An Essay on Cultural Diversity, Healthcare

1、an essay on cultural diversity, healthcare disparities, and cultural competencein american medicinerichard allen williams, m.d.clinical professor of medicineucla school of medicinelos angeles, californiait is both a privilege and a pleasure to address the j. robert gladden orthopaedic society in lau

2、sanne, switzerland at the invitation of augustus white, m.d. i have been called upon to provide a presentation of the status of health care for african americans and other minorities, and i welcome this task. my credentials for being placed in this position of honor span my medical and academic care

3、er, which began when i was an undergraduate pre-medical student at harvard in the early 1950s and continued through my training in cardiology at harvard medical school and what is now brigham and womens hospital in boston. my exposure to the realities of the medical system as it relates to blacks an

4、d other minorities continued through my experiences at the dr. martin luther king, jr. hospital in watts, california and subsequently at my current home base at the ucla school of medicine, where i have been on faculty for 32 years. during that time span from my undergraduate years to the present, i

5、 have not only witnessed some dramatic events and developments regarding the delivery of health care to the nations medically neediest populations, i have also been privileged to play a role in them. examples are my founding of three organizations which have had an impact on healthcare delivery and

6、medical education for minorities. the first one was the central recruitment council of boston hospitals in 1968, which was successful in changing the paradigm of medical education in those institutions from a history of virtually never having had any african american postgraduate trainees, e.g., int

7、erns, residents, and fellows, to a situation where hundreds have now been educated. the second one was the founding in 1974 of the association of black cardiologists, which i started as an attempt to address the special needs of the black community with respect to cardiovascular health. it has had a

8、 tremendous impact on the way in which black patients with heart disease are managed, and 32 years later, it operates out of a new multi-million dollar international library, research, and conference center in atlanta, georgia; it is generally regarded as the best small medical organization in the c

9、ountry. the third organization that i founded is the minority health institute which was initiated in 1985. it is dedicated to decreasing healthcare disparities by educating healthcare professionals about cultural competency and the need for cultural sensitivity in treating a diverse population. it

10、regularly sponsors seminars, symposia, and forums on the unique health problems of blacks and other minorities. as i developed interest in the provision of a more humane type of healthcare delivery and the elimination of healthcare disparities, i took the opportunity to write and edit a number of pu

11、blications dealing with these issues. included are the textbook of black-related diseases, an 800-page book which was published in 1975 and is a compendium of diseases peculiar to african americans;1 humane medicine, volumes i and ii, which offer a new paradigm in medical education and healthcare de

12、livery, published in 1998 and 2001;2,3 and my most recent work, eliminating healthcare disparities in america: beyond the iom report, which is now in press and will be available in early 2007. the latest book is an edited compilation of evidence and wisdom on the subject by many of the best experts

13、in the nation. all of the information above serves as background from a personal perspective for our consideration of the theme of this essay, which has to do with how cultural diversity and cultural competency are interlinked with the reduction and elimination of disparities in healthcare and healt

14、h status, and how racial and ethnic bias impact on the health and welfare of those most in need of our best medical efforts. i will now offer a discourse on that theme.definitions of key termsthe concept of racethe word race is derived from the latin generatio (a begetting) and is a complex of seman

15、tic ambiguities, according to anthropologist elizabeth s. watts.4 it is a controversial expression of taxonomic interest that is useful for classification because it uses phenotypical similarities to subdivide the human species (homo sapiens) into artificial and superficial categories based on skin

16、and eye color, body proportions and facial features or physiognomy, and color and texture of the hair. it also distinguishes populations by the frequency of certain genes.5 from an anthropological standpoint, three primary categories of race are accepted by most authorities: caucasian (white), negro

17、id (black), and mongoloid (asian, yellow), but other classifications have been offered by various authorities down through the centuries.6 the attempt to organize humankind into different groups based on phenotypical characteristics originated with the swedish taxonomist linnaeus (karl von linne) in

18、 his epochal work, systema naturae (a general system of nature), written in 1735, in which he invented the binomial classification that allows all entities in nature to be described as a member of a species and a genus. in the typological classification constructed by linnaeus, caucasians, whom he c

19、alled europeans, are held in the highest regard, while the negroid types, whom he designated as africans, are held in the lowest. several other attempts have been made to classify man on a biological basis, and skin color has been the principal criterion used. ancient greek mythology related that di

20、fferences in skin color throughout the world were created when the sun god, helios, permitted his son phaeton to drive the sun chariot. phaeton was an erratic driver who flew too close to certain parts of the earth, causing the residents of those areas to become burnished, and too far away from othe

21、r areas, causing people there to have blanched skin and the climate to be cold. however, it was humans themselves, not the gods, who decided how to rank people according to the color of their skin. insulting treatises have been published by anthropologists such as carlton coon7 demeaning blacks and

22、other persons of color while exalting whites. even before coons pronouncements, there were efforts to place blacks in a different species category from whites. the most notorious example was the development of the pseudoscience of phrenology, invented by franz josef gall8 . through this thesis, medi

23、cine aided and abetted the pro-slavery forces by indicating that measurements of human skulls with calipers, pioneered by retzius,9 demonstrated that whites had larger internal skull capacity and therefore larger brains and more innate intelligence than blacks. the inference was that blacks were low

24、er creatures and were deserving of being subjugated to slavery. other scientists joined in the denigration of blacks. the pinnacle was reached on february 8, 1848, when the distinguished fellows of the academy of natural sciences of philadelphia met to hear a lecture by their most revered member, th

25、e eminent craniologist dr. samuel george morton. morton had already written his epic crania americana10 in 1839, and at the philadelphia meeting he presented an 18-year-old hottentot boy who had been sent to him from south africa by a craniologist, samuel gliddon. dr. morton, commenting on the young

26、 mans head, described it as completely foreign to the european concept of the ideal physical features for the human species. his theory of racial inferiority were taught in medical schools throughout the country and were endorsed by some of the most respected scientists and physicians of the day, in

27、cluding dr. charles meigs, dr. john collins warren, and dr. louis agassiz of harvard. thus, it is clearly seen how the concept of race was distorted and resulted in racism, bias, and stereotyping. the concept of ethnicityto escape the pejorative implications of race, ashley montague invented a new t

28、erm in 1964, ethnic group.11 because ethnic implies membership in a socially rather than a biologically defined group, the hope is that the bias and bigotry associated with the use of race can be avoided by using the terms ethnic group and ethnicity. accordingly, the ethnically relevant term african

29、 american is more preferred by some to the biologically related expression black. however, simply changing the focus from the biological to the social characteristics of a population group does not eliminate bias. it might be argued that most cases of racial discrimination are actually instances of

30、social discrimination, although this renders the bias no less onerous. the common denominator in racial and ethnic bias is the bigoted perception, developed by one group about another group that differs in some way, that the first, bigoted group is superior in some way. science and medicine are ofte

31、n used to support these perceptions, as indicated above in the phrenology example. such examples can serve as catalysts, helping to convince people in the more powerful, controlling group to accept the subjugation of others to the demands, denial of access to care, brutality, enslavement, and other

32、indignities to which racial and ethnic minorities are exposed. the bigot is somehow absolved of guilt if the people who are tortured, murdered, exploited, enslaved, or provided substandard medical treatment are seen as different and inferior, or are dehumanized. it is in the nature of prejudice, as

33、described by harvard sociologist gordon allport,12 to blame the subjugated, powerless group for the trials and tribulations with which it is beset. this might also be called blaming the victim. this prejudicial process is seen in the writings of wilhelm schallmeyer (1857-1919) in germany, who united

34、 social darwinism with the theory of innate degeneracy, which held that mental retardation, shortsightedness, mental illness, and other negative traits were caused by a degenerate constitution. in doing so, he provided the rationale for managing human reproduction that was used by the nazis against

35、the jews. this was an early example of ethnic cleansing. similar pronouncements were made by fritz lenz, a scientific theorist for nazi thought, as documented by proctor, lifton, and muller-hill.13,14,15 in more recent years, the eugenics theory, which advanced the view that society should be protec

36、ted against the perpetuation of allegedly inferior people through sterilization and isolation, was propagated by harvard professor bernard davis, the writings of harvard professors richard herrnstein and joseph murray in their book, the bell curve16, in which they allege that blacks are intellectual

37、ly inferior to whites, and in the works of jensen, eysenck, and others who have assaulted the integrity of black mental health and intellectual capacity. it is obvious, therefore, that merely substituting terms (e.g., ethnicity for race) does not eliminate racism. as medical professionals, we must d

38、evelop a sensitivity regarding these issues that will help us to manage our patients according to the special needs and considerations that they require as members of discrete racial or ethnic groups. the concept of cultureaccording to fabrega, the term culture involves a groups system of social sym

39、bols and the meanings of those symbols.17 culture looks beyond what fabrega calls the biomedical portrait of disease and involves the mores, traditions, customs, rituals, language, and patterns that are peculiar to a distinct group of people. it may have tremendous effects on the view of health care

40、 held by people in a given culture, and it can affect their understanding, trust, acceptance, and use of the healthcare system presented to them. cultural factors may also determine the extent to which an ill person understands his or her disease; as physicians, we tend to explain illness on an orga

41、nic basis (e.g., in terms of some infectious or other process affecting the skeletal, nervous, cardiovascular, gastrointestinal system, etc.). however, a patient from the maya indian town of zinacantan in the highlands of chiapas, mexico, may not be able to understand illness in the context of weste

42、rn orthodox medicine, thinking instead of disease as a foreign process or spirit entering the body.18 a patient from haiti who believes in voodoo medicine and has been treated with kerosene-soaked sugar cubes for a cold by a voodoo practitioner may not understand that he or she has developed serious

43、 renal disease because of this treatment and needs urgent medical attention to reverse it. there are many considerations surrounding the complex nature of culture and its impact on health care. clinicians should be thoroughly educated about the cultural norms that their patients observe and should w

44、ork with their system of cultural values rather than against it or entirely outside of it. the concept of religionreligious beliefs are frequently involved in patients understanding of illness and compliance with prescribed treatment. it is the most delicate of the concepts explored here. the subtle

45、ty of its nature derives from the very meaning of religion, which may be defined as a system of beliefs based on a groups faith in the power of a supreme being or beings. the impact of religion has sometimes been obstructive in the past to the advancement of science and medicine on the basis of alle

46、gedly heretical practice which seemed to contradict religious dogma; practitioners such as avicenna were burned at the stake, tortured, or ostracized for views that were out of step with prevailing religious doctrine. for instance, vivisection or dissection of the human body was forbidden for centur

47、ies in europe, and it was not until andreas vesalius published de humanis corporis fabrica (structure of the human body) in 1543 that human anatomy was studied in a thorough manner.19 religion still has a pervasive influence on medicine today. the most noteworthy example is the rejection of blood tr

48、ansfusions by jehovahs witnesses, which has led to the development of techniques for bloodless surgery and to the wider use of blood substitutes to accommodate patients who are subject to these religious restrictions. the technique of bloodless or transfusion-free surgery is even used in heart surge

49、ry, for instance, at institutions such as the university of pennsylvania hospital under charles r. bridges, jr., m.d., chief of cardiothoracic surgery.the concept of classthe idea that people in american society are separated by their membership in a certain class is not new; we often speak of lower

50、, middle, and upper-class categories, which are based upon financial status, and there is even an extension of this primary grouping schema in that many now consider that there is an underclass of extreme poverty and homelessness. there is no doubt that the financial means available to a group helps

51、 to determine the type of healthcare it receives. tudor hart20 (hart jt. the inverse care law. 1971, lancet; 1: 405-412.) has described what he calls the “inverse care law”: those who are most in need of medical care receive the least amount of it, and, we might add, the poorest quality. because the

52、 type of care one receives may be determined largely by the ability to pay for that care, this renders our system one of “wealth care” instead of health care. the interrelationship between disease, health, race, and social class has been firmly established.21 (krieger n, bassett m. the health of bla

53、ck folk. disease, class, and ideology in science. monthly rev 1986; 38, 74-85.) it is important to recognize that looking at the intersection of class, race, and healthcare delivery, race is the most predominant factor in determining access to care and quality of care received. this means that healt

54、hcare disparities occur more commonly in blacks than in whites even when individuals analyzed from each group have the same class, educational, and health insurance status. health insurance coverage is one of the determinants of class. it is recognized that more than 46 million americans, or about 1

55、6 percent of the population, are uninsured or underinsured. most of these individuals are poor minorities, particularly hispanics and african americans. correcting this problem must be at the top of any agenda to remedy the healthcare crisis. healthcare disparitiesin 2003, the institute of medicine

56、of the national academy of science released the results of a long investigation commissioned by congress on racial and ethnic differences in healthcare delivery, access to care, outcomes of treatment, and other parameters. these results were published in the book, unequal treatment: confronting raci

57、al and ethnic disparities in healthcare.22 i was fortunate to be a reviewer for the book. the study committee defined disparities in healthcare as “racial or ethnic differences in the quality of healthcare that are not due to access-related factors or clinical needs, preferences, and appropriateness

58、 of intervention”. in other words, these differences are due to discrimination, bias, and prejudice. the iom report, as it is popularly called, identified several areas in which disparities are found, including differences in amputation rates, with blacks having a 3.6 percent higher rate than their

59、white medicare peers, according to gornick (1996). the iom report also emphasized that there is a range of patient-level, provider-level, and system-level factors that may be involved in racial and ethnic healthcare disparities, beyond access-related factors. over 100 citations of healthcare disparities covering virtually all fields of medicine were exemplified in the iom report. no attempt will be made in this presentation to detail the numerous problems which exist. the book may be accessed onlin