Building Cultural and Linguistic Competence
When there is a very dense cultural barrier, you do the best you can, and if something happens despite that, you have to be satisfied with little success instead of total successes. You have to give up total control. . . .
—Anne Fadiman (2001)
■ Objectives
1. Discuss the underpinnings of the need for cultural and linguistic competence. 2. Describe the National Standards for Culturally and Linguistically Appropri-
ate Services in Health Care. 3. Describe institutional mandates regarding cultural and linguistic
competence. 4. Articulate the attributes of CULTURALCOMPETENCY and CULTURALCARE.
The opening images for this chapter depict the foundations for the building of CULTURALCOMPETENCE. The first image is that of a dandelion that has gone to seed (Figure 1–1). All of the seeds are united, yet each is a discrete entity—they represent the numerous facets necessary for cultural competence. Figure 1–2 is that of a “fake door” in Vejer de la Frontera, Spain. It is a reminder of personal beliefs that shut out all other arguments and ways of understanding people. Figure 1–3 is a translucent door in Avila, Spain, where it is possible to look into a different reality and because it is not locked—one can open it and recognize
Figure 1–1 Figure 1–2 Figure 1–3 Figure 1–4
4 ■ Chapter 1
the view of others. Figure 1–4 represents the steps to cultural competency. A more detailed discussion of each image follows in the forthcoming text.
In May 1988, Anne Fadiman, editor of The American Scholar, met the Lee family of Merced, California. Her subsequent book, The Spirit Catches You and You Fall Down, published in 1997, tells the compelling story of the Lees and their daughter, Lia, and their tragic encounter with the American health care delivery system. This book has now become a classic and is used by many health care educators and providers in situations where there is an effort to demonstrate the need for developing cultural competence.
When Lia was 3 months old, she was taken to the emergency room of the county hospital with epileptic seizures. The family was unable to communicate in English; the hospital staff did not include competent Hmong interpreters. From the parents’ point of view, Lia was experiencing “the fleeing of her soul from her body and the soul had become lost.” They knew these symptoms to be quag dab peg—“the spirit catches you and you fall down.” The Hmong re- garded this experience with ambivalence, yet they knew that it was serious and potentially dangerous, as it was epilepsy. It was also an illness that evokes a sense of both concern and pride.
The parents and the health care providers both wanted the best for Lia, yet a complex and dense trajectory of misunderstanding and misinterpreting was set in motion. The tragic cultural conflict lasted for several years and caused considerable pain to each party (Fadiman, 2001). This moving incident exem- plifies the extreme events that can occur when two antithetical cultural belief systems collide within the overall environment of the health care delivery sys- tem. Each party comes to a health care event with a set notion of what ought to happen—and, unless each is able to understand the view of the other, complex difficulties can arise.
The catastrophic events of September 11, 2001; the wars in Iraq, Afghanistan, and Libya; the countless natural disasters such as Hurricane Katrina and the earthquakes in Haiti and Japan; and our preoccupation with terrorist threats have pierced the consciousness of all Americans in general and health care providers in particular. Now, more than ever, providers must be- come informed about and sensitive to the culturally diverse subjective meanings of health/HEALTH,1 illness/ILLNESS, caring, and curing/HEALING practices. Cultural diversity and pluralism are a core part of the social and economic en- gines that drive the country, and their impact at this time has significant impli- cations for health care delivery and policymaking throughout the United States (Office of Minority Health, 2001, p. 25).
1This style of combining terms, such as health/HEALTH, will be used throughout the text to con- vey that there is a blending of modern and traditional connotations for the terms. The terms are de- fined within the text and in the glossary. Furthermore, when terms such as CULTURALCOMPETENCY and CULTURALCARE and others are written in all capital letters, it is done so to imply that they are referring to a holistic philosophy, rather than a dualistic philosophy.