Universal Human Rights Month: Equality in Healthcare

December is Universal Human Rights Month and we’re taking a look at equality in healthcare. Join us as UC San Diego’s Dr. Seth Hannah examines what healthcare institutions can do to ensure patients receive the same high quality care regardless of their identities. Simply put, how can healthcare do diversity better?

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Welcome back to Aya Healthcare’s Healthcare equity exchange. Thank you for tuning in. We’re committed to bringing you varied perspectives on issues related to diversity and inclusion. We appreciate you for joining us and building a workplace and a world that celebrates our differences and welcomes everyone. Educating ourselves is the first step towards that world.

Since December is Universal Human Rights Month, we thought it was the perfect time to discuss diversity in healthcare. Today we’ll hear from Dr. Seth Hannah, the academic coordinator of the Global Health program at UCSD. He provides an anthropological look at how healthcare organizations respond to diversity. What is diversity, and how do we move toward an understanding of hyper diversity? Stay tuned for a discussion of these questions and more.

Hello I’m Dr. Seth Hanna, academic coordinator of the Global Health program and a lecturer at UC San Diego. The fight for global health equity begins here at home, where our communities grow more diverse by the day and access to high quality health care remains out of reach for far too many. With the Institute of Medicine’s publication of the landmark report Unequal Treatment in 2001, a new era of research and activism emerged in response to growing evidence that health care providers, even physicians, can be biased and treat patients differently on the basis of their race, ethnicity, or other social identity characteristics.

But what exactly should we do in response to such troubling information? What can healthcare institutions do to actually ensure that patients receive the same high quality care regardless of their identities? I’d like to share some of my thoughts with you on this topic based upon my research examining how medicine understands the challenges of diversity and has constructed institutional responses to reduce healthcare disparities.

One of the major ways healthcare institutions have responded to diversity is by emphasizing that individuals with different racial and ethnic identities have different cultural orientations, and that these cultural orientations are often not shared by their medical providers. Because of these cultural differences, the thinking goes, patients may not receive the best quality of care possible, due to misunderstandings or difficulty communicating their experiences.

Recognition of this cultural mismatch has led to a culture counts movement and an attempt by some institutions to educate providers about potential cultural differences that may exist between themselves and their patients. What is commonly called cultural competence training. They hire staff members with similar identities and cultural orientations as their patients and even construct culturally specific services specially targeted to meet the needs of specific patient populations.

Other institutions, however, maintain that it is not necessary to directly address cultural differences because basic skills of good doctoring can be enough to uncover the biomedical problems faced by the patient. This leads to a spectrum of approaches to cross cultural healthcare, ranging from no culture represented by a universal approach to care, all the way to an all culture model represented by the construction of an entire clinic around the cultural needs of one discrete patient group.

The currently favored policy approach falls into the two boxes you see here on the right, cultural competence training and the development of culturally specific services. A key point that I would like to emphasize is that both of these approaches are rooted in an important shared principle that individuals with different racial and ethnic identities share common group based experiences and that they have cultural orientations in common with each other that are not shared with other groups. That is racial and ethnic groups exist, they can be readily identified by medical providers and that they share a common culture. Now, this shared principle might seem self evident, maybe even like common sense.

However, anthropologists don’t understand culture in this way. Culture is actually not a variable or the property of groups; it’s an individual’s orientation to the world developed on the basis of life experience and the meanings they develop over time through social interaction. This more modern understanding of culture has led to an emerging set of policy responses premised on the idea that yes, culture definitely matters, but in a more individually specific way. Individuals with similar racial and ethnic identities may often share common experiences such as shared neighborhoods, activities, religious communities, political views or shared experiences of discrimination, but this is not always the case. Individuals have unique family lives, preferences, inner psychic world, personalities and a set of lived experiences unique to themselves alone.

This suggests a policy approach that encourages health care providers to be curious about their patients unique lifeworlds, to ask questions about their cultural orientations and to not make assumptions about them based upon their presumed racial and ethnic identities. In short, it calls for cultural humility and the use of anthropological methods such as ethnography within the clinical encounter, to better get to know the culture of their patients. This approach is especially needed today when the racial and ethnic mix of the population is growing much more complicated. Older approaches to cross cultural healthcare are rooted in simple census based understandings of diversity, such as, what we call the ethno-racial pentagon. The mix of only five major racial and ethnic populations, Black, White, Hispanic, Asian, and Native American.

The diversity of our patient populations cannot really be captured in just five racial and ethnic categories, or solely in terms of race and ethnicity for that matter. In Boston, where I conducted my research in a number of psychiatric clinics, the Black-identified population was more than a third foreign born and another third were the children of recent immigrants from Haiti, the Dominican Republic, Puerto Rico, Jamaica or Cape Verde.

The Hispanic-identified population came from numerous countries across Central and South America, Puerto Rico, and the Dominican Republic, many of whom, are frequently identified racially as Black. I argue in my work that this is not merely diversity, it’s hyper-diversity, a dynamic and multidimensional cultural environment with an ever-changing and hard to classify population that is growing in communities all over the country and reconfiguring social life within newly integrating neighborhoods.

Healthcare institutions can improve health equity by recognizing this hyper-diversity. They should attend to multiple forms of difference in their patient population, including their racial and ethnic identities, their social class backgrounds, sexual orientations, religious beliefs and practices, cultural values, lifestyles and personal experiences. It’s difficult to tell which aspect of a patient’s identity or experience will be important in any given situation.

Clinicians should keep an open mind and treat each patient more as an individual. Clinicians can do this by using anthropological tools in their work. The stories patients tell of their illness experiences are crucially important for helping clinicians diagnose and treat disease. Clinicians should pay close attention to these stories and ask questions about the daily lives and experiences of their patients.

Every patient’s experience is unique and clinicians should resist making judgments about their patients based on their identities or their cultural group memberships. This can actually lead to harmful stereotypes and poorer quality care. Thank you for listening.

Thank you for reading (or watching!) and stay tuned for more insightful content related to healthcare, equity and inclusion.