White People Have Culture

“Mauri” or life principle, illustration by Nancy Nicholson in Dr. Rangimarie Turuki Pere’s book, te wheke: A celebration of infinite wisdom. Awareness Book Company, 1997.

The word ‘culture’ is misused and abused. We often use the word ‘culture’ as some strangely polite code word for race and ethnicity, for people who are somehow ‘not like us.’ And those of us white people, part of the dominant culture, typically don’t even believe that we have our own culture–like racism, we can’t see it because of our own power and privilege.

Within health care, we have trainings, courses, (and silly multiple-choice tests) on ‘cultural sensitivity’ and ‘cultural competence.’ As if being sensitive to or competent in this thing called ‘culture’ is possible, and if possible, as if it is a good thing. When what we should be doing is teaching to cultural humility and its Kiwi sister, cultural safety: building in self-reflection, life-long learning, and work to see/undo institutional racism.

I’ve written about different aspects of this issue in previous blog posts: “Cultural Competence, Meet Cultural Humility” (8-16-11), “Cultural Humility Redux” (2-2-14)  and “Cultural Safety: A Wee Way to Go” (3-12-14). Until recently, I much preferred the name/concept of ‘cultural humility’ over the name/concept of ‘cultural safety,’ mainly because I didn’t comprehend the need for the word ‘safety.’ My white privilege comfortable blindness there. But the escalating, deeply disturbing litany of racist violence in our country has forced me to see–duh!–the need for ‘safety.’ My recent return to New Zealand, the birthplace of the term ‘cultural safety,’ also opened my eyes to deeper layers of nuanced meaning of this term, of this work.

Jim Diers, MSW and I co-led an international service-learning study abroad program, “Empowering Healthy Communities,” on the North Island of New Zealand this past summer. We had a group of twenty-two engaged university students, across a range of health science and ‘other’ academic disciplines, and from a rich diversity of self-identified race/ethnicities. As many of them pointed out in their final written reflections, they learned as much from living with our group for five weeks as they did from interactions with New Zealanders. We spent a lot of our time working alongside and listening to community members on various Maori marae (villages), as well as Pacific Islander and other marginalized groups in New Zealand. We learned of their strengths, considerable community non-monetary assets, of their hopes for the future–as well as their challenges and historical traumas…the subtext being the need for cultural safety within health care, as well as within all other New Zealand institutions.

As part of a traditional Maori greeting, people introduce themselves–not by our typical name and credentials/work/university, but rather by details of where you are from: the names of the mountain and river of the land of your family/tribe. So for many members of our group, it was “My mountain is Rainer (or Tahoma as local tribes call it) and my river is the Duwamish (currently an industrial dump/Superfund site..).” And “My people are from Italy, England, Nepal, Mexico, the Philippines (and wait–why ‘the’ with Philippines?–important history lesson of oppression there), China, Israel….” Lovely diversity, except that none of us, unfortunately, could claim Native American/Indian ancestry. We were always asked about that by our Maori hosts–another important history lesson that wasn’t lost on our students. Through participating in this seemingly simple ritual of greeting, we all learned about our own cultures.

At the end of our study abroad program, we received an amazingly powerful talk on cultural safety from Denise Wilson, RN, PhD, a Maori New Zealand nurse and Director of the Taupua Waiora Centre for Māori Health Research at AUT School of Public Health and Psychosocial Studies here in Auckland. She talked to the students about her work with cultural safety in New Zealand–about the need for the ‘cloak’ of cultural safety. She told the story of well-intentioned Pakeha (white/European New Zealander) nurses asking their Maori or Pacific Islander patients, “What are your cultural practices,” and being met with polite, blank stares. “Because that’s our language, our terms, not theirs,” she added. She gently admonished our students to get to know themselves, their own cultures and biases, and to practice humility when working with people they perceive as ‘different’ from themselves–to listen, and “really listening takes time.”

Her closing quote, from Dr. Rangimarie Turuki Pere, whose book I reference in the photo caption in this post, was this:

“Your steps on my whariki (mat)/Your respect for my home/opens my doors and windows.”

Words to live and work by.

Study Abroad: The Evidence

IMG_5154 (1)
Signpost near the Waiheke Island(New Zealand) ferry landing. Photo credit: Josephine Ensign/2015

Until recently, the effects of study abroad experience on college students were mainly anecdotal in nature—more in the form of personal testimonials from students about what they gained through the experience: “Such a blast! Best bar scene ever and their drinking age is 18–how cool is that?!” and “Did you bungy jump yet off the Kawarau Bridge in Queenstown?” to the more serious “It opened my eyes to the way Americans are perceived in other countries.” But parents, university administrators, and funding agencies increasingly want hard evidence on the cost-benefits of study abroad experiences.

The number of U.S. students studying abroad has more than doubled in the past decade. During the 2013/14 academic year (latest stats available), 289,408 students studied abroad for at least a month for academic credit. (Source: Opening Doors, an initiative of the Institute of International Education.) The Institute of International Education recently launched the Generation Study Abroad campaign to double the number of U.S. university students who study abroad by the end of the decade. The campaign also aims to increase the diversity in race/ethnicity, academic disciplines, destinations (the UK and European countries are the vast favorites), and gender. Racial/ethnic minority students, first-generation college students, and STEM majors are underrepresented in study abroad programs. In addition, 65% of study abroad students from the U.S. are female. Are young women more adventuresome somehow?

Here are some intriguing findings from recent studies on the benefits of study abroad programs. Controlling for prior GPA, credit-taking, and SAT scores, a student who studies abroad has a 10% greater chance of graduating in four years than a student who does not. Why would that be, I wonder? It does run counter to what many parents–and even some academic advisors–worry about with study abroad, that it will complicate a student’s credit requirements and therefore delay their graduation. In my own case with a ‘junior year’ study abroad experience, the summer semester’s worth of credit allowed me to graduate a year early. Perhaps through study abroad experiences, students see the value in completing their undergraduate degrees as quickly as possible and getting on with the rest of their lives.

Study abroad experience has been shown to increase students’ self-reported cultural sensitivity, self-confidence/adaptability in dealing with complex, unfamiliar living/working/studying conditions, and knowledge of world geography. The American Association of Colleges and Universities identify intercultural understanding as an essential learning outcome for contemporary university liberal arts education. Employers and graduate school admissions committees place value on prior international study abroad and other international experiences (such as volunteering). For health professions students, study abroad experiences would seem to be ideal for helping to increase cultural knowledge/humility, as well as perspective (and humility!) on the failings of our U.S. healthcare system.

Before our study abroad program started this summer, I asked our current group of twenty-two university students who are here in New Zealand studying community health, to write down at least four personal goals they have for themselves. While a month is not a lot of time for a study abroad experience, it can be impactful, plus I have found it is more accessible to a broader demographic of students who otherwise might not get to have a study abroad experience.

We have an amazing and quite diverse group, many of whom are in (or going into) health professions education, including nursing, social work, medical anthropology, global health, pre-med, and pre-physical therapy. Here (paraphrased to protect identities) are some of what they wrote/shared with me in terms of their goals for this study abroad experience: “To find my place as a global citizen.” “To be able to problem-solve bravely and maturely.” “To learn new ways to manage my stress.” “To let the fire in my heart truly burn for global health.” “To get the chance to slow down and really reflect on where I have been and where I want to be in the future.” “To be able to practice cultural humility and greater global awareness.” “To push my boundaries and push myself outside my comfort zone; deal with difficulties in a mature manner.” And finally, from one of our many ‘first time out of the U.S.’ students, “I hope to have culture shock and awkward moments where my ‘Americanism’ shows.”

If our students accomplish even a few of these personal goals during our study abroad program, I will consider it a grand success.


New Zealand Postcards: Cultural Safety: A Wee Way To Go

DSC01879 - Version 2DSC01418This week I had the good fortune of meeting with Denise Wilson, RN, PhD, a Maori New Zealand nurse and Director of the Taupua Waiora Centre for Māori Health Research at AUT School of Public Health and Psychosocial Studies here in Auckland. She talked about her work with cultural safety in New Zealand.

Like many indigenous peoples across the world–including our own in North America–Maori cultural conceptions of health and well-being tend to be much more holistic and less individualistic than mainstream Western ones. As Ms. Wilson explained, for most Maori patients she has worked with (clinically and in research), spirituality and connection with their land and extended family are the most important aspects of health. The Maori word for land, Whenua, also means placenta: it is what nourishes you. The history of colonialization, and being displaced from ancestral lands, have had profound negative effects on Maori health and well-being.

The term ‘cultural safety’ came from a Maori nursing student, Iriphapeti Ramsden (1946-2003), who in the early 1980’s stood up in class one day and asked something like, “We talk about patient safety, physical safety, and ethical safety, but what about cultural safety?” She was specifically referring to the difficulties Maori patients and their families (as well as Maori nursing students such as herslef) have within the Eurocentric health care system in New Zealand. These difficulties continue to contribute to New Zealand’s large health inequities and low representation of Maori nurses and other health care providers in the healthcare system. Ramsden went on to receive her PhD, developing the concept and practice of cultural safety. I discovered that Dr. Ramsden was part of the New Zealand feminist Spiral Collective, which ‘self-published’ Maori writer Keri Hulme’s book The Bone People after it was rejected by all major publishers. The Bone People, of course, went on to win the Man Booker Prize. One of my all-time favorite books, I assigned it as our New Zealand study abroad Common Book this quarter.

According to Denise, a culturally unsafe practice is “anything that diminishes, demeans, or disempowers the cultural identity and well-being of an individual.” A culturally safe or unsafe practice is determined by the patient and the patient’s family (another form of what we term in the U.S. ‘patient-centered care.’) Denise told me that a good ‘cultural safety’ question nurses can ask patients (and their family members) is, “What are things that are really important to you that we need to consider in your care?” Cultural safety includes an emphasis on self-reflection (and action) by the nurse in terms of understanding his or her own cultural and social attitudes that affect their care of patients and communities.

Cultural safety has been taught in New Zealand nursing programs for over twenty years. Since 1992 it has been a requirement for nursing and midwifery registration examinations. What started off as a bicultural focus (Maroi and Pakeha/non-Maori), has been expanded to include things like migrant status, gender/sexual orientation, socio-economic ‘class’ status, and disability. The concept of cultural safety has been adopted by regions in Australia, Canada, and the United States. Denise acknowledged the significant advances that have been made in New Zealand in terms of cultural safety, but she concluded with: “We do have a wee way to go.”

Cultural safety seems to have much in common with my favorite U.S. ‘cultural’ concept of cultural humility, which I have written about in a previous post. Cultural humility was developed as a concept by the African-American physician-nurse duo Tervalon and Murray-Garcia in their 1998 article, “Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education.” (Journal of the Poor and Underserved, 9(2) 117-125.) Since then, both the practice and concept of cultural humility have been further refined. Cultural humility emphasizes: 1) a commitment to lifelong learning and critical self-reflection, 2) recognizing and changing power imbalances, and 3) developing institutional accountability. Take a look at the excellent 30-minute video Cultural Humility: People, Principles and Practices by San Fransisco State professor Vivian Chavez.

Even closer to (my) home of Seattle, the historical roots and “remnants of our unresolved past” of racism and classism are powerfully presented in Shaun Scott’s short documentary A Really Nice Place to Live. In the film, Shaun Scott points out that Seattle is a byproduct of White Western Frontierism. He references historian Richard Drinnon’s work on the ‘Metaphysics of Indian-Hating,” where Drinnon asserts that all of American’s domestic and international race and class dynamics can be traced back to our original interactions with our ‘own’ Indigenous peoples.

We all have a wee way to go in terms of addressing and redressing the effects of racism and classism and all the other ‘isms’ of the world.


The first photograph here is of the friendly and informative staff at the Alliance Health booth at Auckland’s annual Pasifika Festival, which I attended this past weekend. The staff members were promoting community awareness and prevention of rheumatic heart disease. New Zealand has the highest prevalence of rheumatic heart disease of all industrialized countries, and the highest rates are among Maori. It is a result of untreated ‘strep throat’ and is considered a disease of poverty. One of their community-led ‘interventions’ was the creation of Mama’s House as a culturally-appropriate way to engage the Pasifika community.  “Knowing that mothers, sisters and aunties are the first port of call about all matters relating to family health and well-being. After all, ‘Mama knows best’.” It also happened to be International Women’s Day. (And I also had just played ‘Mama-Nurse’ for some of my students who had developed penicillin- resistant strep throat, resulting in some ‘interesting’ interactions with the New Zealand healthcare system, which–like our own–has ‘a wee way to go.’)

The second photo is an interactive game show called “The Survivors,” part of the Maroi section of Wellington’s excellent Te Papa Museum exhibition Slice of Heaven: New Zealand’s Twentieth Century History. As this photo shows, one of the decisions you have to make while playing the game is whether you (as a Maori young woman in the 1970’s) went to the shorter/cheaper nurse aid program or to the longer/more expensive (and heavily Pakeha/’White European’) program to become a Registered Nurse. Guess which choice led to better outcomes, including lifespan for this woman?

New Zealand Postcards: Happy Hoppity Hobbity Hybridity

DSC00850There’s nothing like being in a foreign country to make you more aware of your own. I’m writing this blog post from the comfort of the Maori whare runanga (meeting house) section on the upper level of the lovely Auckland Public Library. Ironically (or not) the traditional carved spiritual ‘story-telling’ motifs of the Maori, complete with the familiar haka (male war dance with protruding tongues,  is nestled next to a display of first-edition English children’s books, including Winnie-the Pooh, Alice-in-Wonderland, and The Tale of Peter Rabbit. Happy hoppity hobbity hybridity.

The term ‘happy hybridity’ comes from New Zealander Professor Jacqueline Lo, who now teaches at the Australian National University in Canberra. Dr. Lo writes about the politics (and economy) of feel-good multiculturalism vs. the difficult politics of anti-racism. The photograph I’m including in this post is of a mural at an Auckland bus stop, nicely illustrating the perceived Utopian ideal of happy hybridity/multiculturalism. As in most places in the world, this is the public face or veneer of peaceful blending of cultures (and socio-economic classes) that we all like to project. It is never nice to dig deeper, to look in people’s garbage bins or their medicine cabinets, to peek behind the public face/masks, even if they are in our own backyards–or are our own. I always feel conflicted when I travel to and live in another country (I’m here teaching in New Zealand for three months); I want to keep a critical gaze on a place but I also don’t want to become a cynical, ungrateful guest: just another Ugly American Tourist.

In doing some reflection on these complex issues, I stumbled across a wonderful blog post “Postcards from the Edge”  by Ruth DeSouza (her blog is called Nurse Academic in Australia). In this post she writes about happy hybridity vs. the politics of racism within a New Zealand context, from her perspective as a New Zealand Indian now living in Australia. She does a great job of ‘complicating’ the issues of race/class/culture.

So I continue to reflect on my own racial/ethnic class biases as I go off in search of happy multicultural Hobbits. Did anyone notice Peter Jackson’s almost humorous attempts to be more racially/ethnically inclusive in his latest Hobbit movie? There were–gasp!–dark-skinned ‘good people’ in Laketown, although he still cast Maori actors in roles as part of the ‘dark forces of evil.’


For an excellent ‘close to home’ (for me anyway) short video/documentary on Seattle’s own historical roots (and current consequences) of racism/classism, I recommend historian Shaun Scott’s “A Really Nice Place to Live” (linked on the University of Washington’s Seattle Civil Rights and Labor History Project). It’s worth a view and a share. I use it in my courses and it always provokes good classroom discussion on an often ‘taboo’ topic in nursing.

Cultural Humility Redux

English: Haystack
English: Haystack (Photo credit: Wikipedia)

It is past time to retire the term ‘cultural competency’ in favor of the more enlightened ‘cultural humility.’  The word ‘humility’ is a problematic one for people, especially for health care providers or academics used to doing everything possible to avoid being humble. We are groomed to be arrogant. (See earlier post “Cultural Competence, Meet Cultural Humility” Aug. 16, 2011.)

But I’m reminded of one of my favorite quotes from a favorite author, William Maxwell, from his book Time Will Darken It:

“People often ask themselves the right questions. Where they fail is in answering the questions they ask themselves, and even there they do not fail by much. (…)There is no haystack so large that the needle cannot be found. But it takes time, it takes humility, and it takes a serious reason for searching.”

I juxtapose this quote with one from Craig Irvine who teaches in the Columbia University Program in Narrative Medicine. Mr. Irvine is a former Benedictine monk whose area of expertise is narrative ethics. He talks about empathy (necessary for cultural humility) as being “my experience of the mystery of my relationship with another person” as opposed to the usual understanding of empathy (in healthcare settings at least) as knowing the other person or “stepping into their shoes.” Craig states, “empathy brings me to myself.” (Quotes are from my notes of a talk he gave at a narrative medicine conference I attended in October, 2010).

We really never can know someone else, and as William Maxwell points out, many times we fail to even know ourselves. But in the words of Lyle Lovett, “Who would you be if you didn’t even try?”

That brings me to my hearty recommendation of a relatively new video I happily stumbled across yesterday (thanks to Community-Campus Partnerships for Health.) The video was written/produced by Vivian Chavez and is titled, “Cultural Humility: People, Principles and Practices.” (Aug. 9, 2012 release date/ 30 minutes in length.) The video features interviews with various people, including physician Melanie Tervalon and nurse/educator Jann Murray-Garcia, co-authors of the journal article “Cultural humility vs. cultural competence.”(Journal of the Poor and Underserved, 9(2) 117-125.)

According to Tervalon and Murray-Garcia, the three principles of cultural humility include:

  1. Lifelong learning and critical self-reflection
  2. Recognizing and mitigating power imbalances
  3. Institutional accountability (they emphasize for the power imbalances, but I would add accountability for the structures/support/leadership necessary for lifelong learning and critical reflection… these are usually woefully lacking.)

While watching this video for the first time I was thinking—wait! Where are the white people in this? But at least I did recognize my own white privilege arrogance in the question. I continue searching in my haystack.

Cultural Competence, Meet Cultural Humility

Who owns culture
Image via Wikipedia

And then, meet your twin second cousins, cultural sensitivity and cultural awareness. Oh yes, and here is your crusty old uncle, cultural knowledge….

They all have something to do with culture, and with what we are supposed to do with culture. In the health care setting, we’re expected to be aware of and sensitive to the fact that there are differences in people according to their culture. We’re supposed to take basic and continuing education in culture as applied to healthcare and hence, become competent in culture. One fundamental problem with this is that there are hundreds of different definitions of “culture,” so it’s not even clear what we’re supposed to be competent in.

Culture, in the socio-cultural anthropological sense and not in the high society sense, is permeated with the spirit of The Other. And since all early anthropologists in the US were white English-speaking males, the “Others from another culture” were all non-white, non-native English-speaking people. In the US these different cultures started off with the conveniently located colonized North American indigenous people, the “Indians.” The even older roots of anthropology from the UK were intent on studying “exotic, primitive people from other lands” that were being colonized. Anthropological writings were a source of entertainment for the colonizers back home, as well as a tool for continued conquest of, rule over and exploitations of people from other cultures.  It is important to acknowledge these uncomfortable historical facts about anthropology—and about culture. It is important to know that similarly smarmy things are still being done with anthropology and the “study of culture.” Anthropologists are part of modern US war efforts, including in the current war in Afghanistan. Anthropologists have been part of the Vietnam War counter-insurgency, and part of the continued War on Drugs. And they are largely responsible for the current emphasis on cultural competency for health care providers.

There are many problems with cultural competency. Besides the largely unquestioned operational definition of “culture,” as well as its origins in American-European notions of colonialism, institutionalized racism and oppression, there is the idea that culture is static and can be reduced to a laundry list of evil eyes, hot and cold foods and fertility rituals. Then there is the idea that someone can be competent in culture. As if you can get a certification card in cultural competence, just like you can get a certification card in Basic Life Support or Blood-born Pathogens. Oh wait—you can get a cultural competency card. Recently, I would have gotten one, if I had passed the multiple-choice test given as part of an online series of tests to become credentialed by a local hospital. I wasn’t planning to work there, but I had to take the tests in order to have a student placed for a clinical rotation. The test questions seriously irritated me. They were all written with the assumption that people from another culture are non-white ethnic minorities or people from another country.

I have spent the past thirty years working with refugee/immigrant, homeless (majority African-American and Native American) and sexual minority groups of people. I have lived and worked for extended periods of time in Northern Thailand, survived culture shock and reverse culture shock (warning: don’t go from working with malnourished, growth-stunted Burmese street children to Whole Foods in less than 24 hours). The most important resources I had in this work were co-workers from diverse backgrounds and disciplines who I could bounce things off of—frustrations I was having in understanding different patients—frustrations with the lack of adequate interpreter services, frustrations with my own assumptions and biases. We were able to problem-solve—and problem accept—together. There are some things that just can’t be fixed. Our health care team was able to openly discuss racism, oppression, white privilege, ethical dilemmas that no textbook can ever cover, and do informal self-reflection activities during and after clinic. This was not culturally competent care, it was culturally humble care.

Many people from the US bristle at the term “humble,” since it has religious zealot overtones, and it shares the same word root as “humiliate.” I like humble because it is from the Latin “humus:” ground or dirt. Culturally grounded, culturally dirty, culturally humble. Cultural humility was first coined by Tervalon and Murray-Garcia in their 1998 article, “Cultural humility versus cultural competence: a critical distinction in defining physician training outcomes in multicultural education. (Journal of the Poor and Underserved, 9(2) 117-125. Their definition of cultural humility emphasizes a lifelong commitment to self-reflection, and to paying attention to power inequities inherent in the healthcare encounter. It is an interesting article, but is unfortunate in that their one example of cultural competency “gone bad” in clinical care was by a nurse. But then, an otherwise excellent nursing article on cultural humility uses as their one example of global health “gone bad” that of a physician. (Levi, “The Ethics of Nursing International Clinical Experiences” JOGNN, 2009).  Being humble is hard work.