chapter  7
Islam and Dying in the United States: How Anthropology Contributes to Culturally Competent Care at the End-of-Life
ByCortney Hughes Rinker
Pages 15

I was on a conference call with hospital administrators, health care providers, consultants, and researchers from the North and Mid-Atlantic States involved in developing a proposal for federal funding that addressed the need to keep patients from being re-admitted to the hospital within thirty days of discharge. This proposal was in response to the 2010 US health care law that authorized the government to fine hospitals “because many of their patients are readmitted soon after discharge” (Rau 2012). This is “part of a multipronged effort by Medicare to use its financial muscle to force improvements in hospital quality” (Rau 2012). On the call it was concluded that the surveys provided to patients in the hospital before discharge about the care they will receive at home and discussions with nurses and medical staff about discharge instructions were inadequate; we needed to understand what was happening at home and in their communities in order to provide a better picture as to why patients are being re-admitted within one month. As the only anthropologist in the group, I believed that it was critical to realize

that patients do not stay in the hospital and, therefore, we needed to better understand how culture and social circumstances impact whether or not they follow their discharge instructions and if they do, to what degree. It is also important to realize that non-compliance is a choice that people are able to make (Campbell et al. 2001). In this instance, many of the involved hospitals’ re-admissions were due to class issues and the fact that several of the patients relied on public health care and did not have a private family physician to follow up with after discharge. They often used the emergency room as primary care even though critical care is very costly. At that point I realized the importance of culturally competent health care and taking into consideration people’s backgrounds when caring for them and when designing treatment plans. At the time, I was a postdoctoral fellow working with a health care organization in rural Virginia where many of the patients qualified for government assistance. In working with administrators and physicians to

improve the quality of primary care, I did more research on cultural competence in health care and how we could apply it. In this, I realized that class was not an issue often addressed in practice and discovered that the term is frequently used in a very narrow sense to refer to the treatment of ethnic minorities, rather than in a more robust sense that encourages providers to offer treatment and home care instructions that take into consideration issues such as religion, gender, sexuality, and class in addition to ethnicity. Cultural competence has become a buzzword in the health care system in the

United States and internationally (Baker and Beagan 2014; Catalano 2012), but there is not a single definition for it. In the United States, much of the literature on culturally competent health care focuses on the need to address health disparities among ethnic minorities. Kelly Baker and Brenda Beagan write, “Although the term ‘cultural competence’ has been expanded beyond its initial definition in order to include gender, social class, and sexual orientation, in practice it tends to still be equated with ethnicity and race” (Baker and Beagan 2014, 580). According to the Centers for Disease Control (CDC 2014), “some minorities experience a disproportionate burden of preventable disease, death, and disability compared with non-minorities” making it imperative to design health care programs and treatment regimens that take into account cultural and social factors so that they are successful. The CDC (2014) encourages health communication to take the culture of a population into consideration and to have “behaviors, attitudes, and policies come together in a system, agency, or among professionals to enable people to work effectively in a cross-cultural situation.” Culturally competent health care requires,

a commitment from doctors and other caregivers to understand and to be responsive to the different attitudes, values, verbal cues, and body language that people look for in a doctor’s office by virtue of their heritage. The concept of tailoring health care is not a new one; we already have medical specialties based on age and gender. Cultural sensitivity is one more dimension of that kind of refinement

(Goldsmith 2000, 53, emphasis added)

We can see that this definition of cultural competence stresses the need to understand “heritage” and thus leaves out other attributes like religion, gender, sexuality, and class that could have an impact on health decisions and behaviors. Joseph Betancourt et al. (2003, 294) state that an essential part of cultural com-

petency is the interactions between patients and the health care system. They write:

A “culturally competent” health care system has been defined as one that acknowledges and incorporates – at all levels – the importance of culture, assessment of cross-cultural relations, vigilance toward the dynamics that result from cultural differences, expansion of cultural knowledge, and adaptation of services to meet culturally unique needs … The movement toward cultural competence in health care has gained national attention and is now recognized by health

policy makers, managed care administrators … providers, and consumers as a strategy to eliminate racial/ethnic disparities in health and health care. There is, however, an ongoing debate as to how to better define and operationalize this critical yet broad construct.