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It’s your first time in a U.S. hospital // You don’t speak the language // You can’t read the signs // How can you tell doctors the red welts on your back are the result of a healing ritual, not a sign of abuse?

Care Across Cultures

By Linda Keslar // Photographs by Erica Berger // Winter 2007
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Ann Tang

There’s no wait for culturally sensitive care at the Bilingual Chinese Module at Kaiser Permanente Medical Center in San Francisco, where the module’s chief, physician Anne Tang (in red dress and shoes), confers in Chinese with a patient.

If you had asked Lia Lee’s parents what caused their daughter’s epilepsy, they might have told you, through an interpreter, about her soul wandering from her body. They might have said, too, that the medications her Western doctors prescribed were frequently changed, difficult to administer and caused side effects—and so they failed to follow the prescriptions. They might even have suggested things could have turned out differently had Lia been born in the Lees’ native Laos. But her birth was at a hospital in Merced, Calif., and at three months of age, the girl suffered her first epileptic seizure. Others followed quickly, becoming increasingly severe, and despite compassionate, often heroic care from physicians and nurses during 17 hospitalizations, Lia sustained irreparable brain damage.

In the Hmong language, epilepsy is known as qaug dab peg, literally “the spirit catches you and you fall down” —the title of the highly regarded book by Anne Fadiman, which recounts Lia’s failed journey through the American health system in the early 1980s, a passage beset by language barriers and a clash of cultures. Lia’s doctors put their faith in a regimen of antiepilepsy drugs, while her family, blaming malevolent spirits, wanted to appease them with animal sacrifices and other traditional healing techniques. Lia, caught in the middle, did not get well.

Fadiman’s account mirrors the experiences of legions of immigrants and their American health care providers. Those new to this country, particularly when they come from non-Western cultures, face many hurdles in receiving care, and similar problems plague native-born minority populations. Moreover, to varying degrees, these issues affect all Americans as they set out to navigate the medical culture. In the case of immigrants, not speaking the language is often only the beginning; they may also wait longer before going to the doctor—in some cases, until treatable conditions have become dangerous—or have different expectations about their care. And their beliefs, often unfamiliar to their new doctors and nurses, can influence whether they comply with a treatment plan.

Volunteer health educators
Instructive if not nutritious, plastic food is a teaching tool for volunteer health educators in the Armenian community around Glendale, Calif.

It’s a problem most health care organizations recognize with a growing sense of urgency. “Hospitals only have to look outside their doors to see increasingly diverse populations,” says Rick Wade of the American Hospital Association. In response, Wade estimates, some three-quarters of the 5,000 hospitals in the United States have embarked on “cultural competence” programs, an array of patient education, prevention and intervention strategies related to ethnicity, religion and language. Moreover, there’s a growing emphasis on formulating standard policies and practices to address cultural issues of care. But it’s far from clear what those standards should be. “Right now, people are struggling with defining cultural competence and how to achieve it,” says Anne Beal, a physician and senior program officer with the Commonwealth Fund, a New York City foundation focused on health care issues.

That uncertainty doesn’t stem from lack of attention. Reducing disparities in health care has received serious attention since the mid-1980s after a government study painted a bleak picture of care afforded to African Americans and other minorities. Since then, an array of government and private-sector offices and programs have been launched, including the Office of Minority Health (OMH) in the U.S. Department of Health & Human Services. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, a 2002 report by the Institute of Medicine (IOM), added to the sense of crisis, documenting lower-quality care for minorities even when insurance status, income, age and severity of illness were taken out of the equation. The IOM’s findings, says Beal, “turned the lens on the medical system itself,” ratcheting up the pressure for fundamental changes.

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1.The Spirit Catches You and You Fall Down, by Anne Fadiman [Farrar, Straus and Giroux, 1997]. This account, of a child lost between two ways of healing despite heroic efforts by everyone involved, has become an icon of the cultural competence movement.

2.Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, by the Institute of Medicine [The National Academies Press, 2002]. Landmark analysis of health care disparities affecting racial and ethnic minorities that found evidence of health care providers’ stereotyping and biases as contributing factors.

3. “Language Barriers to Health Care in the United States,” by Glenn Flores, The New England Journal of Medicine, July 20, 2006. Analysis of research revealing that hospital patients with limited English proficiency are at risk for poor and sometimes life-threatening care.

4.“Cultural Competence and Health Care Disparities: Key Perspectives and Trends,” by Joseph R. Betancourt et al., Health Affairs, March/April 2005. Discusses how cultural competence is emerging as an important strategy to address health care disparities in managed care, government and academia.

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