Markkula Center of Applied Ethics

A Difficult Birth: Navigating Language and Cultural Differences - Reflections by Nayamin Martinez

Ana Lopez is not alone. Thousands of indigenous women and men from the southern states of Mexico (primarily Oaxaca, Guerrero, Michoacan, and Chiapas) have migrated massively to the United States since the late 1980s. These persons confront in their daily lives situations like Ana's experience at East Valley Hospital.

Indigenous migrants who have been in this country for longer periods are more knowledgeable about how to navigate the complex health and social systems. However, newcomers confront numerous personal and cultural barriers. First among these is the difficulty of communicating in English and often even in Spanish. The illiteracy and low education levels of many new immigrants also make it very challenging to survive in a country where everything is done through papers. Additionally, indigenous people prefer traditional medicine over Western medicine, not only because in their home communities Western medical services are scarce, but also because they trust the ancestral healing methods that have helped them for centuries. While living in the U.S., indigenous persons have no option but to seek services in clinics and hospitals, environments that are completely unfamiliar to them and that frequently are incompetent to understand them and provide culturally appropriate care.

In Ana's case, the first inadequate thing that the hospital staff did was to fail to provide her with an interpreter in her first language. Federal and state laws mandate hospitals to ensure adequate communication with patients. What happened to Ana is the rule and not the exception. Most of the time, indigenous persons are provided an interpreter in Spanish, since hospital staff assume that, coming from Mexico, they speak this language. The lack of adequate communication could have resulted in adverse consequences for Ana and her child. Luckily for the hospital administrators, Ana and many other indigenous migrants ignore that they have the right to be provided an interpreter in all agencies receiving federal funding; otherwise the hospitals can be sued.

Not providing an interpreter was not the only communication problem, however. There also appeared to be a conflict with the terminology that was used to provide information to the family. Although the case does not disclose the details of how the medical information was given to Ana and her family, one can assume that the terms described (e.g. C-Section, APGAR scores, neonatal encephalopathy, neonatal ICU) were used during the conversation with Ana and her husband. If this was the case, we can be sure that the couple did not understand. Indigenous people are generally not familiar with medical terminology; thus they cannot understand what they are being told if they are just listening to scientific concepts. The right thing to do is to provide an explanation using simple terms that describe the relevant health conditions.

One other way in which the staff behaved in a culturally incompetent manner is by the reaction they had when Ana's husband asked permission to bring a traditional healer to see the baby. Although health professionals may not share the non-Western health beliefs of a particular group, that does not give them the right to judge those beliefs and show disappointment if their patients hold those beliefs and practices. Cultural competency starts with showing respect to others cultures, and that respect includes withholding judgment about their health beliefs. The nurse should not have expressed her disagreement with those beliefs. She could have explained in a polite manner that the baby's health was at risk and thus that it was not recommended to expose the baby to other treatment until he was stable. Saying this in a polite manner, and omitting the comment "your baby is under the care of the best medical experts," would have been a better approach. The nurse's reaction, which once again is the rule rather than the exception in almost all health care settings, reveals that she was trained to believe that Western medicine offers the most advanced methods to restore health. However, this belief is completely subjective to the health paradigm that a person or a culture holds. Indigenous groups trust more in traditional medicine that in Western medicine; thus very likely Ana and her family would not agree with the nurse's comment.

Yet another problematic behavior of the hospital staff was judging Ana's unemotional manner as indifference to her baby's condition. There are always differences in how each person expresses his or her emotions; however, those differences are greater when the persons belong to different cultures. Among the indigenous communities, particularly among the Mixtecs of Oaxaca, it is uncommon to express emotions, especially in front of a stranger. If on top of that, we take into consideration that Ana and her family did not fully understand what was going on with the baby, it is not surprising that Ana was not crying or falling apart when she saw her baby in the neonatal ICU.

Following are some general recommendations for health professionals who deal with cases like Ana's:

FIRST: Our main recommendation for health professionals who are concerned with cultural competence is to take the time to know about the culture of their clients, so that they can better understand these clients.

SECOND: Always provide an interpreter in the first language of the patient, as well as easy-to-follow explanations of medical situation and procedures.

THIRD: Respect the cultural beliefs of your clients, even if you do not share them.

FOURTH: Be open and flexible to adapt to the needs of culturally diverse clients. Allow traditional healers to visit indigenous patients in the hospitals. An example of this openness and flexibility can be found in some hospitals in the Central Valley of California. There, some Hmong patients are allowed to bring shamans into the hospitals, as long as the shamans do not practice anything that contradicts the medical treatment. While the visits of the shamans do not jeopardize the physical condition of the patients, they have proven to be very useful in improving the patients' peace of mind and attitude towards medical treatment. This could be replicated for other cultures such as the indigenous from Mexico. Like it or not, the indigenous migrants will continue practicing traditional medicine, many times combining it with Western medicine, something that medical anthropologist Bonnie Bade has defined as "transcultural medicine."

Return to the case
Introduction to Culturally Competent Care
Introduction to Culturally Competent Care for Latino Patients

Nayamin Martinez has been the Health Project Coordinator at Centro Binacional Para el Desarrollo Indígena Oaxaqueño for seven years. Located in Fresno, California, the organization implements programs that impact the economic, social, and cultural development of indigenous communities.

July 2008