The material in this section is part of a larger project by the Markkula Center for Applied Ethics on culturally competent care; that is, health care that is sensitive to the differing values and needs of cultural subgroups within our pluralistic society. These materials focus on the challenges that can confront Hispanics in American health care settings.
The cases and reflections illustrate the kinds of challenges patients and health care professionals face when they come from different cultures and speak different languages. Underwriting for these materials was provided by a generous anonymous donor.
The largest and fastest growing minority population in the United States today is commonly referred to as "Hispanic" or "Latino." While not considering Hispanics as a distinct race, the U.S. Census (utilizing federally delineated categories) defines someone "Hispanic" or "Latino" as "a person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin regardless of race."1 The term does not refer only to Spanish speakers, however; many people usually thought of as "Hispanic"-the people of Brazil, for instance, or those from indigenous Mexican communities-often do not speak Spanish at all, or at least not as their primary language. The term "Latino" has become more commonly used in recent years to describe those whose primary ethnic heritage stems from Latin America. These terms are often used interchangeably, including by the U.S. Census Bureau, although "Hispanic" is more often utilized in governmental and market research and statistical record keeping, while "Latino" perhaps enjoys more popular usage today. Importantly, many Latinos themselves prefer the latter term, since it avoids reference to the more recent European colonial powers (from "Hispania," or the Iberian Peninsula) that laid claim to Latin America in the fifteenth and sixteenth centuries. In this article I will make use of both terms, relying more heavily, however, on "Latino."
In 2007, the total U.S. Hispanic or Latino population surpassed 45 million, or 15 percent of the total U.S. population. By the year 2050 that figure is expected to rise to 24 percent of the total U.S. population. Latinos comprise the largest minority group in 20 of the 50 states. Some states have extremely large Latino populations; for instance, as of 2006, 36 percent of Californians (13.2 million people) identified themselves as Hispanic or Latino, as did 36 percent of Texans (8.6 million people). In Santa Clara County the figure is 25.7 percent-over a quarter of the total population. These numbers include Mexican-Americans, Puerto Ricans, Central and South Americans, Cubans, and many other communities although, throughout California, the vast majority of Latinos identify themselves as of Mexican background. The U.S. Latino population is also quite young relative to the general U.S. population; in 2007, the median age for the former was 27.6, compared to 36.6 for the latter.2
Recent immigration trends have contributed heavily to the increases in the U.S. Latino population. This is especially (though far from uniquely) true in the agricultural sector of the U.S. economy. For at least the past century, a relative lack of jobs in Mexico has been driving many Mexicans north in search of work. The Bracero program, a guest worker program started in 1942, was designed to bring experienced agricultural laborers to the U.S. from Mexico and led to a huge influx of Mexican immigrants. Although the program ended in 1964, the immigration trend has continued to the present day, and many of these immigrants work as migrant laborers in the U.S. agricultural system. Today, one in three farm workers are newcomers to the United States, with most of these coming from Mexico. The Immigration Reform and Control Act of 1986 granted amnesty to immigrants who came to the U.S. before 1982; but the northward trend from Mexico and other parts of Latin America has continued since then, and many who have crossed the U.S.-Mexican border now live in the United States illegally. Very often they have faced extremely hazardous conditions crossing the border-enduring hunger, dehydration, violence from vigilantes, rape, abuse, severe weather conditions and harsh treatment by border agents.
In terms of health, on some measures Latinos are better off than other ethnic groups. For instance, 2002 estimates of life expectancy for Latinos was 77.2/83.7 years (male/female) compared to 68.4/75.1 for African-Americans and 74.7/80.1 for non-Hispanic whites.3 Latinos are less likely than non-Hispanic whites and African-Americans to suffer from heart disease (which is nevertheless the leading cause of death in all three groups). Yet Latinos are at particular risk for diabetes mellitus, tuberculosis, hypertension, HIV/AIDS, alcoholism, cirrhosis, and death from violence.4 There is also a disproportionately high prevalence of acute care in the treatment of Latinos; that is, too often patients delay medical care until their conditions worsen and necessitate immediate attention. There are likely many possible reasons for this, including poverty and lack of health insurance, and thus at best irregular access to health care; cultural factors that might cause patients to delay seeing a doctor, for example, the expectation that one should tolerate pain without complaint; and a belief that certain conditions (such as pregnancy) are natural and do not require medical attention.
In spite of the large and rapidly increasing size of the U.S. Latino population, there has been no corresponding influx of Latinos working in the U.S. health care system. In fact, the number of Latino physicians dramatically lags behind Latino population growth; and, according to cross-cultural health care expert Larry Purnell, Latinos are the most underrepresented major minority group in the entire U.S. health care workforce.5 This discrepancy contributes to many different linguistic and cultural hurdles for Latino patients, as well as for their health care providers.
First among these, of course, is a language barrier. Although most Latinos living in the U.S. do speak at least some English, 60 percent of Latino adults speak primarily Spanish at home.6 According to the U.S. Census, more than half of U.S. Latino residents age 5 and older speak English "very well," but a nevertheless significant number of Latino adults speak English "not well" or "not at all."7 In the context of a hospital or medical clinic, where medical terminology can be complicated and communication often takes place quickly and amidst elevated emotions, this language barrier can be especially problematic. In fact, compared to both white Americans and African-Americans, Latinos generally report feeling less listened to and understood by their doctors, as well as less able themselves to understand their doctors; and they are twice as likely to leave a doctor's office with unasked questions. They are also far more likely than whites to feel that they are treated unfairly by providers or by the medical system.8
These gaps and dissatisfactions become even more troubling in the context of significant disparities in access to health insurance and to the health care system in general. Latinos are far more likely than the overall population to live in poverty; the poverty rate in 2006 was 20.8 percent, compared to 12.3 percent for the overall U.S. population. Moreover, 32.7 percent (nearly one-third) of all U.S. Latinos completely lacked health insurance that year, compared with 15.3 percent in the general population; and nearly half of Latinos reported being uninsured at some point during the previous year.9 Latinos are nearly two and a half times more likely than whites to report that they have no regular doctor.10 Even among many insured Latinos, coverage and care are far from adequate. According to a study done at UCLA, 15.7 percent of non-elderly Latinos in either fair or poor health, who are covered under MediCal or Healthy Families (both California low-income health insurance programs), report having no usual source of care but rather obtain their clinical health care on an ad-hoc basis, if at all.11
Some Latinos find their health care in non-clinical places, relying on folk medicine and traditional healers. This reliance does not necessarily replace modern biomedicine; rather, herbal remedies and other non-allopathic treatments often are utilized in conjunction with Western medical care. One way of describing the distinction is that modern Western doctors are primarily trained to diagnose and treat diseases (in a purely biomedical sense), while traditional healers approach the patient as one suffering from an illness-that is, a culturally located experience of sickness.12 Among some Latino subcultures, folk illnesses such as empacho (a digestive ailment), mal de ojo (the "evil eye"), mollera caida (fallen fontanelle), susto (fright illness), and nervios (vulnerability to stressful experiences) are commonly described; and traditional healers range from curanderos (Mexican healers) and sobadores (traditional masseuses and bone setters) to yerberos (herbalists) and espiritistas (spiritual healers).13 Reliance on folk medicine certainly is not to be found in every, or even most, Latino communities; but it does exist as part of the health care landscape and is found among many patients from Mexico, as well as from various other regions within Latin America. Significantly, some patients appear to experience greater improvement after meeting with folk practitioners than with Western doctors.14
Apart from these language and socioeconomic disparities and variation in the way health care is envisioned and sought out, differences in the way values are ordered and articulated can also strain the clinical health care encounter for Latino patients. As with any circumscribed ethnic group, there is, of course, enormous cultural heterogeneity among Latino patients-to the point where it seems almost ludicrous to try to identify broad cultural tendencies across such diversity. Still, at the risk of oversimplifying, several trends emerge:
-simpatia-politeness and the avoidance of hostile confrontation
-personalismo-the value of warm personal interaction
-respeto-the importance of showing respect to authority figures, usually including health care providers
-familismo-collective loyalty to extended family and commitment to family obligation;
-fatalismo-the belief that individuals cannot do much to alter fate15
Again, it is imperative to stress that these values represent broad generalizations that may or may not apply to any individual patient or in any given situation. Each person is unique and simultaneously formed by a variety of cultures and subcultures, not to mention personal choices and socioeconomic circumstances. Still, being aware of these larger values may help health care providers to understand a particular patient's behaviors and actions in the context of larger cultural inclinations. For instance, a doctor could perceive as evasive a patient who declines to make direct eye contact, when in fact,that patient may be demonstrating respect for the doctor's position and authority. Similarly, a patient's silence when presented with a difficult treatment plan, rather than conveying agreement, may in fact indicate that patient's desire to maintain a polite relationship with the health care provider and avoid difficult or conflictual situations. Indeed, such a patient's silence might best be interpreted as an indirect and nonverbal form of disagreement.
The value of familismo perhaps deserves to be emphasized for the important role it plays for many Latino patients. Generally speaking, Latino cultures include a more family-centered decision making model than the more individualistic or autonomy-based model embraced by modern mainstream biomedical culture in the United States. Rather than operating on the ideal of an informed, active individual who makes decisions based on his or her own personal good, many Latino cultures consider as paramount the individual's obligation to the family and broader community. Hence, the individual's good cannot be neatly separated from his or her community. Moreover, the family itself can play an enormously important role in supporting and empowering the patient within the medical setting. In one survey of Mexican American nurses, family support was identified as one of the most important areas to which health care providers should attend while caring for Latino patients. Additionally, within this family-centric decision making structure, there may be particular gender-based roles. For instance, Latino mothers may determine when medical care is warranted for a family member, though a male head of household may formally make the decision to send the family member to a medical center.16
These broad generalizations are just that: broad generalizations. They are a starting point, not an ending point; in other words, they call practitioners to look more deeply into the particular cultural, linguistic, and socioeconomic contours of their patients' backgrounds and to open themselves to alternative ways of understanding and interpreting their patients' actions and requests. The point deserves emphasis: Health care providers must be cautious not to oversimplify the values, customs, and beliefs that characterize any ethnic group-especially one as heterogeneous as Latinos. They also must beware of the tendency toward "othering"; that is, the penchant to understand non-dominant groups as inferior, exotic, or deviant.17 Some efforts at cultural competence may incline toward these unhelpful postures. Yet the call for cultural competence can-at its best-urge practitioners to adopt instead a stance of cultural "humility": one which encourages an open mind, and a recognition that each one of us sees the world through our own very distinctive cultural lenses.
Keeping these cautionary notes in mind, the cases and commentaries in this section seek to address numerous issues that arise in the course of providing clinical health care for Latino patients of various backgrounds. The commentaries provide perspective and insight on what went right, what went wrong, and how things might have gone differently in these culturally challenging situations. They are written by health care providers and others who work with the relevant Latino sub-community. The final commentary, drawing on the others, seeks to join the issues from an explicitly bioethical perspective.
- Reflection by Rebecca J. Hester
- Reflection by Nayamin Martinez
- Reflection by Marc Tunzi
- Reflection by Karen Peterson-Iyer
- Reflection by Silvia Austerlic
- Reflection by Marc Tunzi
- Reflection by John Silva
- Reflection by Karen Peterson-Iyer
1Elizabeth M. Grieco and Rachel C. Cassidy, "Overview of Race and Hispanic Origin 2000," Census 2000 Brief, U.S. Census Bureau, March 2001.
2U.S. Census Bureau News, "U.S. Hispanic Population Surpasses 45 Million," Press Release, Thursday, May 1, 2008; U.S. Census Bureau, "Hispanic Americans By the Numbers," accessed at www.infoplease.com/spot/hhmcensus1.html; and U.S. Census Bureau, "State and County QuickFacts: Santa Clara County, California," 2006, accessed at http://quickfacts.census.gov.
3Pan American Health Organization, "For U.S. Latinos, Shared Heritage Has an Impact on Health," June 9, 2004 (www.paho.org).
4Center for Disease Control and Prevention, "Leading Causes of Death," accessed at www.cdc.gov/men/lcod/index.htm; and Richard Allen Williams, "Cultural Diversity, Health Care Disparities, and Cultural Competency in American Medicine," Journal of the American Academy of Orthopedic Surgeons, Vol. 15 supp. 1 (Sept. 2007).
5Larry D. Purnell and Betty J. Paulanka, "Mexican-Americans," chapter in Transcultural Health Care: A Culturally Competent Approach (Philadelphia: F.A. Davis Company, 1998): 397-421.
6Kaiser Permanente National Diversity Council, "A Provider's Handbook on Culturally Competent Care: Latino Population," 2nd ed. (Kaiser Foundation Health Plan, 2001): 4.
7Hyon B. Shin and Rosalind Bruno, "Language Use and English-Speaking Ability: 2000," Census 2000 Brief, U.S. Census Bureau, October 2003, accessed at: www.census.gov/prod/2003pubs/c2kbr-29.pdf.
8Holly Mead et. al., "Racial and Ethnic Disparities in U.S. Health Care: A Chartbook" (The Commonwealth Fund, March 2008), Charts 6-25 and 6-26; and Joseph R. Betancourt, Alexander R. Green, and J. Emilio Carrillo, "The Challenges of Cross-Cultural Healthcare-Diversity, Ethics, and the Medical Encounter," Bioethics Forum 16 (3).
9Carmen DeNavas-Walt, Bernadette D. Proctor, and Jessica Smith, "Income, Poverty, and Health Insurance Coverage in the United States: 2006," Current Population Reports, U.S. Census Bureau, August 2007; and Mead et. al., "Racial and Ethnic Disparities," Chart 5-2.
10Mead et. al., "Racial and Ethnic Disparities," Chart 4-1.
11Jennifer Aguayo et. al., "Important Health Care Issues for California Latinos: Health Insurance and Health Status," UCLA Center for Health Policy Research, January 2003.
12Arthur Kleinman, Leon Eisenberg, and Byron Good, "Culture, Illness, and Care: Clinical Lessons from Anthropologic and Cross-Cultural Research," Annals of Internal Medicine 88: 251-258 (1978).
13 Kaiser, "A Provider's Handbook," 6-7.
14 Kleinman et. al., "Culture, Illness, and Care," 252.
15Glenn Flores, "Culture and the Patient-Physician Relationship: Achieving Cultural Competency in Health Care," Journal of Pediatrics 136 (January 2000): 14-23; see also Maria R. Warda, "Mexican Americans' Perceptions of Culturally Competent Care," Western Journal of Nursing Research 22/2 (2000): 203-224.
16"Communicating with Your Latino Patient," University of Washington Medical Center, 2007; accessed at https://depts.washington.edu/pfes/PDFs/LatinoCultureClue.pdf.
17Delese Wear, "Insurgent Multiculturalism: Rethinking How and Why We Teach Culture in Medical Education," Academic Medicine 78/6 (June 2003): 549-554.
Karen Peterson-Iyer is a program specialist in health care ethics at the Markkula Center for Applied Ethics.