-year-old Sary Mao, a Cambodian resident of the Bronx and longtime member of advocacy group Mekong NYC, was found in a stairwell at the facility following reports of a foul odor emitting from the fifth-floor emergency exit.
“We are heartbroken … She was very much a part of our health justice campaigns,” Khamarin Nhann, campaign director of Mekong NYC, told Epicenter-NYC via email. “Our work is around addressing root causes and figuring out how we create more accessible services and resources … This is a health justice issue that impacts all communities of color.”
While the focus has largely been on the circumstances around finding the body, Epicenter-NYC looked into Mao’s official cause of death, how prevalent it is among particular communities and systemic barriers experts say health care systems should work to address.
The inequity issue with the “silent killer”
Mao died from hypertensive cardiovascular disease (CVD), according to the office of the chief medical examiner. Known as the “silent killer,” as people may show no symptoms, it’s one of the top causes of sudden death in the United States. Nationwide and citywide, it also disproportionately affects Blacks, Hispanics, and Asians as compared to non-Hispanic white people. It’s harder to control blood pressure among all non-white groups, based on factors that range from diet and physical activity to a greater prevalence of obesity and ethnic and racial differences in regard to salt sensitivity. These ethnic groups are also more likely to die from hypertensive CVD.
People of Asian descent in the U.S. are less aware that they even have high blood pressure, according to a large national study. This is true even though Asians and Asian Americans have the highest health insurance rates of any racial or ethnic group in the U.S. and receive treatment at rates comparable to white people. Similar to Latinos, language barriers among Asians might be a big factor explaining their lower rates of awareness and control of their blood pressure, researchers say.
Yet another factor are lower rates of health literacy, which are common in the Southeast Asian immigrant population, and “can impede individuals from comprehending CVD risk factors, preventive measures and the effective management of chronic conditions,” according to Bei Wu, the vice dean for research at NYU Rory Meyers College of Nursing. “This challenge is further exacerbated by language barriers and cultural nuances.”
The problem with hypertensive CVD among Cambodians
Among Cambodians in the U.S., limited medical literature shows that they have high rates of hypertension and cardiovascular-related deaths, including stroke.
Some experts think the CVD-related deaths might have to do with the long-term effects of Cambodian refugees’ starvation and malnutrition during the Pol Pot regime in the 1970s and while in refugee camps. Pol Pot forced millions of Cambodians living in cities to work on communal farms in the countryside, leading to starvation, disease and exhaustion from overwork. Babies born to malnourished mothers may be at higher risk for insulin resistance as adults, which can lead to diabetes, which can raise someone’s blood pressure.
There may also be a psychological aspect to malnutrition and long-term starvation that Cambodians and other refugees experience, some researchers say. Overeating has been linked with stress and coping mechanisms for these groups. This, in turn, can complicate efforts to prevent and manage diabetes — which, again, can contribute to hypertension.
Unlike the case with Koreans in the U.S., most studies show that health insurance coverage isn’t the biggest barrier to health care access or good cardiovascular health for Cambodians. Across the board, a lack of transportation, low levels of health literacy and severe language barriers among Cambodians show up as key obstacles. In the case of Khmer-speaking Mao, advocates raised questions around language access about the “emergency exit” sign at the facility, which was printed only in English.
The hyperlocal problem with hypertension: Cambodians in the Bronx
We know even less about the cardiovascular health and health care of Cambodians in the Bronx. There’s this, though, from the largest recent study on Cambodians in the Bronx: Among those 18 years and older who participated in 97 surveys from 2004 to 2007, one in five reported they had hypertension. But only one out of three with hypertension had received any counseling or education on how to manage their condition.
What’s more, less than half of Cambodians in the Bronx who were surveyed had ever checked their cholesterol. High cholesterol can cause high blood pressure, as cholesterol plaque can make arteries hard and narrow, making it that much harder for the heart to pump blood through them. Either high cholesterol or high blood pressure can cause heart disease. Thirteen percent of Cambodians in the Bronx who were surveyed said they had high cholesterol. Only half of those had received any counseling or education about the condition.
About 34% of Cambodians in the Bronx who were surveyed also knew someone in the community with another hypertension-related factor: diabetes.
The dearth of culturally sensitive programs to manage chronic conditions is one compounding factor that disproportionately impacts local Cambodians and other Southeast Asian groups, said Wu.
Nhann agreed, citing the challenges of Mekong NYC’s community of Cambodian and Vietnamese refugees and immigrants: “We come from a history of war, violence and genocide, so there are higher rates of mental illness, PTSD, depression in addition to other health disparities,” he said. “Access to quality health care services is important. We need to address in a holistic approach that is inclusive of the community and culture that [we] come from.”
What solutions do experts recommend?
Some of the unmet cardiovascular health care needs facing Cambodians in NYC highlight clear recommendations:
Improve language access
The huge role of language barriers suggest medical interpretation and educational materials on hypertension, high cholesterol and other specific conditions in Khmer and other Southeast languages would go a long way to improve the quality of health care education. The current New York State Department of Health (NYDOH) language access plan for limited English proficient people includes only one resource in Khmer: a 58-page guide for parents on early intervention for children under 3 years old who may have a developmental delay or disability.
Leverage lived experiences
Educating staff on the Cambodian community’s history, culture and experiences as refugees could also help address key gaps in understanding, experts say. Hiring community members as staff would leverage shared experiences with local Cambodians.
Raise awareness of community resources
Researchers are at work to help policy-makers, medical and public health professionals and the general public better understand issues on cardiometabolic diseases among Asians in the New York-New Jersey metropolitan area. The Rutgers-NYU Center for Asian Health Promotion and Equity, where Wu is a co-principal investigator, is one such regional research hub.
Community advocacy organizations like Mekong NYC have been fighting for more equitable health care access for Southeast Asians in the Bronx and throughout New York City. Among other services, they provide Khmer and Vietnamese interpretation, resources on the health status and needs of Southeast Asians, and support through the NYSDOH patient navigator program.
Epicenter-NYC’s own on-the-ground efforts in understanding and helping neighbors better navigate food pantries in Queens is part of a larger initiative to support food justice. Lack of access to nutritious food is one of many factors that contribute to cardiovascular health disparities among refugee, immigrant and other racial and ethnic groups that have been historically underserved. Read more of our food justice work here.
This is part of a series of articles exploring health inequities in New York that is funded by a grant from the Commonwealth Fund.