African-Americans have the highest death rate from breast cancer of any racial or ethnic group in the country.
In part because they're not getting diagnosed early enough. Fear keeps many from seeking screening. There aren't any African-American Nancy Reagans or Olivia Newton-Johns to reassure black women that you can lose your hair and it will grow back or lose part of your bosom and emerge just as sexy, loved, and confident as ever.
Religion is also an effective barrier in some communities, according to medical anthropologist Deborah Erwin. Twelve years ago she heard an elderly woman announce, "If God wants me to have a mammogram, he'll tell me!" Erwin decided then and there to work through the churches. Katherine Jahnige, MD, community outreach coordinator for the Siteman Cancer Center and director of the Witness Project in St. Louis, points to the Christian tradition of "claiming," which, in biblical terms, means you can speak something into reality (for many believers that translates into: Talk too much about breast cancer and you'll get it).
Latinas over 40 are the least likely of any group to have mammograms, according to the Society for Women's Health Research in Washington, D.C.
The biggest obstacles are lack of insurance and legal documentation, but some barriers are emotional. Sister Concha De La Cruz, a 62-year-old nun and pastoral minister for the Hispanic community of St. Louis, remembers growing up with other Mexicans in hot, dusty, Spanish-speaking El Paso. "Many Mexican women do not trust doctors to this day," she says. "They prefer to use herbs. And there used to be a culture of extreme modesty—'Nobody can look at me, nobody can touch me.'" For her generation, in fact, virginity was such a fragile treasure that even a doctor's gynecological exam was shunned lest it compromise a woman's purity.
"That is changing," Sister Concha says with relief, although some women do confide in her about husbands so macho they don't want their wife's breasts examined. Sister Concha sighs heavily, remembering how her own father refused to take her mother to the doctor. "He was extremely jealous. If the doctor wanted a follow-up appointment, he would say, 'Well, the doctor's fallen in love with you.'"
Asian-Americans often forgo mammograms because they don't see breast cancer as a threat.
Back home, that may be true: Rates across Asian countries are extremely low. But according to the National Asian Women's Health Organization, by the time an Asian woman has been in the United States for one decade, her risk of breast cancer has increased by a whopping 80 percent.
Katherine K. Kim, PhD, professor emeritus of nursing science at Grand Valley State University in Allendale, Michigan—who herself recovered from breast cancer decades after emigrating from Korea—has researched other barriers that impede Asian-Americans from getting screened and treated. There's a real fear of social stigma—the worry that should a woman be diagnosed with breast cancer, her husband will leave her or the community will shun her. Kim also found that extreme modesty often plays a large role—many of these women are too embarrassed to undergo an examination.
"The idea of prevention is pretty Western," says Bogomolov. "If you believe your life has been preordained from the moment you were conceived, the disease is either going to occur or it's not. All we can do is show that the interventions being offered are on their life path.
Barbara Bogomolov, who directs refugee health services for Barnes-Jewish Hospital in St. Louis, is strategizing how to reach her observant Muslim patients from countries like Afghanistan and Pakistan who find mammography an affront to their understanding of body modesty. One idea: Train those already permitted into their homes—for example, nuns who teach English—to talk about mammograms and breast health. Another plan is a mammography van completely staffed by female technicians who will stress that mammograms are necessary to keep a woman healthy and pure before Allah.
When Jackie Nolte, who is part Cherokee, was diagnosed with breast cancer three years ago at the age of 54, she found herself angered by the prospect of chemotherapy. "I could not give the white people my hair," she muttered.
At Las Fuentes Health Clinic, Gynecologist John Molina's Native American patients remind him daily that what Western science calls fatalism is, to them, simply acceptance. "Breast cancer doesn't even faze them," he remarks, "because they feel that whatever happens will happen." So screening carries no urgency.
Intense modesty makes it unlikely that these women would ever perform a breast self-exam, says Molina. "They don't even like talking about breasts much less feeling them." He adds that Apache, Hopi, and Navajo women will see healers before medical doctors. "What finally brings them into the clinic is pain. By the time you get pain, it's an advanced cancer."
While the incidence of breast cancer among Native Americans is lower than that of other groups, the mortality rate in some parts of the country is higher, according to available research. Molina suggests that health care providers might do well to learn who the healers and elders are in the community and work through them.
Jeannette Batz Cooperman, PhD, has written for the Utne Reader and Glamour.