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October 8, 2010

Diversity, the Enlightenment, and American Medicine

By David Paulin
The story of America (the one Obama won't tell you) starts with British settlers and their vision of a new country. Next came European immigrants who assimilated into the culture created by those settlers.

And despite speaking different languages and coming from myriad cultures, those settlers and immigrants had much in common. Among other things, they were children of Europe's 18th-century Enlightenment -- an era in which reason and science became a new religion, albeit a secular one.

Some of America's most breathtaking achievements have been in medicine -- the science of healing human beings. And pre-ObamaCare American medicine is today the envy of the world. Dr. John Olsen, a prominent cardiologist, wrote with much pride about this in an op-ed for the Seattle Times:

Our students are the product of intense competition ... Outstanding medical centers have arisen in most major cities in the country, attracting talent from around the world ...

Our national conferences routinely attract thousands who seek to validate their ideas on the most competitive stage. The best journals, the most publications, and the most scientific accolades are garnered by physicians working in this country.

We have deciphered the genome and developed dialysis, bone-marrow transplantation and catheter-based cardiac interventions. Our population can get advanced imaging studies or virtually any laboratory test performed promptly and reliably. A simple call to 911 provides instant access to a remarkable countrywide system of emergency care.

Could anything be missing from this upbeat assessment from a proud American physician?

"Yes," says diversity expert Nydia Gonzalez: American medicine needs more "cultural sensitivity" in order to accommodate the non-Western beliefs of new immigrants from non-Western traditions -- immigrants who are changing America's demographic landscape. Indeed, as America's demographic landscape changes, American medicine must change, too, becoming more culturally sensitive and diverse, Gonzalez contends in an article published in the Austin American-Statesman: "Dose of cultural sensitivity helpful in health care setting."

American medicine, in other words, is no longer primarily about science and values rooted in the Age of Enlightenment. And nor is it about intense competition, in which medical schools and medical centers vie for the best and the brightest: It's now about "diversity," too, says Gonzalez.

Gonzalez, associate vice chancellor for institutional diversity at Tarrant County College in Forth Worth, Texas, says it's not enough for a physician (or translator) to speak to a patient in the patient's own language. They also must demonstrate "sensitivity to and respect [for] ... religion, customs, values and traditions -- all these values around health care that shape the approaches that we take to health and illness."

In other words, science rooted in 18th-century Enlightenment values is no longer the cornerstone of American medicine.

Could what happened at a Minneapolis medical center be a harbinger of things to come? To accommodate a large population of Muslim immigrants from Somalia, hospital administrators at "Hennepin County Medical Center developed an obstetrical staff made up almost entirely of women after Muslim Somali women objected to having male doctors deliver their babies," reported the New York Times last year.

Nydia Gonzalez may well applaud such cultural sensitivity. But couldn't all those Somali women have been "culturally sensitive" to American medical traditions? Or does cultural sensitivity not apply to Western traditions and values?

As an expert on diversity and cultural sensitivity, Gonzales has an impressive background, and an interesting one. She previously held "diversity-related" positions at Yale University and the M.D. Anderson Cancer Center in Houston, noted the Statesman. Even more interestingly, she speaks with much insight about "cultural sensitivity" because she was raised in what might be considered a non-Western tradition.

Gonzales, you see, grew up in South Texas, where she was exposed to non-Western medical care -- the type found in backward parts of Mexico.

As the Statesman explains:

Growing up with insight into two cultures provides the backdrop for Gonzalez's interest in cultural competence among health care providers. She said that when she had a fever as a child, a curandera, or faith healer, was called to the family's house to rub an egg from the crown of the girl's head down to her feet. Once the egg was cracked and left in a saucer under her bed overnight, the state of the egg indicated whether her illness was caused by mal de ojo, the evil eye -- a concept that exists in cultures around the world.

If that wasn't the case, her family figured she likely had an infection easily treated by driving to a pediatrician's office in Weslaco for a shot of antibiotics.

In the time and place where Gonzalez grew up -- in the 1950s in South Texas -- it was common for Hispanic families to seek health care from a curandera as well as a medical doctor, she said. Now that she is an expert in organizational diversity, she has a name for the treatment she was given.

"I didn't know it then, but what I was really experiencing was integrative medicine," Gonzalez said.

What a strange way to describe such treatments -- as part of "integrative medicine." For those who've never heard of "integrative medicine," it's a relatively new approach to medical care, a holistic approach practiced at some medical centers in which traditional care is combined with things like nutrition, fitness, and yoga.

I'm no medical expert, to be sure, but I doubt that "integrative medicine" would involve the Mexican voodoo that Gonzalez was exposed to as a child.

Putting forth the case for "cultural competence" among physicians, Gonzalez points to America's changing demographic landscape, where white "Anglos" (as she might put it) are heading toward minority status. It's a landscape, of course, that's far different from the one created by British settlers and European immigrants, now that millions of immigrants are here from non-Western and non-European cultures: Africa, the Middle East, Latin America, and the Caribbean.

American medicine and physicians must change to accommodate them, says Gonzalez, who offered this mouthful of insight:

There's a compelling need for cultural competence just by responding to projected demographic changes to eliminate long-standing disparities in people of diverse cultural backgrounds. Really, nowhere are the divisions of race, ethnicity and culture more sharply drawn than in the issue of health care in the United States.

Besides "cultural sensitivity," Gonzalez maintains that American medicine needs lots more "diversity," too. As the Statesman explains,

"In response, health care organizations have been issued 14 national standards known as Culturally and Linguistically Appropriate Services (CLAS) by the Office of Minority Health, a division of the U.S. Department of Health & Human Services. CLAS mandates on providing translation services at no cost to patients are required of health care organizations that receive federal funds. Overall, the list of guidelines calls for care that's respectful of a patient's "cultural health beliefs and practices and preferred language." The standards also suggest that a health care organization's staff should reflect the demographics of the surrounding community and should receive training in cultural sensitivity.

Besides interviewing Gonzalez, the Statesman's reporter dug up a hip physician in Austin who's a big fan of cultural sensitivity training. Dr. David Kessler told the paper that "[w]hether it's a class or reading the newspaper every day, it's incumbent upon you to get that training. That's what it means to be an informed citizen in this country."

Dr. Kessler, I have a recurring nightmare: It's that I wake up in a hospital run by you and Nydia Gonzalez, a hospital in which people are hired based not on merit, but on their ethnic backgrounds and skin colors. This is a hospital in which, in the room next to mine, I can hear Nydia Gonzalez's witchdoctor performing the "egg" treatment that Gonzalez claims is part of "integrative medicine" -- a ceremony consistent with your cultural sensitivity.
on "Diversity, the Enlightenment, and American Medicine"