Essays, poems and Stories of an African-American

Thursday, 30 May 2013

Summer happy go round



The warm and humid weather sent warm and dense air down our lungs. The concrete and glass buildings gave off a glare that hit the eyes and skin with a slightly scalding heat-wave. Most of the people out in the commons of the City Hall were topless or shirtless or putting on something that kept them decent but also kept the sun away in a way. There were very few people in the library and the air-conditioning gave a cool air. Yesterday between 12 noon and 4 pm around the smoke-break lounge there were around 20 smokers and the bicycle rack had over 12 bicycles locked firm. Today and at the same time between noon and 4 pm, the library was almost empty but outside people were loitering or resting in shades of many kinds from tree-shades, umbrellas or in-doors. I was seeing summer (it is my second in the USA, but not my first summer outside Africa. I came to USA at the tail end of last summer as well). This far north from the Equator and in a society that has seen and documented the different weather changes, I kept on wondering how this would play out in an African setting. I know that here, in the ‘west’ a season is given a name basing on three or four factors: the sun; wind; condition of ground and; reaction of this to the people’s social interactions. In Africa, most especially my own culture the seasons are named by what is produced and what cannot be produced. The crops or vegetation are the major factors that influence the naming of a season. I most certainly believe summer would be given a name with a literal meaning of ‘non-will-not-show-their-bare-teeth’ or ‘the laughter-signs-on-the –cheeks', given the fact that spring is also harvest time for some crops or 'kick-the-bed-covers-off ' given the discomforting heat at night.  Harvest time brings laughter but the promising and permanent warmth of the sun brings permanent smiles. Or because there are now more flying insects that are a nuisance around the eyes and ears, they could have such a name: 'restless-arm,' given the fact that one is always waving away the winged ones.  Anyway, summer has shown off its early days now. Today is one of those very first days that announce summer is here. I am so happy and look at this as a rite of passage for me. I have been here; I have seen it and live it one day at a time.

Monday, 27 May 2013

Long term effects of low activity and risky nutrition practices among New Americans from East Africa: Implications for Endocrinology and Population health planning.

Summary

INTRODUCTION: According to the UN Special High Level meeting on global non-communicable diseases, high fat diet, inactivity and substance abuse are risk factors. These exacerbate events for cardio-vascular (CV) diseases, lung diseases, hormonal deficiencies, obesity and cancer. Medical check-ups make it possible for earlier diagnosis of CV risk factors. Physical exercises help reduce CV risks. Early, timely and regular medical check-ups, active lifestyle, moderate use of alcohol and non-smoking help in timely diagnosis and management of metabolic-syndromes. This study sought to gauge these levels of activity, risk-factors and attendances for medical check-ups among ‘Ugandan-in-America’. By ‘Ugandan-in-America’ is meant, a person of Ugandan descent who has stayed in USA for 6 months to 20 years or beyond.

METHOD:  Using key informant interview and observation guides, 3 categories of Ugandans in America were followed for 7 months from August 2012- Feb 2013.  The breakdown is as follows: 70 were above 50 (32 females: 38 males); 100 were between 30-40 years (52 females: 48 males) and; 20 who were between 15-22 years (15 males: 5 females). The states visited were Illinois, Massachusetts, California and Texas. 

FINDINGS: In the past 12 months, 30 (thirty) respondents had gone once for a medical check-up: 12 were above 50 years; 7 were between 30-40 years; 10 were between 15-22 years. 22 (22-30 years) had accessed ante/post-natal services. 12 (3 males: 9 females) chronic care and for anti-hypertensive medications. 2 males (19 & 23 years) accessed cancer treatment services regularly. 22 (2 were above 50 years and 20 were below 36 years) had engaged in a regularized physical fitness activity. 65 continued taking OTC pain relievers. All 190 had attended a Ugandan-led social gathering. 12 deaths related to end-stage heart disease and 2 from sickle-cell-anemia were noted.

“I do play soccer and am on the school soccer team. We are 4 children and our parents have bought membership for us at the local YWCA. My father and mother are members too but they never come to exercise. I do attend social gatherings organized by Ugandan-Americans” [Key Informant, 15 year old teenager.]
Conclusion: Efforts to encourage ‘Ugandans-in-America’ to adopt lifestyles that promote quality life in USA are possible through their peer networks. These act as primary mobilization platforms for population health services.




Introduction:

Two factors; ‘low activity’ and ‘risky nutrition’ used in this paper are based on experiential initiatives by respondents. They, however, are not the only factors hindering access to health services and adoption of practices that help prevent endocrine-related illnesses in Ugandan-American. When it comes to non-communicable diseases, integration of prevention initiatives should be combined to target endocrine, tobacco[i] and alcohol-related morbidity and mortality. The term ‘activity’ in this paper covers: personal initiative to seek out a health care provider; engaging in exercise; to ensure foods or ingested substances are healthy and; joining health clubs or support initiatives. As a new comer demography, Ugandan-Americans can use their households (see table 2) or community meetings to promote a culture of scheduled weight control. This can be an entry point into encouraging various forms of positive adherence. Uganda is one of the countries in Africa. It is on the eastern side in an economical-geopolitical zone called East-Africa. Ugandans are ‘new-comers’ in USA (In this paper the terms used interchangeably are: Ugandans-in -America or Ugandan-Americans. The terms are not in the same sense as that of the United States Citizenship and immigration services. They are used to provide insight into real-time physical address). Being new, Ugandan-Americans need support and empowerment to access or afford social services such as, health. This calls for adopting behavior, dedication and re-education to understand the USA targeted health objectives. The conceptual approaches of family medicine[ii] that promote a beneficial relation between doctor-patient should be explored as an entry point for many Ugandan-Americans who may not be familiar with demanding, access and utilization of US health services.  Medicine in the 21st Century has been, and continues to be a life preserving influence. Life preserving practices are prescriptive and self-executed based on informed choices, affordability, proximity or peerage. The US has high quality medical services with a variety of choices. These choices include: accessing screenings, vaccinations and counseling with/without co-payment, co-insurance or deductible. Depending on one’s age, and at no cost, it is possible to access: blood pressure, diabetes, cholesterol, various cancer screenings, mammograms, colonoscopies consequential counselling according to age and lifestyles, life planning skills, nutrition counselling, weight control, well-baby, well child-visits from birth to 21 years of age, routine vaccinations, ensuring healthy pregnancies, pneumonia and flu shots. In order to enjoy the health benefits it engenders adherence to efforts such as, routine visits to a health-care provider. By taking an initiative to talk to one’s health care provider, one not only receives healing, hope and compassion but information on covered preventive services[iii]. In this case, one would expect universal, timely and regular health-seeking behavior. However, this is not the case for Ugandan-Americans as this paper attempts to show. Medicine as a service is now packaged and quantified in means that make it user-friendly. The risks and benefits are now communicated with the patient or client in mind. It makes it easier for a potential patient or client to engage in negotiations for critical and prospective choices[iv]. In this paper, we show that for the average Ugandan-American, translating health benefits into life preserving practices is still elusive.  This paper was prompted by the 12 deaths related to end-stage heart disease and 2 from sickle-cell anemia that occurred during the same period of study. Medical intervention was sought in all cases but, it was sought at a late stage. There was an expressed opinion that the ‘costs’ are exorbitant. Costs can be higher if one waits longer to see a doctor; in such a situation a visit to the outpatient department may end up into hospitalization. Efforts will be taken to quantify the influencing factors, deterrents and enablers for Ugandan-Americans to prevent and control metabolic syndromes. Risk factors for alcohol and tobacco-related morbidity and mortality will be highlighted. Knowledge that alcohol, tobacco and endocrine-related diseases are ‘silent killers’ has not been translated into Ugandan-American life preserving lifestyles. The ‘silence’ means it is unseen, is not clear and of no threat. This being the case there was no need to plan for it.  These silent killers are in form of: cardio-vascular (CV) diseases, lung diseases, hormonal deficiencies, obesity and cancer. Ugandans-in-American need to establish community structures to address health issues. They need to understand that non-communicable diseases are common causes of illnesses and death. This can be in adults and children. The various aspects of US Health policy and school health system are helping in ensuring school-age children access health care services. The immunizations and routine check-ups were adhered to.  The housing, education, education and social protection for families point towards lowered rates of child deaths. There were cases of congenital anomalies receiving adequate treatment. It was not possible to check out a large number of children to know extent of causes of morbidity and mortality in children.  Child morbidity and mortality data list: injuries and poisonings; neoplasms; circulatory diseases; digestive diseases; respiratory diseases; infectious diseases; neurological disorders and; congenital anomalies[v]. If opportunity allows health aspects of children born to Ugandan-Americans will be investigated in future. Marked characteristics among adult Ugandan-Americans who formed the bulk of respondents for this study were observed between:  the recent comers (below 2 years’ stay in USA) and; those who have stayed here more than 2 years. Ugandan-Americans who had stayed longer in US negotiated health better. There were those who were formally employed and had insurance cover and; others whose jobs or work schedule did not allow them time and space to seek medical check-ups. It is in the latter group that the more risky practices such as: low or no annual medical checkups, high fat diet, high salt ingestion, self medication, use of pain-reliever OTCs, low morale for sports and marked substance use were found. These are risk factors for non-communicable diseases[vi]. Medical checkups are an opportunity to initiate interventions in case any form of infection, illness, anomaly or malignancy is detected. It reduces on missed opportunities to break a cycle that would lead to debilitation, acute or chronic situations. There are opportunities for mobilization of Ugandan-American community members to embrace cultural tools engendering change towards quality life in USA. According to the Ugandan-North American Association (UNAA), there are over 100,000 adult Ugandans in USA who have interacted or attended UNAA sponsored meetings since its inception. This is one medium of mobilization that needs tapping into.

Methods:

This is a qualitative study using an observational checklist and a key Informant Interview guide.  It was possible to get structured answers to posed questions from identified respondents. Children helped in corroborating information around nutrition and exercising as this statement from a 15 year old teenager shows: “I do play soccer and am on the school soccer team. We are 4 children and our parents have bought membership for us at the local YWCA. My father and mother are members too but they never come to exercise. I do attend social gatherings organized by Ugandan-Americans.”
 Key questions prompted conversation around health, diet, work, sleeping patterns, diet, exercise, visits to health facility and recreation. Participation and immersion in various Ugandan-American communities at different locations in four (4) states of America with large populations of Ugandans increased on representativeness.

Study Population:

There are social patterns unique to Ugandan-Americans. Some include: showers, social meetings, entrepreneur conferences and faith-based meetings. These meeting spaces provided the bulk of respondents and subsequent focused discussion was possible from these first time encounters. This study was done in 7 months from August 2012- Feb 2013. 190 respondents were followed: 70 were above 50 (32 females: 38 males); 100 were between 30-40 years (52 females: 48 males) and; 20 who were between 15-22 years (15 males: 5 females). The states visited were Illinois, Massachusetts, California and Texas.


State

Illinois

Responses

Massachusetts

Responses

California

Responses

Texas

Responses

Aspect (Out of 190 respondents or 45 H/holds)

Annual medical checkups (10)

Annual medical checkups (10)

Annual medical checkups (06)

Annual medical checkups (06)

Based on 45 H/holds

High

Fat diet (07)

High

 Fat diet (08)

High

 Fat diet (11)

High

Fat diet (05)

Based on 45 H/holds

High-salt ingestion (10)

High-salt ingestion (10)

High-salt ingestion (20)

High-salt ingestion (05)

Based on 45 H/holds

Planned fresh fruits, vegetables, lean protein and fiber as part of H/Hold meals (04)

Planned fresh fruits, vegetables, lean protein and fiber as part of H/Hold meals (08)

Planned fresh fruits, vegetables, lean protein and fiber as part of H/Hold meals (07)

Planned fresh fruits, vegetables, lean protein and fiber as part of H/Hold meals (06)

Based on 45 H/holds

Ensure green vegetables or salads as part of the planned household nutrition; a chart recording weight or blood pressure readings and regular visits to a health facility (02)

Ensure green vegetables or salads as part of the planned household nutrition; a chart recording weight or blood pressure readings and regular visits to a health facility (04)

Ensure green vegetables or salads as part of the planned household nutrition; a chart recording weight or blood pressure readings and regular visits to a health facility (05)

Ensure green vegetables or salads as part of the planned household nutrition; a chart recording weight or blood pressure readings and regular visits to a health facility (04)

Based on 45 H/holds

Relate co-payment, coverage policy and US Preventive services (04)

Relate co-payment, coverage policy and US Preventive services (09)

Relate co-payment, coverage policy and US Preventive services (08)

Relate co-payment, coverage policy and US Preventive services (07)

Out of 190 respondents

Tobacco Use (05)

Tobacco Use (38)

Tobacco Use (24)

Tobacco Use (08)

Out of 190 respondents

Alcohol Use (07)

Alcohol Use (58)

Alcohol Use (34)

Alcohol Use (08)

Out of 190 respondents

Use of pain-relievers/Self medication OTC’s (10)

Use of pain-relievers/Self medication OTC’s (40)

Use of pain-relievers/Self medication OTC’s (38)

Use of pain-relievers/Self medication OTC’s (10)

Out of 190 respondents

Substance Use/Herbal Therapeutics (03)

Substance Use/ Herbal Therapeutics (10)

Substance Use/Herbal Therapeutics (08)

Substance Use/Herbal Therapeutics (04)

Based on 45 H/holds

Physical exercise/ form of sports (05)

Physical exercise/ form of sports (05)

Physical exercise / form of sports (06)

Physical exercise/ form of sports (05)

 Table 1 Aspects per states visited

State

Illinois

Massachusetts

California

Texas

Weight Control at H/hold level (Based on 05 H/holds)/month

Physical exercise/form of Sport (05)

Physical exercise/form of Sport (05)

Physical exercise/form of Sport (06)

Physical exercise/form of Sport (05)

Bicycling

02

02

02

02

Aerobics

03

02

01

01

Tennis

02

02

04

04

Jogging

02

02

02

02

Brisk walk

02

02

02

03

Stair-walk

01

01

01

01

Leisure-walk

03

03

03

02

Dancing/Clubs

03

04

03

03

Swimming

04

04

04

02

In-door Treadmill/Elliptical

02

03

04

02

Sauna

02

02

02

02

 Table 2 Weight Control-related behavior and practices

Study definitions and determinants:

Key determinants: sex; age; legal status; length of stay in USA; living conditions (whether living in apartments/suites or houses); checking use of medicines (whether they are OTCs or prescribed medicines), social activities and; kind of food eaten including medication. 45 house-holds (15 apartment/suites and 30 bungalow homes) in all were visited (see table 1.) and the following were on the observation checklist; observing for tell-tale sports shoes in the shoe racks; presence of an exercise machine (e.g. elliptical or treadmill); inquiry into membership with a sports’ club and insurance plan and; sleeping patterns of house-hold members.  A respondent was someone who had stayed in USA for 6 months and above. Lifestyles observed to increase risks for CV included: Inability to translate information about health objectives into life preserving activities and poor or no linkage of weight to diet or vice versa. High fatty foods, added sugar drinks in form of ‘quick foods’ and use of saturated fats were noted variables (see table 1). Baseline variables included: ensuring green vegetables or salads as part of the planned household nutrition; engaging in sports/exercise; a chart recording weight or blood pressure readings and regular visits to a health facility. A knowledgeable respondent was one who had received counselling, knew their recent weight and blood pressure from a health worker in USA, could relate co-payment, coverage policy and US Preventive services to a minimum health seeking package and was ready to plan for a healthy life.  A compliant respondent attended a medical check up health service in the past 12 months leading to up to the study and engaged in a form of sport. Most house-hold settings provided opportunities to engage in light house-chores, taking up a flight of more than ten steps every day, running or a form of physical exercise that caused sweating and any form of recreation. Ugandan-Americans have all the contexts that define a beneficiary of the Affordable Care Act (ACA)[vii]. The ACA in offering first-dollar coverage for various preventive services enables patients overcome a major deterrent from obtaining needed services[viii].

Analysis:

In carrying out this study socioeconomic status and health indicators (SES) were used to link morbidity, mortality, health care utilization, health risk factors, prevention, health insurance and personal health care. 32 households had members who had attended annual medical check-ups: respondents here knew their recent weight and blood pressure from a health worker in USA In all 45 households visited, high salt and fat ingestion was in form of ‘quick foods’. When asked why, 110 respondents said ‘quick foods’ saved time. 45 respondents could not recall when they had last had fresh fruits, vegetables, lean protein and fiber planned as part of the foods taken on a regular basis. They cited job pressures left no spare time for shopping. They also did not know their recent weight and blood pressure from a health worker in USA. Planned fresh fruit, vegetables, lean protein and fiber as part of H/hold nutrition plans occurred in 25 households. 15 households ensured green vegetables or salads as part of the planned household nutrition had a chart recording weight or blood pressure readings and a culture of regular visits to health facility was established. 28 households had members who could relate co-payment, coverage policy to US preventive services. They had plans outlined to visit their health-care provider. They knew which health facilities their health care providers belonged to. 75 respondents smoked. 99 respondents used alcoholic drinks in above allowable measures. 108 respondents self-medicated using OTCs regularly and did not their recent weight and blood pressure from a health worker in USA. 138 respondents did not have health insurance cover or health safety net provisions. 55 respondents used energy drinks and enhancement supplements. 21 households had members engaged in regular sports/exercises (see tables 1 & 2). The recorded sports were: tennis, bicycling, weight lifting, aerobics, jogging and swimming.   All the children under 19 years had completed all immunizations and those with ailments were receiving medical care. This was possible because they were beneficiaries of various insurance plans targeting children. 43 adults were fully insured and it was possible for them to access regular health care services including regular check-ups. They knew their recent weight and blood pressure from a health worker in USA. 53 (30 adults and23 children below 21 years) respondents had ever done a dental check up.  As with other works there are observations around health conditions for children below 18 years by family incomes among Ugandan-Americans that reflect national percent of poverty level data and insurance coverage[ix]. Reported cases of: asthma, attention deficit hyperactivity disorder, emotional or behavioral difficulties, food allergy, skin allergy, respiratory allergy and forms of infections were noted. In the past 12 months, 30 (thirty) adult respondents had gone once for a medical check-up following unexplained headache and joint pains.103 respondents had no voluntary plans to visit a health clinic. All 190 respondents could relate; no physical sports; use of tobacco; indiscriminate sodium in-take; prolonged use of alcohol beyond allowable measures and; self medication, e.g., decongestants, pain relievers, steroids, diet pills and some antidepressants as risk factors for endocrine-related illnesses. 60 had translated their knowledge into initiatives to prevent endocrine-related illnesses.  There is need to provide information about practices that lower blood pressure. One such decision is to switch to DASH-Dietary Approaches to Stop Hypertension-diet. It involves eating more fruits, vegetables, whole-grain foods, low-fat dairy, poultry and nuts. It is advisable to eat less red meat, saturated fats and sweets as well as reducing sodium on one’s diet. Use of medicines, exercise and forms of therapies that promote relaxation are other ways to manage hypertension or control weight was noted on a low scale. Regular exercise helps lower one’s blood pressure. It is advisable for adults to get 150 minutes of moderate-intensity exercise every week. This can include, bicycling, aerobics, walking briskly, gardening. Muscle-strengthening activities are recommended at least two days a week and should work all major muscle groups[x]. 129 respondents had two or more jobs and none of the jobs provided health insurance cover. In 17 households members pooled together funds for utilities and many had two or more jobs. Having more than one jobs made it difficult to find spare time for personal health care. All 190 had attended a Ugandan-led social gathering. 12 deaths related to end-stage heart disease and 2 from sickle-cell-anemia were noted. 20 households had 22 female respondents above 55 years. 08 had physician diagnosed diabetes and managed their diabetes with medication, 06 were hypertensive and 04 engaged in physical exercises on a weekly basis as a result of a health workers’ advice. Of the 38 males above 55, 19 were diabetic and had no recollections of where their charts and home testing kits were. They were not engaged in strict glycemic control procedures.   06 of the 38 males above 55 years said they were aware of high blood pressure signs and engaged in physical exercise. Respondents from 17 households had heard about cancer, diabetes and causes of hypertension. Diabetes and hypertension are silent killers. Primary diagnosis of diabetes, hypertension, glomerulonephritis, cystic kidney and urologic conditions should not go untreated or poorly controlled because they end fatally as end-stage renal disease[xi]. At national level there is a reported poor glycemic control among persons with diagnosed diabetes with hemoglobin A1c of 9% and above in adults above 20[xii]. 70 respondents had a form of health insurance, 90 had a life insurance “that in case of death would cover for interning remains back in Uganda[xiii].” The forms of social gatherings popular among Ugandan-Americans include: showers, cultural galas, membership to organizations (Ugandan-North American Association, Ugandan-Californian Community, and Ugandans at Heart, Ugandan-Diaspora Boston Meetings, Ugandan-Catholic Associations, Ugandan-Islamic associations, Ugandan-Protestant Association, Buganda Chapters and other gatherings). All respondents had attended one or two gatherings in which Ugandans in America meet. If Ugandan-Americans are motivated to attend social-gatherings, it is possible to use these spaces for health outreach services.

Discussion:

Understanding and navigating the preventive services stands out highly for many Ugandan-Americans. It is a skill that will give them confidence to access and plan for health. There are a whole range of activities on a personal level Ugandan-Americans can engage in to promote quality health. Sports, recreation, social meetings and support clubs could be some. Ugandan-Americans need to set aside time to visit a health-care provider to get to know issues around health status needs, interventions and coverage.[xiv] Ugandan-Americans need to establish community-led health care initiatives. These are peer networks which in turn create a critical number that demands health services and engages in health preserving practices. It makes it possible to train health-care mobilisers from among Ugandan-Americans who in turn conduct follow up services and continuum care adherence support. This was echoed by two cervical cancer survivors receiving chemotherapy. These two were of the view that there should be health education sessions targeting Ugandan-Americans. This they hoped would be an empowerment in embracing preventive practices such as vaccination. There was need to provide information on benefits of inoculations of say, Human papilloma virus (HPV). There are strains of cancer causing HPV which can be prevented by vaccines. The virus, transmitted during sex, causes cervical cancer as well as vaginal, vulvar, anal and oral cancers[xv]. The health education sessions, it was suggested should show advances in medical fields but at the same time make it possible for one to make decisions to access medical check-ups and the follow up continuum. Information as that found in the Surveillance, Epidemiology and End Result (SEER) and Population-based cancer registries should be made available in forms that promote informed decisions.  Ugandan-Americans need to be made aware of morbidity, mortality, health care utilization, health risk factors, prevention, personal health and insurance coverage. This model could be replicated and should prepare them to adopt practices that promote health lifestyles. It could contribute to lessening morbidity and mortality[xvi].  The number of new cancer cases per 100,000 population range from 7.5 in the case of Cervix uteri to 148.4 for prostate cancer[xvii]. Ugandan-Americans need to relate this kind of information to their own lives. This includes personal initiative to engage in life preserving practices. It is possible to plan for health for a Ugandan-American community estimated at 60,000. The primary mobilization platforms can be through their peer networks. This paper was written to inform that kind of mobilization.


Acknowledgements:
In making this study as less intrusive as possible, the Ugandan-American community leaders (with titles of ‘Mukulu’, ‘Kojja’or ‘Ssenga’ are the chosen elders) in all states where Ugandans are found helped provide a soft landing spot. The Ugandan-North American Association (UNAA) and various social spaces in which Ugandan-Americans mix acted as insightful contexts.





[i] American Lung Association, state of tobacco control 2013 report. Washington: American Lung Association, 2013.
[ii]  Lucy M. Candib: Medicine and Family; A feminist Perspective. New York: BasicBooks. 1995.
[iii]  www.healthcare.gov/news/factsheets/2007/07/preventive-services-list.html
[iv] Mol Annemarie: The Logic of Care: health and the problem of patient choice. London: Routledge, 2008

[v] WHO Mortality Database, 2012

[vi] UN Special High Level meeting on Non-Communicable diseases, 2012

[vii] Solanki G. Schauffer HH: Cost sharing and the utilization of clinical prevention services. Am J Prev Med. 1999: 17 (2): 127-133.
[viii] Hinman AR: National Vaccine Advisory Committee. Financing Vaccines in the 21st Century: recommendations from National Vaccine Advisory Committee. Am J Prev Med 2005; 29 (1): 71-75.
[ix]  Table 46 (pages 1-5). Health conditions among children under 18 years of age by selected characteristics: United States, Average Annual, selected years 1997-1999 through 2008-2010; Health, United States 2011. Page 180.
[x]www.webmd.com/hypertension-high-blood-pressure/ss/slideshow-hypertension-overview?ecd=wnl_men_050713&ctr=wnl-men-050713_ld-stry&mb=
[xi]  Tables 51(pages 1 & 2):  End-stage renal disease patients, by selected characteristics: United States, selected years 1980-2008: Health, United States, 2011.
[xii]  Tables 50 (pages 1 and 2): Diabetes Prevalence and glycemic Control among adults 20 years of age and over by sex, age and race and Hispanic origin: United States, selected years 1988-1994 through 2003-206: Health, United States, 2011;  Pages 188-189.
[xiii]  A statement made by 62 year old diabetic and hypertensive Ugandan-American female respondent from California, USA.
[xiv]  www.healthcare.gov/law/features/rights/preventive-care/index.html
[xv]  Telegram & Gazette Friday, May 10, 2013, Page A 3.
[xvi]  National Center for health statistics: Health, United States 2011; with special feature on Socioeconomic status and Health. Hyattsville, MD 2012.
[xvii]  Tables 47 (pages 1-3): Age-adjusted cancer incidence rates for selected cancer sites, selected geographic areas, selected years 1990-2008; Health, United States 2011; Trend Tables pages 181-184.