The development of a community-based integrated health care system for the San Francisco Chinese community.

Author:Chow, Edward A.
Position:9D Paper

(Original Title: Accessing Culturally Competent Health Care in the 21st Century)

Much has been written about the experience of the Chinese in America. However, there has been little consideration given to how the Chinese obtained health care. The early immigrants came with their own Eastern traditions, but how the Chinese were able to gain access to Western medical care in the largest Chinese settlement in America is an important part of the history of the Chinese. The history of Chinese medicine goes back centuries, perhaps millennia. (1) How those who were raised in one medical system would accept another medical system, and how they would gain access to Western medicine in an environment of discrimination are exemplified in the development of the Chinese Hospital and its integrated medical system.

Of the approximately 12 million Asians and Asian Americans living in the United States, the Chinese comprise the largest ethnic group (2.4 million), with heavy concentrations in large metropolitan areas such as New York, Los Angeles, and the San Francisco Bay Area. The city of San Francisco is home to approximately 152,000 people of Chinese descent, approximately 20 percent of the city's population. (2) The characteristics of San Francisco's Chinese population differ from the city as a whole. Significant segments of the local Chinese population in San Francisco struggle financially and educationally due in part to San Francisco often being the first port of entry for immigrants and a comfortable enclave for the elderly. On average, the Chinese of San Francisco tend to be less educated, have a larger proportion of elderly and youth, and have lower average family incomes than the general population. Over 108,000 of San Francisco's Chinese are foreign-born, with about 50 percent of this group having limited English proficiency. Among the Chinese aged sixty-five years or older, nearly 70 percent speak English poorly or not at all. Many struggle financially, with 20 percent of Chinese households having an annual income of less than $15,000. Chinese households are also less likely to have an annual income greater than $75,000. Additionally, the average Chinese household is larger than that of whites, so that the financial resources are spread more thinly within their households. In comparison to the general San Francisco population, more Chinese lack a high school diploma and fewer attain a bachelor's degree or higher level of education; in fact, 25 percent of the adult population have less than a ninth grade education. This is largely due in part to the disproportionate number of older Chinese who are less educated than their younger counterparts. These conditions affect their ability to gain access to the Western health care system. (3)

While the history of the Chinese in California, specifically San Francisco, is relatively well known, the history of their access to health care is not as often discussed. Chinese immigrants were systematically excluded from participating in social and political institutions in San Francisco and California. A variety of taxes were unfairly levied upon the Chinese, ranging from discriminatory mining and laundry taxes to taxes funding public education despite institutional dental of access to public education. (4) Chinese immigrants were also denied the opportunity to obtain American citizenship and therefore the right to vote and influence policy as well as the right to testify in courts. Chinese immigrants were required to pay a hospital tax upon entry into San Francisco. Despite their monetary contributions, they were denied access to San Francisco City and County Hospital. Yang recounts several examples of Chinese individuals being refused admission to the City and County Hospital even with seemingly medically severe conditions, for example, pulmonary tuberculosis. Between the years of 1870 and 1897, there were never more than thirty-four Chinese admitted to San Francisco City and County Hospital in any given year, even though the city's Chinese population exceeded 8,600. (5) While the Chinese comprised 5 to 10 percent of the population of San Francisco, Chinese patients made up less than 0.1 percent of total admissions to the hospital.

Exclusionary practices of the hospital and the San Francisco Board of Health only partially explain the low admission rates of Chinese during this period. The distance from Chinatown made it inconvenient for Chinese to seek care from the hospital; additionally, travel to the hospital made individuals susceptible to violence such as rock throwing, assault, or mob violence, which were not uncommon during the period. Additionally, linguistic barriers made communication and the clinical encounter difficult to navigate. (6)

Chinese physicians and their traditional practices were often the preferred sources of care for Chinese...

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