Culture and Medicine: Reflections on Identity and Community in an Age of Pluralism

Labels of Identity—Race, Ethnicity and Culture

One of the great challenges in modern medicine is creating effective therapeutic relationships in an era of ever-increasing cultural diversity. Our hospitals and communities have become global villages where, daily, many languages, cultures, and customs intersect, clash, merge, and evolve. Yet in spite of this spiraling complexity, health caregivers, physicians, and patients visit and revisit this therapeutic encounter ever hopeful that it will provide solutions and solace. Beliefs, communication, and trust are the currency for a successful interchange. They are not the “stuff” of normal scientific discourse but they are every bit as real. How can we negotiate this uncertain terrain of relationship more effectively? Are there principles to guide us and stories to illustrate the pitfalls? Is there a “primer” for this?

I would like to relate a story that introduces the meeting that occurs between worlds when two people encounter each other in all their particularity and richness and with the depth and intimacy that Martin Buber referred to as a meeting of I and Thou.¹ Something is created in this—a new experience of Self and Other. Mr Buber wrote I and Thou in 1922 and it remains one of the most remarkable documents on relationship ever written. In it he said: “All real living is meeting”^1p11 and “In the beginning is relation.”^1p18 It is in this spirit that I engage in these deliberations with you.

Story of a Mexican-Indian Woman

I once took care of a 70-year-old woman—a Mexican-Indian from northern Michoacan near Patzcuaro, the homeland of the Tarascan people. The mountains and lakes in this part of Mexico participate with the people to create a beautiful serenity that surrounds the area and its towns. Towns with names like Tzintzuntzan. She was like the place that she came from and every month for a year, on the same day at the same time, she brought this serenity to me and to the medical clinic at the county hospital where I worked.

Our hospitals and communities have become global villages where, daily, many languages, cultures, and customs intersect, clash, merge, and evolve.

Medical clinic, in contrast, was squeezed into an afternoon of an already impossible schedule. It was supposed to be a break from the ICU and the wards, but it wasn't. The waiting room was wall-to-wall patients, and add-on and walk-in patients crowded the 20-minute appointments into 5–10 minute visits. The exam rooms, in a semi-circle, had two doors so the patients could be roomed from the hallway. We worked on the opposite side, “protected” from the waiting room and hallways and charting, on an open counter at a nurse's station that had more medical students, interns, and residents than nurses.

When I would see this woman's name on the chart I felt myself relax a bit. I always had the same picture of her in my mind. I knew she would be sitting quietly inside the exam room, peaceful and out of place against the institutional green walls. She always greeted me with a smile, and the kind, dignified look in her eyes calmed me. Her white hair, always pulled back, contrasted beautifully with the brown skin of her Indian face. We spoke in Spanish and I remember the old formal type of Spanish she spoke, a remnant of the colonial past. She had type-2 diabetes and hypertension, not too bad really. All of it came under easy control with a few medicines and I often spent our short time together simply reassuring her and enjoying her quiet demeanor while we talked about life (“cosas de la vida”).

One day there was quite a fuss at the front desk. One of the patients had come an hour late and the receptionist was trying to reschedule her for another day and time. The patient was adamant that she had to be seen and wouldn't reschedule. The receptionist came to me and asked me if I would add her on at the end of the day. I did and two hours later I saw the chart come up. I was very surprised to see that it was this same woman. It was so out of character for her to make any disturbance. When I came in the exam room she was distraught and tearful. I had never seen her lose her composure like this. I sat with her and asked her to tell me what was wrong. She told me that her husband who was in his late 70s had recently developed very bad congestive heart failure, had been in the Emergency Room and could no longer live at home. All of this had made her miss the bus, which she always took at the same time and at the same place. She then went on to tell me an amazing tale of traveling for five hours to get across town. She had to take a different bus, which left her at a corner she had never been to. She was illiterate and couldn't read any language, so the street signs were of no help. When she got off at a strange place and when people gave her instructions, even in Spanish, it was still very difficult for her to find her way. And she was very shy about letting anyone know that she couldn't read. This is so difficult for people—literacy. She and her husband were living in a garage with no heat or running water and because of his illness they were about to lose their place. This had upset her terribly.

I had seen her for a year, spoke to her in Spanish, and felt close to her, but in this moment I realized how much I didn't know the world in which she lived. She came every month into my world; I didn't enter hers—or maybe, truer yet, we came together between worlds.

… to be part of a culture is to be “bound in a set of connecting stories …”

A Terminology of Race, Ethnicity, Culture

As a foundation, it is necessary to work through some terms—race, ethnicity, and culture.

Race

Race is a troubled concept. It is now very much in dispute in biology. Genome studies have shown a remarkable degree of genetic similarity among races and a lack of correlation with phenotypic characteristics. There is much greater mixing between the races than was ever appreciated. For whatever differences people around the world have it appears that they are genetically more alike than different, about 99.9% worth. So race appears to be more of a social construct than a biological one.

In her book on Cross-Cultural Medicine, JudyAnn Bigby “recognizes race as a social construct that originates from societal efforts to separate people based on their looks and culture.”^2p1–3

Nevertheless, despite the ambiguities in the biology of race and its definitions there is no disputing the reality of racial prejudice in the world and the injustice and suffering it creates.

Ethnicity

Ethnicity describes certain subgroups that share ancestry, history, or culture. Factors that bind members of an ethnic group are diverse and include geographic origin—for example New England, the Deep South, the Southwest, Texas, or Hawaii—language or dialect, music, literature, cuisine, religion and gender roles. The US government classifies Hispanics as an ethnic group that may be of any race.² More recently the term Latino has come into use to downplay the role of Spanish and the implication of origins in Spain.

My sister, who is a romance language scholar, tells me that “Latin” or Latino, as an origin, is a Western term that refers to the Roman Empire. So, of course, the French would be Latin by this definition—not helpful for the New World Latino. We will return to these troublesome labels.

Culture

Ms Bigby defines culture as “a shared system of values, beliefs, and learned patterns of behavior.”^2p2 As defined, it can apply to ethnic groups, regional groups, and professional groups.

I find Clifford Geertz's comment more helpful. In his epochal work The Interpretation of Cultures,³ he says: “… man is an animal suspended in webs of significance he himself has spun. I take culture to be those webs, and the analysis of it to be therefore not an experimental science in search of law but an interpretive one in search of meaning.”^3p5

He continues that culture does not cause behaviors, social events, or processes. Rather culture “is a context … within which” those behaviors, social events or processes can be intelligibly described.^3p14

Jerome Bruner, in his characteristic brilliance, comments that to be part of a culture is to be “bound in a set of connecting stories, connecting even though the stories may not represent a consensus.”^4p96

Self and Community in Story and Image

In a fundamental sense culture is about identity or self in relationship or community. And community as a web of relationships surrounds self as a context. And context is culture, an interpretive community. Wittgenstein used the term “thought circle”⁵ and Ludwig Fleck used “thought collective”⁶ to describe these communities that we use for the social construction of reality.

The Self as a person is both being and acting in the world, ie the Self has both an ontologic and praxeologic status. Furthermore a person is not made (constructed) in isolation but rather in relationship. In other words the Self is “distributed, reflexive, and constructed.” Let me explain: A person is born with a history and into a culture and inculcated with this from conception. S/he therefore takes his/her existence from events distributed across history or time and space. S/he is reflexive (reflective) or consciously remaking him or herself, and constructed (both conservative [self-organizing] and creative [self-transcending]).^4,7 Finally action is “situated” in the world, ie, in a context and that context is culture.

The Strange and Varied Experience of the Chicano

What's in a name? Who is a Latino? When I was young the term Chicano was usually derogatory. The old people used to say “Chicano corriente” to point out the lower status that Chicanos seemed to occupy. If they were young Chicanos, I wasn't supposed to be with them. It could also refer to tough guys—the Pachucos—also people I wasn't supposed to associate with. And yet Chicanos were not Mejicanos. Mejicanos still knew Mexico, had ties there, went there; Chicanos rarely did. And when they did go to Mexico, Chicanos often felt out of place. Their Spanish wasn't good, it was Spanglish or pocho—more terms that made you feel bad, even in Mexico. This is confusing when you are young. Later on, leaders of the Civil Rights Movement, like Martin Luther King, Jr, led us to a new awareness, and James Brown taught us: “Say it once, say it loud. I'm Black and I'm proud.”⁸ So Chicano became a term of pride.

In New Mexico, where my family originated, people pride themselves on being proper Hispanos. New Mexico was a Spanish colony and then part of Mexico for longer than it has been part of the United States. Some of the old people there still wear the traditional black suits or dresses with mantillas of colonial Spain on their heads. They didn't want to associate with Chicanos or even Mejicanos. There you had to be a “Manito”—a true New Mexican—to attain preferred status. The history of New Mexico reaches back to the colonial period, the late 1500s. And in certain places your family was not even much Hispano but more Pueblo, or Mescalero, or Mimbreno. This is very much Indian country and in my own family there was Apache and Pueblo on both sides. During the Apache wars of the late 1800s it was unsafe to be Indian and worse to be Apache. So everyone had Spanish names and called him or herself “American” when the authorities asked. The authorities usually referred to them as Mexicans, even if they had never been in Mexico. I'm not sure what the “authorities” were, though they probably weren't Chicano. I once asked my grandfather, who was Pueblo, what country he was from—he said he didn't like either one very much.

If you are from Arizona you might be a Yaqui, who speaks Spanish, or Navajo or Papago (O'odham). And there was everything in between, like my friend Jesus.

Jesus

I met Jesus about ten years ago working on a project in Sonora, Mexico about 200 miles south of the Arizona border. I was part of a group working with the Seri (Concaac) to record sacred songs, chants, healing ceremonies, and oral history. The Seri Indians are southern neighbors to the Pima and Papago (O'odham) of Arizona. Their homelands are on the Sonoran coast, about 100 miles north of Hermosillo. Jesus lives there in Mexico and speaks Spanish. I asked him about his parents. “Mi mama hablaba O'odham y nacio en Arizona, (My mother spoke O'odham and was born in Arizona)” he told me. His father was from the Mexican side of the border but also Seri. You wouldn't call Jesus a Chicano, or a Hispano, nor a Mejicano (because the Seri regard themselves as a sovereign nation). He definitely is a Seri, and he is a Papago too, but not an Arizona Papago. You can see how these labels are confusing.

Choosing Categories

In the 2000 United States Census, for the first time, participants were allowed to choose more than one category. Among Native Americans in California almost 50% have mixed ancestry with Hispanic or Latino. This underscores the very close relationship between Latinos and indigenous peoples throughout the Americas.

Even if we clarify and apply these terms it can still be confusing. For example, Hawaiians are Native Americans even though they are also Pacific Islanders. This has been a problem for demographers. In Hawaii, where mixed racial ancestry is the norm, researchers regard racial identification as less important than language(s) spoken in the home and birthplace of parents.

Another example: Is a Spanish-speaking, black woman from the Dominican Republic (who lives in East Palo Alto) Latina, Hispanic, African-American, Afro-Caribbean, or all of these?

… behind each label lies a real person with a very particular, indeed unique, story.

Rebeca

I have a good friend, Rebeca, whose family is European and Jewish. They found their way to Mexico during the diaspora of WWII. She grew up in Mexico, speaks Spanish to her children and either English or Spanish to her patients in her work as a nutritionist. Her parents now live in Israel. She embodies the beauty of Latino culture—the kindness or friendliness (simpatia and personalismo), politeness (respeto), importance of family—these qualities are hallmarks of Latino culture.⁹ To me, Rebeca is very much a Latina.

Two summers ago I was in Sao Paolo, Brazil, where 20 million people live. There I visited the famous Japanese community known as Liberdade, “Freedom.” I met third generation Japanese Brazilians who spoke Portuguese and only a little Japanese. They could be called Sansei, but are they Latin Americans, or Japanese Latin Americans, or Latinos?

Julian

Julian was born at Stanford hospital, grew up in California, and is a professional skateboarder. Recently he worked in a restaurant as a cook. His coworkers were Mexican and called him Bruce Lee because he looks Asian and doesn't speak much Spanish. His boss, who is white (EuroAmerican), tried to speak to him in Spanish because he didn't believe him. His mother is Sansei, third generation Japanese American, born in California to parents who are farmers in the Coachella Valley. I am his father. When I asked him if I could talk about him, he said, “Why?” and looked at me as if to ask, “Aren't I just like everyone else in California?” Well, yes.

These are all labels of identity and we all use them in various ways; sometimes they are necessary. We have to name the world in order to interact with it. The main point is to remind us that as we use these labels and categories, remember they are fictions at best, and behind each label lies a real person with a very particular, indeed unique, story.

Cultual Competence—What About The Term?

Cultural Competence

The term originally derived from an institutional use where it describes the goal of having health caregivers who, in addition to other technical competencies, have a “cultural” competency. As such it implies the existence of an external standard against which competence is measured, for example proficiency in language for translators or professionals. In this usage it is understandable and the skills it implies are essential for the professional. But when used in wider parlance it implies that culture is monolithic and static and has a univocal interpretation. In this sense it is not useful, and can even be harmful, as it can lead to narrow reifications that pose as culture. So what should we do? Jettison the term? Take the dialogue beyond it to multiculturalism, or to local knowledge?

Local Knowledge

Local knowledge is a term used by Geertz to underscore the importance of context, situation, and local conditions in experience and behavior, local conditions that give rise to an endless range of possibilities in interpretation. He concludes, “the interpretative study of cultures represents an attempt to come to terms with the diversity of the ways human beings construct their lives in the act of leading them.”¹⁰

… all interpretation is done from some vantage point, someone's point of view, some perspective.

Perspectivism

Perspectivism is a term used by Richard Tarnas¹¹ and Jerome Bruner⁴ among others to emphasize that all interpretation is done from some vantage point, someone's point of view, some perspective. And that perspective is neither neutral nor transparent.^12,13

Clinical Templates

LEARN¹⁵.

• Listen to the patient's perspective

• Explain and share one's own perspective

• Acknowledge differences and similarities between two perspectives

• Recommend treatment

• Negotiate mutually agreed upon plan

Eliciting the Explanatory Model of Illness¹⁶.

• What do you call your illness?

• When did your illness begin?

• Why do you think your illness started?

• What does your sickness do; how does it work?

• How severe is your illness?

• What do you fear most about your illness?

• What are the major problems your illness has caused?

• Do you have any ideas about what treatment you should receive?

The Ethnosphere, Language Loss, and the Value of Diversity

Let me end with a perspective on the value of cultural diversity. It comes from Wade Davis.¹⁷

“The ethnosphere is the sum total of all thoughts, dreams, ideas, myths, inspirations brought into being by the human imagination since the dawn of consciousness. The ethnosphere is humanity's great legacy, the symbol of all that we have achieved and all that we can achieve as a wildly creative and adaptive species. Yet, this rich and diverse legacy is threatened.

“The great indicator of this is language loss. When the oldest of us reading this article were born there were 6000 languages spoken on earth. A language isn't just a body of words and a set of grammatical rules; it's a flash of the human spirit, an encyclopedia of the human imagination. It is a vehicle through which the soul of each particular culture comes into the world. Every language is an old growth forest of the mind, a watershed of thought, and an ecosystem of spiritual possibility. And of those 6000 languages half are not being taught today, they are not being whispered into the ears of babies. Effectively, they are dead.

“Some view this as a good thing: one language so that everyone can communicate. Great idea, I say. Let's make it Lakota Sioux, or Cantonese, or Yoruba, or Tibetan, or Navajo, where nouns are scarce, everything is related and in motion. Suddenly you begin to see what it would be like to be enveloped in silence, to have no means to pass on the wisdom of your ancestors, to anticipate the promise of your children.

“And yet that dreadful plight is the fate of someone on earth roughly every fortnight because every two weeks some elder carries to their grave the last syllables of an ancient tongue.”

Conclusion

As we dig more deeply into the topic of culture and medicine we see with new eyes the extraordinary complexity in the very notions of identity and community. And probably all people have multiple identities simultaneously.¹⁸ One can see how this leads to being a member of several, often very different, communities—all at the same time.¹⁹ We have explored this terrain here and, although sometimes a confusing excursion, I always come away with a renewed sense of wonder at the beauty and richness of the very diverse world that we live in. I wonder what your thoughts are?

Practical Advice.

• Listen: Medical history taking is often more like an interrogation than listening to someone tell their story. Choose instead the approach being called Reflective Engagementor Appreciative Inquiry where the questioner assumes the posture of nonexpert learner.¹⁴

• Self-inquiry: What are your own hidden assumptions, implicit values, unstated goals?

• Language: Literacy and language create worlds, yet linguistic competence is not necessarily cultural competence. Remember that language can be used to control and confuse and that much communication is nonverbal.

• Nonverbal communication: recognize its importance.

• Attributes of a healer: The effective healer has certain attributes. Work to understand them from your own point of view and embody them in practice.

  1. Joyful
  2. Skill or skillful means
  3. Reverence for the work (awareness of participating in the mystery)
  4. Kindness
  5. Humility