Cultural Competence in Medicine: Western Approaches to Healthcare and their Implications on Immigrants’ Care and Disease Management

Abstract

A body of research demonstrates how contemporary Western approaches to healthcare can lead to ineffective care. This is especially prevalent with respect to groups of recent immigrants whose cultural beliefs impact their view of illness and treatment, deviating from the “standard of care” that Western practitioners are accustomed to. For example, some Hmong people choose to preserve their cultural traditions, and avoid doctors, presuming their beliefs will be ignored and belittled by Western medical practitioners. This research builds on the efforts of anthropologist Arthur Kleinman and other social scientists to investigate how to more effectively provide care for recent immigrants through cultural brokerage. Studies show cultural brokerage is critical for creating effective doctor-patient interactions, and neglecting it compromises care. Drawing from case studies that examine medical experiences from the perspectives of three distinct groups: (1) Hmong immigrants; (2) South American immigrants; and (3) American clinicians, this study investigates the benefits and challenges of implementing cultural brokerage in medical care. By addressing the issue from the viewpoint of the patient and provider, this research aims to promote the implementation of these practices in hospitals and clinics worldwide, making cultural understanding and openness to holistic approaches to illnesses a more common practice amongst practitioners.

Introduction

The term “melting pot” came into usage in 1908 to describe the fusion of cultures that had made up the United States (Crossman 2011). There is no singular culture or set of beliefs that guides the country of the U.S., (Crossman 2011). In fact, cultural norms are quite varied across the United States and can cause division (Thomspon 2010). This is the case partly due to the United States being the home of culture wars: debates over issues of public policy. The origin of the “culture wars” dates to the 1960s, when a counterculture emerged and traditional values were challenged (Thompson 2010). According to Thompson, American public opinion is “considerably more ambivalent and internally inconsistent than the image of a culture war implies” (Thompson 2010).

Recently, the immigrant population in the U.S. has been growing. According to the U.S. Census Bureau, the number of current residents born outside of the U.S. climbed by nearly a million last year, rising 14% since 2017, reaching a record high of just over 46 million immigrants with varied statuses, from naturalized citizenship to green card holders, to undocumented (Rose 2023). More specifically, in August 2021, the U.S. Census indicated there has been a radical change in the racial demographics of the U.S. in the last decade, from 2010 to 2020. While the U.S. Hispanic population was 16.4% in 2010, it reached 18.7% in 2020. Similarly, the Asian-American population increased by 35% from 2010 to 2020, which is the fastest-growing ethnic segment of the US population (US Census 2021). This study focuses on the medical treatment and cultural brokerage of two distinct groups categorized under two immigrant populations: Mexican-Americans, who generally identify as Hispanic or Latino Americans, and Hmong Americans, who identify as Asian Americans.

A central dimension of culture is communication and language. With the rise in immigration in the US, cross-cultural communication increasingly occurs in medical environments. However, cultural competency training has remained stagnant, which leads to an increase in miscommunication and misunderstandings between medical practices and coworkers, and medical practitioners and patients as colloquial language, body language intentions, and physical gestures are not standard across different cultural groups (Kastanakis and Voyer et al. 2013).

In an article, “Intercultural Misunderstandings: Causes and Solutions,” Michael B. Hinner states that “Intercultural misunderstandings involve a number of complex causes which can easily escalate into conflicts.” Denotative meaning usually signifies the objective meaning of a word or signal within a culture, but when communicating interculturally, the same word may not carry the same denotative meaning across cultures (Hinner 2017). One example of a simple misunderstanding related to language from Hinner comes from the use of the phrase “faculty.” The German word “Fakultät” refers to an “organizational unit at a German university,” while American English assigns the word department that meaning. Yet, an American university department has faculty members; for example, the department’s teaching staff.

Cultural misunderstandings are especially detrimental in contemporary U.S. healthcare settings. A true example of the struggles immigrants face in Western healthcare is depicted in The Spirit Catches You and You Fall Down book, by Anne Fadiman, an essayist and reporter. This book, an award-winning thorough investigation of the medical troubles of a young girl named Lia Lee, highlights the importance of cultural competency in healthcare. In the beginning of the book, Lia, a young Hmong child who experienced a seizure. By the time she got to the hospital her seizures stopped and the doctors prescribed her antibiotics for a cough she had because her sisters could not communicate to the doctors that she previously had a seizure. The hospital’s lack of interpreters and translators played a large role in this miscommunication. There was one cleaning staff who spoke Lao, which isn’t even Hmong, and even he wasn’t on staff at the time (Fadiman 1997). The book explores how the doctor-patient dynamic is influenced by aspects of culture, such as language, religion, traditions and ways of life (rituals and customs). There is a wide variation within a larger cultural grouping, regional or otherwise, that set of beliefs about health and disease, treatment and “cure.” Our belief systems can even influence how we experience illness. In the case of Lia, the cultural difference transcended just language. In Western medicine, epilepsy is considered an abnormal condition with negative health effects that should be treated, the Hmong view it as a gift. There exists a common Hmong belief that those who are epileptic are gifted with the ability to enter the spirit realm (Fadiman 1997). This story highlights how cultural beliefs may require medical practitioners to alter their “standard” approach and individualize the care they provide.

Knowing these cross-cultural miscommunications are becoming more prevalent in the medical field, this study investigates what factors of U.S. approaches to healthcare, which often do not account for patients’ unique cultural backgrounds, influence recent immigrants’ care and disease management and what effect they have on that care.

Background and Literature

To meet this study’s objective of examining cultural brokerage in healthcare through an analysis of peer-reviewed empirical research, a review of scholarship and analysis of recent research on cultural brokerage was conducted.

To research the importance of cultural brokerage in healthcare, I searched “Google Scholar” and “JSTOR.” Moreover, information was drawn from Anne Fadiman’s 1997 book The Spirit Catches You And You Fall Down. All articles and casework, as well as the book, were chosen carefully in order to optimize credibility by narrowing the year each source was written, the quantity of citations each source has received, and the named authors of each piece.

Once legacy data was collected and analyzed from a sufficient quantity of articles, I aimed to bridge the gap between the perceptions and experiences of medical practitioners in the healthcare industry and those of distinct immigrant groups: (1) Hmong people; and (2) Mexican-Americans. Data was then categorized into four groups: (1) information surrounding cultural brokerage in the modern Western medical system; (2) the background and experiences of the Hmong people; (3) the background and experiences of Mexican-Americans in healthcare; and (4) the viewpoints of physicians in the U.S. The objective of culminating unique research groups is to provide an optimally well-rounded comprehension of cultural competence in medicine.

Defining Cultural Brokerage and its Relevance to Health

Cultural Brokerage is defined as the bridging of the gap between the lifeworld and medicine in cross-cultural perspectives in healthcare, like having a cultural translator. The “lifeworld” is denoted as the “immediate, everyday, concrete whole of the subjectively experienced world” (Dodd 2015). In other words, it is the ground of all knowledge in one’s lived experiences. In cases in which patients come from a more marginalized class, educational, or ethnic background, the lifeworld-medicine gap may be further widened and complicated; thus additional cultural brokerage work is needed. Given the widely documented gaps between the cultures of Western medicine and the lifeworld of Hmong and Mexican-American patients, one can argue that cultural brokering is required, potentially, in any doctor-patient interaction, and not just in cross-cultural settings. Researcher Ming-Cheng Miriam Lo emphasizes the importance of patient-centeredness in her article on cultural brokerage: culturally competent healthcare and having compassion for the needs of individual patients (Lo 1997). Lo proposed a five-dimensional frame-work for conceptualizing patient-centeredness: (1) biopsychological perspective; (2) patient-as-person; (3) sharing power and responsibility; (4) therapeutic alliance; and (5) doctor-as-person (Lo 1997). While the voice of medicine is technology-centered, the patient’s lifeworld voice is largely fragmented due to their experience being multifaceted and complex. The suppression of the lifeworld voice by the institution of Western American medicine is considered highly problematic, as it makes distorted communication, erratic diagnoses or inappropriate treatment plans more likely (Lo 1997). It is vital to find ways to elicit the lifeworld voice of patients; focusing on patient centeredness is one way to do so.

Lo conducted a research study utilizing 24 open-ended, in-depth interviews with primary care physicians who self-identified as having worked intensively with limited English proficiency patients (LEP) and who expressed interest in promoting culturally competent healthcare (Lo 1997). It was concluded that the doctors’ cultural brokerage often required expensive resources that could nurture deeper clinical interaction and continuity of care (Lo 1997). Given the current political economy of the U.S. healthcare system, there were few resources available to fund longer consultations, promote continuity of care, or encourage regular doctor visits to the home, especially at low-income clinics frequented by immigrant and minority patients. There is insufficient time for doctors to see patients, causing providers to rush through the appointment, causing patients to feel uncared for and unheard (Lo 1997). However, the healthcare system is largely constrained by finances, which dictate the quality of care patients receive (Lo 1997). Moreover, the implementation of patient centeredness is limited by a lack of medical resources within the healthcare system, making it difficult to employ cultural brokerage (Lo 1997).

Kleiman draws upon multiple case studies to emphasize the distinction of “illness” versus “disease” (Kleinman 1978). The American model of care is often overly focused on treating the condition of patients. On one hand, patients identify illness problems as “the difficulties in living resulting from sickness.” Conversely, doctors often disregard illness problems because “they look upon the disease as the disorder.” Both views are, however, insufficient, according to Kleinman (Kleinman 1978). The functions of “curing and healing” are likely more productive when done together (Kleinman 1978). It is crucial to break out of the modern “mediocentric orientation” of Western medicine to optimize clinical practice (Kleinman 1978). Clinicians might be blinded by the importance of social and cultural factors’ influence on disease despite the fact that medicine is less relevant in the treatment of patients without biological diseases. One background study revealed nearly 50% of patients listed the reason for seeking care in the U.S. and Taiwan as the treatment of illness problems (Kleinman 1978). In one case study, a 33-year-old Chinese man came to the doctor with symptoms of what the doctor concluded was a mental disorder (Kleinman 1978). However, the patient “denied feeling depressed.” In fact, he attributed his symptoms of dizziness and weakness to not getting enough blood. He began treating himself with “traditional Chinese herbs and diet therapy” while receiving psychiatric care in which he spoke to psychiatrists of his problems in detail. The patient “responded to a course of antidepressant medication with complete remission of all symptoms,” but denied that he was suffering from a mental illness due to his belief that he was actually suffering from a “wind” disorder, otherwise a lack of blood to his body. This case shows how “culture shapes the biomedical view of clinical reality;” while American doctors did not believe the Chinese patient, they learned to treat him while understanding his beliefs and perception of the illness in order to treat him (Kleinman 1978).

The case of the Hmong

History

The identity of the Hmong people is shaped by their historical independence and isolation, living in mountainous regions in northern China approximately 4,000 years ago (Fadiman 1997). Their geographical isolation “heightened their linguistic and cultural distinctiveness.” In the early 19th century, the Chinese government persecuted the Hmong people due to their refusal to “integrate into Chinese society.” Since 1975, more than 200,000 Hmong have fled Laos as refugees. During the 1955-1975 Vietnam war, a portion of the Hmong in Laos were recruited by the U.S. CIA to fight against Communist forces in Laos (Yau). Two years later, the U.S. gave up its involvement in the Vietnam war in 1973, and the North Vietnamese and Pathet Lao Communists took Laos over. A segment of the Hmong were suspected of being U.S. spies and fled Laos to escape persecution (Vang and Flores, 1999). As a result, Hmong people began settling in different countries, including Thailand, Vietnam, and northern Laos. Today, “the Hmong people have spread out all over the world; China, Vietnam, Laos, Thailand, Burma, Australia, Canada, France, Germany and the United States are among the countries to which they have migrated” (Vang and Flores). However, the Hmong retained their cultural practices worldwide. A study in the Catesol journal states, “the ability of the Hmong people to preserve their traditional beliefs and practices has been one of the trademarks of their culture” (Biliterate Voices of Hmong Generation 1.5 College Women: Suspended between Languages in the US Educational Experience). Approximately 90 percent of Hmong refugees have been resettled to the United States. The first flow to the United States included approximately 3,500 Hmong by December 1975. The 2000 Census counted 102,773 foreign born who self-identified as Hmong in the U.S. Yet many Hmong chose to stay in refugee camps in Thailand, waiting to return to Laos (Yau). Moreover, the Hmong have largely been displaced, and the U.S. was central to their upheaval and instability by contributing to the multitude of challenges faced by the Hmong American community.

Perception

Hmong people interpret seizures to be a spiritual issue, not a medical disease. As such, traditional Hmong beliefs are at odds with modern medical intervention. In Fadiman’s book, it is evident Lia’s parents value a holistic treatment to illness as more effective than treatment with medicine. In fact, Lia’s parents believed Lia’s seizures were not the main concern. They believed her seizures occurred when her soul left her body, oftentimes as a result of a loud sound. Additionally, by the time Lia was four and a half, “Lia’s parents had been told to give her at various times, Tylenol, ampicillin, amoxicillin, Dialitin, phenobarbital, erythromycin, Ceclor, Tegretol, Benadryl, Pediazole, Vi-Daylin Multivitamins with Iron, Alupent, Depakine, and Valium.” These medications were prescribed in varying combinations, and no doctors hesitated to question whether Lia’s parents were capable of giving her the prescribed doses. When Lia returned to the hospital with indicative low levels of medication in her body, doctors called Child Protective Services who moved Lia to a different household for 6 months. Despite receiving the proper dosage of medications, Lia’s seizure frequency worsened until she returned to her family. Although Lia’s family attempted to comply with the orders of the doctors, they believed Txiv neebs could optimally treat Lia. Txiv neebs are Hmong shamans who negotiate with spirits to ensure the health of their patients, and most American doctors disregarded the Hmong family’s perceived importance of these shamans to attempt to treat Lia (Fadiman, 1997).

Cultural Policies and Practices

Furthermore, the Hmong have many distinct practices which underscore their uniqueness as a cultural group. In Fadiman’s book, The Spirit Catches You And You Fall Down,” Fadiman describes the common practice of most Hmong women to bury their placentas after giving birth. As such, it was sensible for Foua, Lia’s mother, to desire the doctor to give her Lia’s placenta to take home and bury. However after giving birth to Lia in the Merced Community Medical Center on July 19, 1982, the doctors incinerated Lia’s placenta. This was done because doctors generally feared that allowing the Hmong to take the placenta home may result in its consumption by mothers or the possible spread of hepatitis B (Fadiman, 1997). Moreover, childbirth in Hmong culture “is closely associated with supernatural powers.” Researcher Pranee Liamputtong Rice conducted a study to examine the beliefs and practices of Hmong women in Australia. Analyzing 27 Hmong women, three shamans, and two medicine women, it was found that in the Hmong tradition, the “first 30 days after birth is seen as the most dangerous period for a new mother.”

Importantly, the 27 Hmong women who were analyzed came from Laos where they lived in high mountainous regions. Their environments changed drastically, from living in pure isolation to living in a diverse community. Regardless of the change to a new social environment, the majority of Hmong seem to retain their traditional cultural practices, especially those surrounding childbirth. The Hmong “believe in reincarnation,” and they are “patrilineal and patrilocal.” Family names follow a clan system, and there are “ten clans in Melbourne.” The average Hmong family is large, which is attributed to the central role of family to the Hmong people. In this study, most Hmong women are described to have “four to six children, and it is likely they will continue to have more.” Traditionally, the “Hmong put a high value on having many children,” specifically boys because they can help in farming and continue traditional practices such as worshiping ancestral spirits, caring for their parents in old age, and carrying on the clan name. Such traditional customs are still practiced. Moreover, traditional customs in the 30 days after childbirth are crucial for a mother, as this is the period of time in which women are most vulnerable to “illnesses and misfortune,” according to the 27 Hmong women.

They practice 30 days of confinement post-birth, and list several restrictions. For one, it is widely believed a Hmong woman’s first meal post birth should be a poached egg with white pepper because “this will give a woman strength which is lost during the act of giving birth,” one Hmong test subject stated. Another Hmong woman said, “The truth is that the pepper is the most important. The pepper will help to wash your body so that it won’t give you afterbirth pain.” The elderly emphasize the consumption of hot food after birth so that the “blood will run properly.” If you eat cold food, “your blood will clog after birth.” Hmong women refer to food that is “poisonous” as “jab,” which “can be fatal because it is wrong to the body.” This prohibited food includes “banana and bamboo shoots,” describes a Hmong woman. Another woman said “if you eat ice it can kill you” because of its cold properties. Similarly, green vegetables and fresh fruits are seen as “cold” and are believed to “cause asthma, coughing and swelling in old age.” After childbirth, a new mother is prohibited from entering another clan’s homes. It is believed that “because she is still bleeding her `polluted’ body may weaken the clan spirit (dab qhuas) and bring into that household bad health, illness and perhaps even death.” One Hmong woman stated, “If you forget and you go into their house then you have to go and have ua neeb (shamanic ritual) to heal the house and to clean out your uncleanness, your 28 Midwifery blood, so that the spirit txhiaj meej will come back to live in their house.” Herbs are crucial in maintaining the health of a new mother. Chicken herbal medicine, otherwise called tshuaj quib by the Hmong, is prevalent in confinement. Many new mothers use these herbs to relieve pains after birth, replacing strength lost during birth, providing a good appetite, and improving weight loss during birth. The ten practices above are unique to the Hmong cultural group and have been proven difficult to maintain living in a country surrounded by people of different backgrounds. For one, one Hmong woman stated “in this country (Australia) there is no open fire but there is a heater so we use it.” In fact, the majority of the 27 Hmong women in this study exclaimed their frustrations with attempting to continue their practices in a new country. Some “women do not strictly observe all of the Hmong traditions. This has caused ill health in these women,” one Hmong mother stated. She talked about her daughter who “experienced poor health.” She went to the hospital for about two weeks, and despite the doctors performing various examinations and X-rays, she did not get better until her aunt performed a shamanic ritual (called ua neeb by the Hmong). She received Hmong medicines and her aunt covered her legs with a blanket. Her mother recalled, ‘This made her legs have warmth again, and she got better.” Overall, the Hmong women state to have difficulties abiding by the restrictions of their 30 day confinement period after giving birth in Australian hospitals. While in Australian hospitals “women are encouraged to take active care of their new babies,” the new Hmong mothers view this as problematic because it prevents many of them from resting after birth. The study’s results suggest “Western health professionals must remain aware and respect the indigenous beliefs and practices linking the events of reproduction and the health status of women” (Rice).

In addition to the unique cultural practices of Hmong after child birth, the Hmong retain traditional customs throughout their lifetime. In a study on “Hmong American Adolescents’ Perception of Ethnic Socialization Practices,” researchers MyLou Y. Moua and Susie D. Lamborn interviewed 23 14- and 18-year-old Hmong-American adolescents. A content analysis was conducted of the responses from the interview, and the analysis resulted in “10 categories of ethnic socialization.” These practices included (a) participating in cultural events, (b) sharing history, (c) preparing traditional food, (d) language use, (e) wearing traditional clothes, (f) strengthening family ties, (g) preparation for marriage, (h) participation in religion, (i) encouraging ethnic pride, and (j) expressing high expectations.

The results revealed that 65.2% of the adolescent respondents participate in the annual New Years celebration, funeral rituals, wedding ceremonies, or traditional dances. One 15-year-old boy reported that “his mother encouraged him to observe cultural rituals at funerals, such as listening to the songs performed by Hmong elders using the queej, a flute-like instrument made from bamboo.” 56.5% of the participants mentioned that mothers talked about Hmong history or their specific family history. One 15-year-old girl said, “She [mother] shares stories about the Hmong and how they moved down from China to Laos and Thailand and how they are scattered everywhere.” Additionally, a total of 52.2% of the participants said that their mothers encouraged them to wear traditional clothing. “The cultural experience can include wearing the clothes, helping to make it, and learning to wear it. The adolescents also learn traditional quilting and embroidery skills that are used to decorate the clothes and other items.” Ethnic socialization related to cooking and food was mentioned by 52.2% of the participants. “Some adolescents mentioned that they helped their parents with picking the vegetables and selling them at the local farmers’ markets,” and the use of the Hmong language was mentioned by 52.2% of the participants as an important aspect of ethnic socialization. One 15-year old girl indicated that her mother encourages her to learn the Hmong language: “She really wants us to speak Hmong fluently. At least know how to read and write in Hmong because it will help her out a lot, you know.” Also, religion as a form of ethnic socialization was mentioned by 39.1% of the participants. Shaman is the traditional Hmong religion; “the Shaman religion includes ancestral worship and maintaining spiritual connections with deceased family members.” Most Shaman Hmong believe that when a person loses one of his or her souls, the person will eventually become sick and may die. One 15-year-old girl stated, “My dad’s cousin is one of the shamans. She [mother] really believes in it. [So, can you explain something, like what Shaman represents?] It’s sort of like calling the spirit. If you lost your soul, you have to call a shaman to come in and go find your soul.” On the other hand, a few of the Hmong American participants were Christian and many view the church as a way to remain connected with other Hmong people and to the Hmong culture. The results of this study underscore the significance of traditional practices to the Hmong people outside of those surrounding childbirth. Participants in this study described their mothers as those who encourage them to participate in cultural events, teach them about history, and help them learn food preparation, understand the language, and wear traditional clothes (Moua and Lamborn).

Cultural Barriers in the Medical World

Many Hmong Americans have trouble communicating their beliefs due to language and communication barriers. A research study labeled “Technical Meets Traditional: Language, Culture, and the Challenges Faced by Hmong Medical Interpreters” reveals the communication barriers that exist in the modern medical world. Despite the existence of translators, this study found various factors that affect the ability of interpreters to make accurate medical interpretation for Hmong-speaking patients. In the United States today, approximately “67 million people (23% of the total population) are of a non-White ethnicity, and 61.6 million individuals speak a language other than English at home.” As such, the need for intercultural communication, which denotes a type of social interaction between people of different cultures, between patients and healthcare providers is greater than ever in the modern day. Interpretation is defined as “the processes of encoding and decoding messages, negotiation, and compromise to accommodate differing cultural frameworks of reference and identification.” Medical interpreters are critical for “ensuring effective communication between Limited English Proficiency (LEP) patients and healthcare providers.” Yet even with the best technical translation, “intercultural miscommunication can contribute to health disparities.” Previous studies of Spanish, Hmong, and Japanese interpreters found that “omissions and editorializations (for instance, when interpreters provide their own views on the interpretation of a word or phrase spoken by the patients and providers) were the most common sources of inaccuracies.” Of the 327,000 individuals in the Hmong population in the United States, “37% have LEP. Hmong patients have reported that “low-quality interpretation contributes to poor interpersonal relationships with their providers, emotional distress, and an inability to follow medical treatment plans.” In interviews, 13 Hmong interpreters were asked about their experiences interpreting for Hmong patients. Then, the audio recorded interviews were analyzed by two Hmong nursing students. Three common factors that lead to inaccurate medical interpretation were found: (a) there is a mismatch between the interpreter’s and patient’s gender, (b) discussion involves culturally taboo topics about reproductive body parts and sexual health or activity, and (c) differences exist in culture and generational language between the Hmong interpreters and patients. Specifically, a large part of the inaccuracy of Hmong medical interpreting stems from the challenges of finding words and phrases that are sufficiently equivalent in Hmong and English during medical interpretation. “This gap affects intercultural communication.”

The three factors are listed as such:

1. “Most of the female interpreters expressed having more difficulty interpreting for male patients, particularly older male patients who hold traditional beliefs,” than male interpreters with female patients. Interpreter #1007 stated “I had a much older Hmong male patient, and he did not like the fact that I was a woman… He didn’t really say anything, and he just rolled his eyes at me… “
2. All interpreters in this study agreed that patients are more comfortable discussing issues surrounding reproductive and sexual health with same-gender interpreters. Interpreter #1003 stated, “It gets uncomfortable when I’m interpreting for a male, and he’s going in for concerns about prostate issues or erectile dysfunction. I feel uncomfortable because I feel like I shouldn’t be talking about this.”
3. Differences in culture, generation, and birth/raised location of Hmong translators and patients “were reflected in significant language differences.” For instance, “all the interpreters mentioned that accurate communication with Hmong patients was hindered when the patient was older and foreign-born.”

Moreover, the Hmong language is evolving in its American usage. “Hmong patients, especially older adults and those who are foreign-born, often use borrowed Lao or Thai terms in their speech; since the interpreters do not have exposure to these formerly important contact languages, they perceive the words as a hindrance to accurate communication.” There are a multitude of cultural barriers that hinder the doctor-patient relationship for Hmong Americans in the medical world. However, recognizing these barriers is an important step towards mitigating the barriers (Lor et al.).

Beyond the medical world, cultural inequalities exist in the education system. Hmong people in school experience school life in unique ways due to their family’s experiences. In a study published in the Catesol journal which analyzes the stories told by Hmong people in the educational system, one Hmong girl’s parents didn’t attend any after school events or award ceremonies because they were working. It was hard for her to watch all the other children run to their parents after events, while she had to call her parents to pick her up and wait 30 minutes for them to come. Furthermore, similar to the lack of translators in the hospital in Fadiman’s book, the stories of Hmong people’s experiences before college “showed that the ESL intervention that was supposed to help their language progression was often actually more of a hindrance than a help. The fact that they were labeled ESL and stigmatized by being pulled out of their regular classrooms likely contributed to their experiences of feeling marginalized” (Biliterate Voices of Hmong Generation 1.5 College Women: Suspended between Languages in the US Educational Experience).

Healthcare Inequalities

At the end of Fadiman’s book, The Spirit Catches You And You Fall Down, Lia was in an unresponsive state due to a seizure which lasted too long. She spent four days at the Merced Community Medical Center in this state before returning home to die. However, discouraged by the doctors who Lia’s parents believed were telling them Lia should die rather than could die in the next few days, they set to work preparing natural Hmong healing remedies, boiling herbs and washing her body with the mixture. To the American doctors’ surprise, Lia doesn’t pass away. In fact, two years after Lia entered an unresponsive state, she remained alive. Despite her complete paralysis, her parents diligently care for her, frequently hosting txiv neebs and practicing Hmong animal sacrifices in the name of calling her soul back to her body (Fadiman, 1997).

Similarly, many Hmong aren’t treated substantially due to the doctors’ treatment of disease rather than illness; many Hmong feel under-treated and not cared for. An article on “Hmong Americans and Healthcare Inequalities and Solutions” indicates that “There are many reasons for disparities in the US healthcare system. One is that medical research tends to lump different Asian groups together, so that health risks that affect one group, such as ─ Hmong Americans ─ are averaged out with other groups with very different risks.” The objective of this research paper is to find solutions to the problems to help Hmong Americans get better access to healthcare and maximize its benefit. Previous studies found there are several reasons for the reluctance of the Hmong Americans to access Western healthcare services. These are: (a) the language barrier, (b) errors inputting Hmong American data in computer databases, (3) the cultural aspects of the Hmong Americans such as traditional beliefs, (4) and the cultural insensitivities on the part of healthcare providers. Fadiman’s book legitimizes these beliefs of many Hmong Americans, as oftentimes they experience second-class care. Cultural differences make it hard for the older patients to ask questions to the doctor regarding their diagnosis or prescription. Also, if there is an interpreter available, “there is no guarantee that the interpreter is fully effective because the interpreter may lack the knowledge regarding the Hmong American patients’ background.” As a result of the budget cuts in 1984, the California state government terminated the Hmong interpretation services at various medical center and welfare services office. “The interpreter services are available on a seasonal basis and on casual occasions only. The Hmong’s only choice is to use their children as interpreters, who are not as accurate in translations as are professional Hmong translators” (Berger and Lee, 2011).

Hmong Americans also have trouble accessing the healthcare system. “Since they do not make enough money and work menial jobs, healthcare insurance is hard for them to obtain; thus, access to see medical specialists is sometimes impossible” (Berger and Lee). This makes it hard for them to notice and respond promptly to cancer when it appears. Lack of knowledge of the health field itself is another issue. “Since they are poor, they do not get the proper education to understand more about the advantages of the Western healthcare instead of traditional beliefs in healing the illness.” The Hmong traditional belief of healing is limited to shamanic rituals, herb usage, and massages. Yet many find comfort in these traditional forms of treatment and are less familiarized with the modern Western approach to healthcare, and the inequalities in healthcare underscore their hesitation towards Western medicine. (Berger and Lee).

The case of Mexican-Americans

Like the Hmong people, millions of Latin Americans have recently immigrated to the United States. Latin America became the top origin region for U.S. immigrants in 1990, and by 2019 migrants from Latin America comprised 6.5%of the US population. More specifically, Mexico is the largest source of Latin American migrants to the United States (“Latin American Immigration to the United States,” 2023). Mexicans account for 60 percent of all Hispanics in the U.S. (Haner and Lopez, 2023).

Cultural Policies and Practices

Similar to Hmong cultural practices, Mexican culture commonly promotes alternative health and illness remedies with origins in ancient Mestizo/Indian folktale which view the causes of illness to include social, physical, and spiritual forces. Researcher Lopez’s “Use of Alternative Folk Medicine by Mexican American Women” research showed that “even among highly assimilated Mexican-American women, there persist traditional, indigenous beliefs, and practices” (2005). Indigenous Mexican health care beliefs contrast with Western European systems in notable ways. “‘The curanderismo that many Mexican American families practice today perceives illness both as a biological event (Western European perspective) and as a “social-interpersonal matrix” of causes and cures.”’ In Indigenous Mexico, physical health was viewed to be dependent on a proper balance of the body’s four humors: the hot fluids of blood and yellow bile, and the cold fluids of phlegm and black bile. The body’s symmetry is thought to be restored through ingesting foods and herbs with opposing qualities, sometimes with the guidance of persons with particular knowledge of herbal and food properties. Many Mexican American families practice their own traditions of folk medicine within their home and extended family networks. Candle-lit religious altars may be established in the home for commemorative, religious, and healing purposes. The use of home-made poultices, herbal treatments, and religious amulets are practices transferred from generation to generation which form a group of remedios caseros (home remedies). The article reveals Curanderismo persists for practical reasons which confront many impoverished Mexican Americans for whom U.S. health care systems have failed. Lack of medical insurance (33), language barriers, lack of knowledge of and accessibility to mainstream medical services have also served to sustain an informal system of health care providers and home remedies (19, 34, 35). Equally important may be the lack of culturally sensitive providers available to this growing population (8, 36). One of the primary reasons that Mexican folk traditions may persist is that some of the folk illnesses defy ontological explanations or descriptions that can be readily understood by mainstream doctors (5). The mother who seeks medical care for her child who is believed to be suffering from caida de mollera (fallen fontanel) may often be confronted by a medical staff who view the child’s dehydration and fever to be the result of “parental ignorance, superstition, or simply as abuse and/or neglect.” In contrast, a curandero may offer understanding and relief for the parent. The researcher administered a questionnaire to Latina students, 619 graduate students and 123 undergraduate students. The questionnaire provides evidence to support the “persistence of indigenous health care beliefs and practices among urban, assimilated Mexican American women.” Pearson’s r analysis revealed a significant relationship between age and whether the Mexican Americans had heard of folk healers, with an r of 0.286 and a p of 0.016. The more religious subjects were noted to be, the greater use of folk practitioners (p= 0.001). As indicated, “older respondents were more likely to answer in the affirmative.” Importantly, an r of -0.248 and a p of 0.039 revealed a correlation between the increased use of Mexican medicines and fewer doctor’s visits in the U.S. Although the health status of this study sample was mostly healthy, a significant majority of participants expressed “their comfort levels and communication levels with U.S. doctors as not entirely positive experiences.” On the contrary, a majority of the participants heard of folk healers and many knew of people who had used them. Approximately 26% of the sample had been treated by a curandero, but a greater percentage of individuals used the services of a sobador (Lopez, 2005).

Cultural Barriers in the Medical World

A systematic review of literature by researcher Caraway L. Timmins, “The impact of language barriers on the health care of Latinos in the United States,” underscores the cultural inequalities and barriers of the healthcare system. In the year 2000, 11% of adults in the U.S. labeled Spanish as their “primary language.” However, the U.S. health system is largely geared towards serving English speakers. This study examined language barriers for Latino populations in healthcare from 1990 to 2000. Two of the three studies examining health status or outcomes found “language to be a risk factor for adverse outcomes.” Moreover, six of the seven studies (86%) evaluating quality of care found a significant detrimental effect of language barriers. In fact, non-English speaking status was a marker of a population “at risk for decreased access” to healthcare. Researchers recommend that healthcare practitioners “devise effective strategies to bridge language barriers” (Timmins, 2002).

Practitioners

Many medical practitioners in the U.S. recognize the necessity of bridging the cultural divide to treat patients. The beliefs of contemporary medical western physicians on biomedical care in the U.S. are summarized in Fadiman’s book, The Spirit That Catches You And You Fall Down. On one hand, it is evident there is no sustained doctor-patient relationship with one doctor to develop better understanding of minority patients. Doctors likely don’t attempt to form close bonds with patients of unique cultural backgrounds because they believe they are not competent in understanding them. Lack of knowledge surrounding the histories and perspectives of unique cultural groups can often lead to misunderstandings in the healthcare system. For example, one doctor describes the frequent tension between doctors and patients.Doctors can become frustrated with the viewpoints of these patients and many times give them “suboptimal care” (page 75). Additionally, many nurses considered Lia a “burden and a pest” (page 113). It is evident their lack of understanding contributes to their frustrations. Furthermore, cultural diversity was often an obstacle to doctors. The objectives of doctors in Fadiman’s book do not seem to align with Kleinman’s definition of brokerage- “a concern for the psychosocial and cultural facets that give illness context and meaning.” In the book, according to Lia’s primary doctors, Neil and his Peggy, “cultural diversity [often] ceased being a delicious spice and became a disagreeable obstacle” (page 265). Bruce Thowpaou Bliatout, a Hmong medical administrator who wrote about mental health problems as traditional ailments of the liver, provided suggestions to mitigate doctor-patient relations (page 265).

Conclusion

Overall, this research on healthcare reveals gaps between the cultures of Western American medicine and the experiences of immigrant groups. Moreover, it indicates the importance of cultural brokerage in order to optimally treat patients in the United States. This field of study is highly relevant, as the “U.S. population is becoming increasingly diverse.” By the year 2020, the U.S. Census Bureau projects a 77% increase in the number of Hispanics, a 32% increase in AfricanAmericans, a 69% increase in Asians, a 26% increase in Native Americans, and less than a one percentage point increase in the White population (Kelly, 2005). To remain a country which was “founded on principles of equality and justice for all,” learning to treat all U.S. residents competently in the healthcare industry is vital (“The ERA: A New Foundation for Equality in the United States,” 2023).

Furthermore, the results exhibit the unique perceptions of distinct cultural groups surrounding healthcare, and their preference of traditional practices and customs, such as the use of folk healers. For instance, Hmong Americans use herbs to treat diseases and believe a new mother should partake in a 30 day confinement period after giving birth. Similarly, Mexican Americans utilize folk healers to heal illness. Both groups are evidently reluctant to go to the doctor to be treated, as a majority feel disadvantaged by the healthcare system. Also, many American healthcare practitioners lack the cultural competence to treat patients of diverse cultural backgrounds. The differences between the Western approach to medicine and that of the Hmong and Mexican groups are highlighted by the modern American practitioners’ treatment of disease, rather than illness, as well as their lack of accountancy of the lifeworld into treating patients. Studies indicate that if practitioners are more knowledgeable on the distinct cultural backgrounds of their patients and learn to be more receptive towards their patients’ perceptions of a given illness, doctor-patient relationships will be amended and cultural inequalities in the healthcare system can be mitigated.

This analysis has important implications for the advancement of cultural competence in medicine. The paper explains a framework for properly addressing the treatment of diverse groups by medical practitioners.

Importantly, it is not possible, let alone feasible, to have a translator for every spoken language in the world. As a result, the most effective solution might be increasing the quantity of translators for the five most prominent spoken languages in each state, despite the immense limitations of this mitigation. Furthermore, not speaking a language does not signify a lack of cultural competence or “cultural brokerage.” Cultural competency includes a deeper understanding and acknowledgment of diverse cultural backgrounds and unique perceptions of medical care in relation to illness as a whole.

On the other hand, it is crucial to indicate the limitations of this research paper, as it draws from accounts of people, which serves as data. People’s accounts are subjective and biased. Thus, it is not valid to assume the results are of definite true nature. Additionally, the validity of using research analysis to complete this study is limited in that any limitations or errors made in previous research is carried into this paper.

Considerations

In terms of what should be done next and the future directions of the field, it would be beneficial to conduct future research on different cultural groups in the U.S. The three largest minority groups in the U.S. are Africans, Asians, and Latinos. Given that this study analyzed distinct Asian and Latino groups, it would be important to look at the cultural inequalities of African Americans in the U.S.

In regards to future research, it would also be helpful to widen the scope of this study beyond cultural groups within the U.S., examining groups in South America, Australia, and etc. Although Hmong women in Australia were mentioned in this study, “historically, Latino communities have been part of the fabric of Australia,” revealing the possible benefits of analyzing the cultural competence of practitioners in Australia in regards to the Latino community. One study on “Latinos in Australia” reveals the struggles of the Latino community to assimilate into Australian society. The first wave of Latino migrants to Australia occurred in the mid-1990’s, and the second wave began in 1998. Obstacles Latino migrants encountered when first settling in Australia include the need for “social support networks that help to ease their political, economic, and social integration into Australia” (Río). There is a gap in understanding whether there exists cultural competence in healthcare systems in Australia for minority groups such as Latinos.

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