Cultural Competency in Healthcare
How can Healthcare Help Historically Disenfranchised Communities?: Cultural Competency and Color Blindness
Written by former Genomics Advocacy Intern, Rachel Wu
Though the Hippocratic Oath is meant to bind all physicians to “do no harm,” throughout history, those in power, including hospitals, have participated in the oppression of the disadvantaged and disenfranchised. While some of these biases and microaggressions may be unintended, the effects of racism are still impacting the livelihoods of many minorities. As the medical community tries to address its past failings and discrimination against minority groups, the term cultural competency has gained prominence.
Despite promising intentions, this idea has failed to stimulate conversation between minorities and their caretakers, still allowing practitioners to be in complete control of the quality of healthcare provided. Arthur Kleinman and Peter Benson, medical anthropologists respectively from Harvard University and the University of Delaware, believe that “cultural competency” essentially led to practitioners generalizing patients based on ethnicity and having a list of “do’s and don’ts” for a patient of any given ethnic background. Kleinman and Benson believe that it is problematic to describe entire societies and ethnic groups with such simplifying slogans (Kleinman, 1673). By making assumptions and stereotypes based on nationality, race, or language, doctors run the risk of overlooking the specific factors behind their patients’ condition, such as socioeconomic status, accessibility to basic healthcare needs and a healthy diet, environmental factors in their neighborhood, and other issues. The idea of cultural competency allows providers to act paternalistic in concluding how to best address cultural differences without consulting minorities themselves. It may be impossible to undo the past, but it is essential to rectify the damage to focus on present-day disparities that affect determinants of health. This accountability requires a conscious effort to reflect on how every aspect of our present day lives can be traced back to some historical event.
Cultural competency encourages practitioners to apply their presumptions of a minority’s lifestyle to create a “guideline” for treatment. This fails to provoke enough thought to allow a doctor to visualize historical developments that have led to a high prevalence of certain diseases in historically disenfranchised groups. To address this problem, Kleinman suggested the practice of ethnography, where an anthropologist immerses themselves fully within the culture, language, religion, environment, and living practices of the ethnic group who are the main stakeholder in medical conversations revolving around the historically disadvantaged. Unlike cultural competency, the person engaging with the cultural group is not simply fed a “trait list,” but they can avoid internal biases through direct observation and interaction (Kleinman, 1674).
Through emphasizing the Native community, the practitioner sees firsthand how historical infractions against autonomy have impacted multiple facets of modern Indigenous peoples’ everyday lives. This allows the reader to draw their own conclusions regarding the relationship between several present-day medical issues to histories of discrimination and racism.
A qualitative study performed by University of Massachusetts Boston PhD candidate, Madison Natarajan, emphasized how important it is to consider the history of oppression before making a diagnosis. In her paper studying the high prevalence of Type II Diabetes in Native American populations, Natarajan discovered that there was a lack of healthy food access for those forcibly relocated to Reservations. The lack of government assistance, compounded with forced relocation only a few generations ago, resulted in long-term consumption of cheap, low-nutrition, processed foods that specifically contributed to this ethnic metabolic disease epidemic (Natarajan, 2021). At first, drawing connections between the colonization of Indigenous Native Americans after Europeans arrived and took the land with the high prevalence of diabetes in Native peoples today may seem impossible. However, once the nuances behind historical laws are analyzed, like the 1956 Relocation Act, which cut off government assistance to many Native American tribes, the downstream effects caused by displacement, ostracism, and forced dependence can be seen more plainly. By separating Native Americans from the rest of the American population, much of their autonomy was stripped away, leaving the already-vulnerable population to fend for themselves. According to Natarajan, Type 2 Diabetes Mellitus was often presented as a “by choice” disease, where the patient “chose not to exercise,” or “chose not to eat healthy foods” (Natarajan, 2021).
Clarence H. Braddock III, former chair of the Board of Directors for the American Board of Internal Medicine (ABIM), raises a similar observation in hospitals that are attempting to combat centuries of racism that have harmed Black patients and doctors. These practitioners engage in what Braddock calls color blindness, where they claim to “see no color.” Braddock criticizes this movement as it negates the “lived experience of being Black.” Exposure to racism and microaggressions over lifetimes have led to many adverse health impacts that do not affect white persons with similar socioeconomic statuses. Color blindness assesses prognosis equally, not equitably (Braddock, 29). Both color blindness and cultural competency are surface level changes meant to soothe the angry activists, but they do not pose any benefits for the disadvantaged groups. In fact, they simply avoid the real issue of how centuries of oppression, such as segregation or relocation laws, have resulted in ethnic minorities being naturally at risk for certain diseases. Rather than surface level corrections in the clinic, Braddock suggests targeting “societal level structural determinants” such as housing and income inequality, as those are more helpful to the Black community than thoughtlessly repeating “I see no color” (Braddock, 31). Race and history must not be ignored to ensure that diagnoses and treatments are administered with equity, so that minorities can achieve a semblance of equality.
It is extremely important to emphasize practicing dialogue and listening to other perspectives to ensure that both historical and present-day social injustices are properly addressed. To what extent do historical events from hundreds of years ago affect health determinants today? Should doctors reflect and remember these repugnant beliefs, or should we wipe a clean slate and “start over?” Originally intended to delineate guidelines for medical personnel on handling people from different cultures, the idea of cultural competency fails to initiate meaningful dialogue by erasing the voices of minorities and continuing to allow microaggressions in healthcare today. It is essential to start conversations in healthcare, directly with oppressed minorities, to ensure that their perspectives are being heard and that their voices are not being erased.
Sources:
Braddock, Clarence H. “Racism and Bioethics: The Myth of Color Blindness.” The American Journal of Bioethics, vol 21, no 2, 2021, pp. 28-32.
Kleinman, Arthur and Benson, Peter. “Anthropology in the Clinic: The Problem of Cultural Competency and How to Fix It.” PLoS Medicine, vol 3, no 10, 2006, pp. 1673-1676.
Natarajan, Madison. “Moving from Cultural Competency to Decolonizing Health Care.” Mad in America: Science, Psychiatry, and Social Justice, 2021. https://www.madinamerica.com/2021/06/moving-cultural-competency-decolonizing-health-care/