different styles; providers can reduce their image as uncaring, insensitive, and arrogant by adopting client-sensitive styles of communication and using nonverbal mediums to assure and encourage patients. Most cultures’ rules of communication and social behavior affect medical communication because questioning authority fi gures is considered inappropriate.
Consequently, providers need to encourage clients to ask questions (Press, 1982).
SPECIALTY CROSS-CULTURAL APPLICATIONS OF MEDICAL
avoiding prolonged eye contact, and communicating respect by asking for permission to touch patients. The head nod may convey assent or agreement but may also be a respectful encourage- ment to continue speaking so that the communication may be understood. Agreement should be ascertained rather than assumed. Physicians are slow to learn that even when tHmong patients politely answer “Yes” to a doctor’s many instructions, they are not understanding, much less agreeing, but merely being polite, an acknowledgment that they have been spoken to! Even when they disagree, a polite “yes” rather than challenging the authority of the doctor is a stand- ard behavior.
Emotional communication in the form of laughter may not communicate assent but may refl ect discomfort, embarrassment, fear, or confusion. Facial expressions are generally controlled to convey neutrality and a calm and collected disposition. The expression of anger or a displeased countenance is considered to be disrespectful. Touch is a sensitive issue and should be done only with permission. Touching the head is generally taboo, and women are generally disinclined to have pelvic or breast exams by male physicians.
Recommended treatments should be provided as advice rather than coercion. To obtain com- pliance, it is necessary to develop a treatment plan in conjunction with the family network of elders and clan and offer options rather than force courses of action on them. Sensitive matters and disturbing news should be presented indirectly, and the patient’s condition should be dis- cussed in a manner that encourages hope and positive expectations. Questions about sensitive issues should be addressed indirectly, using stories or asking about people (or Hmong) in general rather than the patient in particular. Death and other bad news may be communicated through metaphor or allusion instead of directly conveying disturbing prognoses, which may be viewed as threats or curses. Physicians should encourage and facilitate the use of cultural healing practices for conditions with spiritual causes, contributions, or consequences.
besides hospitals and clinics, including criminal justice settings, governmental policy development venues, and other situations involving cross-cultural adaptation to issues that have positive effects on health. Medical anthropologists address cross-cultural issues in a variety of contexts that affect health care, including
Teaching, training, and mediation activities to enhance cross-cultural sensitivity and responsiveness in interactions between diverse cultural groups
Research activities, particularly involving community participation and coalitions Advocacy for community health development and provision of health education Administrative functions to change organizational cultures of health institutions Applications in community and public health programs
Roles in clinical settings to enhance therapeutic outcomes as consultants
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Cross-Cultural Training and Mediation
Culture affects health care quality through effects on interactions between patients and providers. Anthropologists’ applications of cultural perspectives in health generally involve intercultural education and training. Training providers in cultural knowledge and cross-cultural perspectives and skills enhances the quality of biomedical practice by facili- tating an understanding of patients’ language and worldview and using intercultural com- munication skills to elicit relevant information. Cross-cultural competence facilitates the resolution of a primary clinical problem—noncompliance—through teaching negotiation skills. Providers’ and clients’ different cultural conceptualizations of health interfere with M. Jean Gilbert
M. Jean Gilbert, Ph.D., consults on cultural and linguistic issues in health care. Current projects include participation on a team that is assessing the cultural and linguistic best practices in MediCal (California’s Medicaid) HMOs and work on a U.S.-Mexico border drug and alcohol prevention program. She has been a visiting professor in the Department of Anthropology, California State University, Long Beach, and director of Cultural Competence for Kaiser Perma- nente, California, where she provided expert consulting to the organization in the design of services to diverse populations and conducted training in cultural medicine to health care pro- fessionals. Before that, she was a National Institute on Alcohol Abuse and Alcoholism Scholar in Latino Alcohol Studies at the Spanish-Speaking Mental Health Research Center, University of California, Los Angeles. From 1978 to 1984, she was associated with the Social Process Research Institute, University of California, Santa Barbara, where she conducted research on Mexican American family dynamics and cross-cultural research on maternal and child health, alcoholism, and health care services utilization. Her interests in medical anthropology are pri- marily in the application of research information and anthropological knowledge for the crea- tion of health care policy and the delivery of services to diverse patient populations.
During the time Dr. Gilbert worked at Kaiser Permanente, she served on various govern- ment-related policymaking bodies to help bring about organizational change that she felt was important in serving diverse patients. She served on the MediCal Managed Care Cultural and Linguistics Task Force, which sought to make policy that would guide culturally sensitive services for culturally diverse and limited-English speakers.
In another cross-disciplinary team effort, Dr. Gilbert convened an expert panel of medical anthropologists, physicians, nurses, and health educators to set standards for the teaching of cultural competency to health care professionals. This collaborative work resulted in the doc- ument, The Principles and Recommended Standards for the Cultural Competence Education of Health Care Professionals (2002), which is widely used in curriculum planning in colleges and universities.
PRACTITIONER PROFILE
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communication, diagnosis, treatment, compliance, and satisfaction with care. Providing physicians with an awareness of the cultural infl uences on both clients’ and providers’ care behaviors can contribute to patient care by providing perspectives linking their different health views. Mediation between diverse perspectives underlies basic medical anthropol- ogy applications in health, including dispute resolution, education, research, advocacy, community development, and institutional cultural change. Mediator functions involve facilitating communication between different cultural and professional groups and trans- lating between conceptual systems. Cross-cultural orientations can contribute to more sat- isfactory patient care by helping providers develop cultural skills in adapting to the diverse client cultures they encounter. Major aspects of clinically applied medical anthropology involve assisting providers in learning the principles for culturally sensitive and compe- tent care (Chrisman and Zimmer, 2000). Anthropological perspectives and cultural knowl- edge involved in preparing health professionals for cultural competency include
Teaching skills for cross-cultural relations, communication, and negotiation Understanding ethnomedical conceptions of illness and approaches to treatment Assessing cultural impacts on health and responses to health problems
Recognizing, assessing, and responding to community health needs Researcher
Public mandates to ensure culturally relevant health services provide anthropologists with roles in determining health problems and needs, developing programs, administer- ing their implementation, and evaluating their quality and effectiveness. Anthropologists’
professional responsibility for the well-being of those studied has produced research focused on responses that can result in direct benefi ts to communities. Anthropologists’
community health research has expanded traditional needs assessments to focus on com- munity strengths, perspectives that emphasize how cultural practices contribute to well- being. Strengths approaches can play an important role in indicating cultural resources to be utilized in developing community health programs: for instance, incorporating mid- wives into campaigns to encourage breast-feeding.
Research on culture and health provides essential data for public health and clinical medicine. Anthropology’s ethnographic and participant observation approaches are the tools of choice for the investigation of the cultural bases of high-risk behaviors. Partici- pant observation involves a direct engagement with people’s ethnomedical systems, pro- viding information about cultural illness beliefs and behaviors that affect care through patients’ conceptualization of and responses to health problems.
Anthropology’s multimethod research approach dovetails with the interdisciplinary nature of health research (Sargent and Johnson, 1996). Anthropologists collaborate with a variety of professionals in ensuring the cultural appropriateness of research, using eth- nography and participant observation to understand health behaviors. Anthropology’s culture-specifi c approaches are fundamental across the human services in developing research proposals, implementing studies, evaluating results, and institutionalizing pro- grammatic changes (Poland, 1985). Anthropology’s holistic perspectives communicate to
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others the interacting economic, political, and social effects on health (Chrisman and Johnson, 1990). Anthropologists use their ability to translate across perspectives to demystify the researcher role and data collection techniques and to explain analyses and value of the research to those studied. Observations of staff behavior at research sites help determine the effectiveness of the implementation of interventions (process evalua- tion; see Chapter Four). Assessing staff perspectives helps ensure that they feel benefi ts from the project, understand its contributions, and are not resistant in ways that under- mine the project.
Cultural perspectives are also essential to epidemiology: research into the factors associated with the incidence of diseases (see Chapter Seven). Because behavior brings people into contact with disease or injury, understanding cultural dynamics of behavior is fundamental to public health and prevention programs. An important cultural focus in epidemiological research is the community morbidity study, which uses community- based (as opposed to clinical) data to reveal the actually experienced incidence of illness, rather than just those conditions presented to physicians. People may not present illness to physicians for a variety of reasons, including the prohibitive cost of services; inacces- sibility of treatment; the cultural acceptance of their symptoms; the inability to leave work, family, or other responsibilities; or self-treatment. Community morbidity studies based on studies of health problems from the perspectives of the public help provide a more accurate picture of the actual incidence of health conditions.
Community morbidity surveys, based in interviewing a sample of the population, provide approaches for assessing unreported conditions and, hence, the actual maladies experienced, including diseases. Accurately assessing the incidence of disease requires a community morbidity study based on assessment of a general population rather than a clinical population. This approach also faces methodological challenges, including ver- ifi cation of self-reported diseases and assessments of determinants of disease that occur over long periods. The usefulness of community morbidity studies is exemplifi ed in Kleinman’s (1980) assessment of the illness reported in a study of Chinese family-based popular health care. Kleinman’s method used the interviews to determine illness epi- sodes, treatment decisions, all treatments applied, and the outcome of illness episodes.
Interviews are generally conducted in the home, including as informants all household members and assessing illness episodes experienced by the household. In community- based interviews, household groups can be asked to report other health care beliefs and practices, particularly cultural remedies, medicinal plants, folk practitioners, and popular mental health resources.
Community Advocacy and Empowerment
Anthropology has a long history of involvement in public health community advocacy and empowerment. These involvements include community development and self-help programs, leadership training, consciousness raising, health education, and health part- nering. Nutrition issues provided a basis for early anthropological involvement in inter- national public health (Ritenbaugh, 1982; Quandt, 1996). Recognition of social causes of malnutrition led anthropologists to advocacy, addressing the funding and development of community resources and health programs to ensure access to food.
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A primary role of anthropologists in international health programs has involved over- coming cultural barriers to adaptation of modern health practices to local conditions (Chambers, 1985). More political roles have been necessary, however. Primary causes of disease in impoverished third-world communities are due to the failure to allocate resources to support public health programs and the development of infrastructure (such as clean water, sanitation and sewer systems, prenatal care, nutrition, and education) nec- essary for healthy life (Rubinstein and Lane, 1990). Recognition of macrolevel effects of the capitalist economy on health produced by economic, social, and political processes spurred the development of an advocacy role refl ected in critical medical anthropology (Baer, Singer, and Johnsen, 1986) and political economy orientations (Morsy, 1996) (see Chapter Eight).
These approaches emphasize empowering communities to achieve changes by alter- ing the distribution of health resources. Community empowerment begins with enlisting the participation of relevant community members and a variety of public and private organizations involved in community health: schools, public health education and pre- vention programs, advocacy groups, and government. Anthropologists work as mediators in ensuring effective collaboration among many entities, integrating their different val- ues, goals, and perspectives using organizational and confl ict-resolution skills. Planning effective health programs requires the formation of participatory research teams that include the local community (Nichter, 1984). This helps ensure understanding of the community’s needs, facilitates acquisition of sociocultural data required by planners, and helps ensure that programs address issues relevant to the community. This requires an understanding of the local community’s health conditions, their communication net- works, and local social and political structures.
Anthropologists may assist community leaders in effecting broader political processes and decision making. Community empowerment emphasizes the development of commu- nity capacities to access resources, participate in political processes, and form community organizations to address needs. These approaches also take prevention perspectives and emphasize the creation of sustainable community programs. This is achieved through changes in community institutions and governmental organizations to affect fi scal and political processes that allocate health resources. Training community research teams creates a community resource that can monitor community health problems and program successes, a fundamental aspect of health.
Applications in Public Health Prevention Programs
The ultimate goal of removing preventable determinants of disease requires changes in life- style and behaviors, not just of individuals but also of communities. Cultural perspectives are therefore essential for effective implementation of the basic goals of public health:
reduction of disease through public health planning, policy development, and program implementation. Understanding how groups of people behave in ways that increase disease is fundamental to developing culturally appropriate programs to change those high-risk behaviors. Effective prevention requires understanding the roles culture plays in placing entire groups at risk. Cultural perspectives facilitate primary prevention by identifying the behavioral and social conditions that may lead to disease. Secondary prevention strategies
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Cultural Defense as Advocacy in the Courtroom
Anthropologists can contribute to health justice through roles as expert witnesses in which they explain the cultural relativity of normal personality, assumptions, beliefs, and behaviors. One aspect involves the cultural defense in criminal law, where aspects of culture that create a person’s state of mind and reasonable assumptions are examined to determine whether a person is guilty of crime or acting under normal cultural assumptions. For instance, did the defendant willfully kill his or her neighbor or did he or she really believe that it was a dangerous witch that they saw in the light of the moon?
Cultures distinguish behaviors that are wrong or criminal from those that result from mis- takes of fact or mental illness that make individuals not responsible for their actions. Awareness of right and wrong and the notion of intent are central to issues many cultures address in determin- ing responsibility and in the determination of criminal guilt in the United States. A person’s mens rea —”state of mind”—is considered in determining guilt in most crimes. An individual’s culturally based perceptions are part of the legal concepts of responsibility and reasonableness (normalcy) that determine legal culpability in criminal cases. These are underlying issues in the cultural defense in criminal law, which involves presenting cultural factors to establish extenuating or mitigating circumstances and the reduction of charges (Winkelman, 1996b; Dundes-Renteln, 2004).
Cultural defenses function through traditional defenses such as mistake of fact, diminished capacity, nonresponsibility, and insanity where mens rea determines the intent that defi nes culpability.
The mental state of a defendant at the time of a crime is a cultural construction and is key to estab- lishing a category of legal defenses called excuses: personal characteristics that establish mitigating circumstances that reduce the severity of actions. Consideration is given to a defendant’s state of mind in degrees of culpability in homicide (e.g., fi rst-degree murder versus negligent homicide or self-defense) and in excuses such as extreme duress, defects of knowledge, reasonable defi ciency, and nonresponsibility. The cultural defense examines personal and cultural circumstances to deter- mine an actor’s state of mind. The mind at fault, a guilty state of mind, is the mental condition gen- erally needed for criminal guilt (Sheybani, 1987). A key concern is reasonableness, “determined from the point of view of a person in the actor’s situation under the circumstances as he [or she]
believes them to be” (Sheybani, 1987, p. 759). Cultural assessments are necessary to appraise an actor’s situation, which is interpreted from the actor’s point of view. Cultural factors affect one’s state of mind, with cultural norms, beliefs, customs, and upbringing potentially leading an individual to a condition of “diminished responsibility,” which may make them guilty of a lesser offense.
Cultural factors determine what constitutes provocative conduct. If the defendant perceives the victim’s behavior as a threat, this may establish that the crime resulted from provocation and reasonable actions based on the defendant’s cultural background. A crime of passion based on perceptions of provocation or threat might mitigate or excuse a crime if it was reasonable and expected for someone in the defendant’s situation. A victim’s violation of cultural norms can arouse passions and obscure reason in an ordinarily reasonable person. There is an absence of malice if an act is committed under extreme emotional or mental duress resulting from provoca- tion as determined by cultural traditions and personal perceptions.
These excuses, a category of defenses long recognized in criminal law, seek forgiveness based on involuntariness, reasonable defi ciency, and nonresponsibility (Kadish, 1987). Central concerns
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normally law-abiding person to act in the same way” (Kadish, 1987, p. 266). Exculpation is based on the concept of the “ordinarily law-abiding person” acting under constraints of knowledge or defects of will. Defects of knowledge undermine intentionality, the mental state necessary for a crime to have occurred. Cultural factors can negate criminal intent because the defendant’s subjec- tive state of mind, resulting from cultural beliefs and norms, can produce a reasonable (mis)under- standing of the situation and consequences of one’s action. “People from a foreign culture may perceive reality so differently from those raised in the majority culture that their assessment of a situ- ation may be tantamount to a mistake of fact” ( Harvard Law Review, 1986, p. 1294). Legal systems have found acquittal, absolution, or insanity in cases where defendants killed devils, witches, or supernatural beings—in human form. The mistake of fact argues that the client lacked the requisite mental state: intention and knowledge of consequences of acts. Because criminal liability requires intent, cultural factors affecting behavior in terms of purpose, or recklessness or negligence, may negate the presence of the necessary state of mind and intent (Lyman, 1986, p. 94).
Nonresponsibility is an excuse based on extenuating circumstances, an inadequate capacity for making judgments as exemplifi ed in the legal insanity defense. Legal insanity is a situation where “mental disease prevented the defendant from conforming his conduct to the require- ments of the law . . . incapable of making choices that count as such because of impaired reason- ing and judgment” (Kadish, 1987, pp. 261–262). Because the person no longer acts as a rational agent, it is not fair to hold the person liable because he or she lacks the normal capacity for judg- ment and reason. The cultural defense may be used in an insanity plea, but it strains the defi nition of mental disease to the point unlikely to be accepted by the courts ( Harvard Law Review, 1986;
Kadish, 1987). This is particularly true when the determination of mental disease is limited to those defi ned by earlier versions of the DSM (but see DSM-IV-TR, 2000). A broader view of mental illness incorporating the concept of culture-bound syndromes is necessary to effectively incorpo- rate cultural factors within the traditional insanity defenses.
Elsewhere I have reviewed the use of cultural factors at the pretrial, guilt, and penalty phases (Winkelman, 1996b). A primary role of the anthropologist as an expert witness involves informal factors, including being a “bargaining chip” for defense lawyers in the negotiation of charges.
Charges carrying the death penalty obligate the state to extensive support of the defense, includ- ing expert witnesses, but lesser charges do not. Cultural information may be used in the guilt phase of trials, but the penalty phase, where mitigating circumstances are assessed, is a more likely context for introducing information regarding character and background circumstances.
Wright (1992) suggests that anthropologists’ testimony establishing mitigating cultural factors involves the defendant’s socialization in informal and formal social institutions and groups, including effects of economic and political institutions, social services, and the justice system. The cultural aspects of mitigating and extenuating circumstances may involve any aspect of a defendant’s background, particularly cultural values and their effects on behavior, socialization regarding aggression and violence, beliefs regarding what constitutes provocation, family and kinship roles and expectations and their relationship to coping and mental health, political and social obliga- tions, and religious beliefs and practices (Winkelman, 1996b).
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