Reflections by Rebecca J. Hester

The question at the close of this case, "Does the staff at East Valley Hospital approach Ana's situation in a manner that is sufficiently respectful of her culture (sometimes called a "culturally competent" manner)?" allows me to address the specifics of Ana's treatment in addition to pointing out some cultural assumptions regarding the idea and practice of cultural "competency." I've organized my comments about the treatment Ana received into two categories: practical and philosophical. In terms of the first, I will address both contextual factors and cultural beliefs, in the hopes of providing some guideposts about understanding Ana's perspective. The second concern is meant to challenge us to rethink our own perspective as providers and researchers in light of Ana's worldview.

Practical Concerns

Contextual factors

To provide culturally "competent" services, the medical providers would need to have some background on indigenous Mexicans in order even to know what questions to ask and how to ask them. Given the reactions of the nurse and the social worker, it appears that neither had been exposed to trainings that would increase their cultural awareness and knowledge, thus leaving them to draw conclusions and assumptions based on their personal perspectives of Ana's situation. If they had received some training, one of the first things they would do after asking a few preliminary questions would be to find an appropriate interpreter who speaks both the same language (Mixteco) and dialect (alto or bajo) as Ana.

The following are important questions to include: Where is she from in Oaxaca? How long has she been here? Learning the region of Oaxaca that Ana comes from will help establish which dialect of Mixteco she speaks, which will in turn make a difference in the kind of interpretation services she will need. Often the respondent will not know which of the two dialects she speaks; however, trained interpreters will know if they are given the name of the town of origin of the patient. Knowing how long she has been in this country will provide important medical insight into the length of exposure she and her unborn son may have had to pesticides or other toxins in the rural agricultural environment where she works and probably lives, as well as into how recently they might have been exposed to the trauma (harsh conditions, hunger, dehydration, rape, theft, abuse, detention, etc.) of crossing the border without papers, assuming she is undocumented. In asking these questions, one can neither assume that she speaks Spanish simply because she is a Mexican citizen, nor that just because she speaks some Spanish she has been in the U.S. for a while. Finally, as is demonstrated in the case study, it cannot be assumed that her affirmative responses to questions in Spanish indicate that she comprehends everything that is said to her.

In addition to using a trained interpreter, the staff would have been well-advised to pursue a sustained conversation with the husband, Hugo. This, however, would have required the staff, including the social worker, to be available to meet with him during evening hours. Husbands sometimes make the decisions for and speak on behalf of their spouses in indigenous Oaxacan communities. This dynamic is due to several factors, which include a culturally inflected gender hierarchy that exposes males to more educational opportunities than females and thus facilitates the development of stronger Spanish-speaking skills. Further, in indigenous communities, men rather than women are the public voice for the household participating in public forums and decision making. Because of their exposure to education, men also have stronger literacy and numeracy skills, which means that they are better equipped to fill out paperwork and understand doses and prescriptions. Depending on their level of education, it can also mean that they have a better understanding of anatomy as defined in Western medical terms than do their wives.

Cultural Beliefs

Having some exposure to or training on indigenous health would have helped the staff decide which foods and liquids would be appropriate for Ana. Ice chips, although commonly given to laboring women, go against the cultural beliefs of indigenous Oaxacans, who subscribe to some of the beliefs of humoral medicine, such as that of establishing a balance between hot and cold. Within this system, labor is considered "cold" and thus should be treated with a "hot" response in the form of warm liquids, soups, and other foods that have "hot" properties. Ice and "cold" foods will only exacerbate the imbalance. Although medical providers should be aware of these beliefs and practices¹, often the families of the patient will have prepared the necessary foods to help with a quick recovery, as cited in the case study.

One aspect of the cultural differences that deserves close attention is that of the competing medical authorities this case brings to light. Although indigenous families might not commonly ask permission for a traditional healer to have access to the baby in the hospital, if it were to occur, such a request should be respected for several reasons. First, to do so would be to abide by norms of cultural competency that suggest that coordination with traditional healers can facilitate continuity of care, prevent complications due to incompatible therapies, and make biomedical information accessible in a way that is concordant with cultural beliefs and practices. Second, indigenous healers (many of whom, like allopathic doctors, have their own specialties) are more than just medical professionals; they are also community leaders and elders whose presence is both healing and comforting insofar as they represent the support of the entire community. Further, because indigenous healers utilize an approach which allows for a lengthy recounting of events in order to discern the cause of the illness, many indigenous people find their presence more comforting and reassuring than that of biomedical staff-who, in their brief interactions with the patient, often do not expose their emotions or affect or engage the emotions of the patient. Finally, these healers are important because they work on a spiritual as well as physical level, exorcising unhealthy or evil spirits from the body of the sick person, often through cleansing ceremonies with eggs or other natural elements (e.g. tobacco, plants). Many indigenous people feel that unless the evil force that caused the illness is discovered and exorcised, they or their loved ones are not healed, regardless of the extensive and undoubtedly competent biomedical care they receive.

A final point on cultural beliefs has to do with the mother's relationship to her son. While we might be looking for evidence of mother-child "bonding," the overt show of emotion in public is not one of the cultural norms embraced by this population. Rather, affection is demonstrated privately. Thus, Ana's seeming distance from her child should not be interpreted as her lack of love or concern for her son, but rather as indicating respect for those around her who should not be made uncomfortable by her public display of emotion.

Philosophical concerns

Several philosophical issues arise in this brief case study which I will only point out without elaborating. The first of these has to do with the assumptions Western practitioners bring to our interactions with indigenous patients, specifically regarding the assumption that they share our ontological and epistemological formulations. That is to say, we assume not only that they have the same understanding of their bodies and their "selves" as we do, but that they also have similar skills (numeracy for example) and values, particularly regarding the role and importance of scientific authority. This case study and the increasing presence of indigenous Oaxacans in the United States challenge these formulations and the values they engender. For example, the presence of an indigenous healer demonstrates that for indigenous Oaxacans, individual suffering is also collective and therefore should be borne and resolved by someone who has been given the authority and recognition to do so on behalf of the community. In a system and society that gives primacy to individual bodies and "selves," medical professionals (who are themselves indoctrinated in medical science) could easily miss this kind of "collective" support expressed through the presence of one person, and its vital importance in healing and recovery for indigenous community members.

In addition, when we find that those we are helping or healing do not share our beliefs, ideas, values and/or practices, our reaction is often to assume a lack of information, knowledge, or will. This supposition is demonstrated by the example of the mother who is assumed either not to know or not to care about showing affection to her sick child. However, if we shelve our worldview and embrace that of Ana, we come to see that it is not out of disregard for her child, but rather out of concern for all who are around her that she reacts as she does. In fact, her arrival at the hospital and her subsequent attempt to bring an indigenous healer demonstrate that she is willing to do whatever is within her power to care for her son and, indeed, for herself. Thus, it is not a "lack" on her part, but rather on the part of those who do not look beyond their cultural norms to find the meaning Ana assigns to her actions.

This leads me to my final point, which is the importance of an indigenous language interpreter. While professional interpreters can greatly facilitate communication and understanding, particularly for the patient, they can also educate the providers on how to interpret the signs and symbols of their indigenous patients. For example, often medical staff, social service providers, and teachers complain that indigenous Oaxacans do not respect them because they don't look them in the eye while being addressed. In one case I witnessed while interpreting for a Mixtec family, the doctor surmised out loud that the woman might be the victim of abuse because she would not look him in the eye and her husband answered every question for her. I took the opportunity to explain to the doctor that she was demonstrating the ultimate sign of respect to him as a medical authority and to her husband as the authority in the household.

To conclude, while this case study is rich for what it reveals about indigenous Oaxacan cultural beliefs, I find it richer insofar as it points up the particularity of the cultural beliefs that inhere in Western medicine, science and philosophy and the superior value assigned to these over "traditional" ways of being and knowing. This perceived superiority is evident in the term "competency" itself, which assumes the ability to know the cultural "other" by learning her customs, practices and beliefs, but not really having to grapple deeply with the differences. Among these significant cultural differences, I want to signal one in particular that impacts approaches to health and healing.

In the West, we believe that securing an individual's well-being first will contribute to the greater good of all. This individualist belief is a long-standing ideology linked to Protestantism, liberalism and capitalism, and witnessed in disciplines such as psychology where the individual patient is encouraged to look after her own mental health before trying to help anyone else. Indigenous communities operate from the reverse logic. They believe that to benefit themselves, they must first secure the well-being of the community. This has been a strategy of indigenous groups for centuries and has helped them survive colonization, imperialism, disease and now the punishing effects of economic globalization and displacement. If our medical system and our healing strategies encourage them to abandon their orientation to community well-being first, we will be depriving them of a vital survival tool under the guise of saving their lives with biomedicine.

Given this, I would propose that cultural "competency" training begin by having those of us working in Western traditions explore our assumptions about who we are, why we do what we do and what the larger meanings of our actions and practices signal in terms of our approach to health and healing. Part of this self-reflective process would include engaging in a dialogue with those whose ways of knowing and being are foreign, but not inferior to our own. This call for reflection and dialogue will not only allow us to think creatively about how to "do no harm" to those whose worldviews do not mirror our own, but will also facilitate the continued survival of a growing segment of our population-a goal which health practitioners hope to achieve with all of their patients. The tools and strategies indigenous community members have to offer could not be more timely if one considers the environmental, economic and physical limits of our current ways of doing business in the West. If we are open and we listen to them, we might not only learn something about who they are, but also about who we are and how we can be more effective at healing our individual and collective body in an increasingly connected world.

¹See Cindy Brach and Irene Fraserirector, "Can Cultural Competency Reduce Racial and Ethnic Health Disparities? A Review and Conceptual Model," in Medical Care Research and Review, 2000, 57:181.

Return to the case
Introduction to Culturally Competent Care
Introduction to Culturally Competent Care for Latino Patients

Rebecca J. Hester is a Ph.D. Candidate in the Department of Politics at the University of California Santa Cruz. Her dissertation tentatively titled "Embodied Politics: Health Promotion in Indigenous Mexican Migrant Communities in California" explores the politics of health and "different" approaches to embodiment. Rebecca works as an instructor in the Department of Latin American and Latino Studies at San Francisco City College in addition to consulting on an agricultural worker health program in two large agricultural regions in California. She is also a board member of Centro Binacional para el Desarrollo Indigena Oaxaqueno (CBDIO), a binational indigenous organization providing health and interpretation services to the indigenous migrant community.