Last year, as a health and literacy liaison funded by Adult and Community Learning Services (ACLS) at the Department of Education, I was responsible for working with programs to assist with integrating and institutionalizing health into their curricula. My work brought me to site visits at Centro Latino, Project Hope and La Alianza Hispana in the Boston region. At a meeting at Centro Latino we were discussing the topic of cross-cultural issues in the health care system, and I mentioned the book, The Spirit Catches You and You Fall Down, by Anne Fadiman. This true story describes a Hmong child suffering from gran mal seizures. The book documents the ongoing communication struggle between American medical doctors and the child's parents. One major conflict in the book centered around the best way to care for the child. The parents and the doctors saw the disease from different cultural standpoints, and eventually they were not able to trust each other or to communicate at all. The child's health was in serious danger, partly because the parties involved perceived her illness and treatment completely differently.

Participants' Stories
At this meeting at Centro Latino, the subject of cultural clashes and barriers in the health care system hit a nerve. Almost all the participants at the meeting had a story to tell of how they felt culturally "out of place" or not respected. One woman mentioned how she and her husband went to a clinic in East Boston because her husband thought he had the symptoms of meningitis. He was a doctor in Venezuela and obviously knew a great deal about this disease. When he mentioned his background and his diagnosis to the nurse and the doctor and suggested that he get an MRI, he was told to go home and take a few aspirins. Late in the evening after waiting in the clinic all day and being told to go home, his symptoms became worse. He returned to the clinic. Finally the doctor gave him a referral to Mass General Hospital (MGH) for an MRI scan. As he expected, the results of the scan came back positive. The doctor at MGH told him that if he had waited much longer he could have died.

Another woman present at the meeting told a story about her Mexican grandmother who was a shaman or medicine woman. As a child she was given various home remedies to use. For example, for the common cold she wore a compress under her clothes. Once her schoolmates noticed the compress and teased her relentlessly. She was ostracized for having different medical/spiritual practices.

Improving Cultural Communication
After hearing these stories, I decided to find out what the hos-pitals in Boston are doing to improve intercultural communication. I visited MGH's Family Learning Center and I found out they were planning the first hospital-wide training in this area. The director of the center, Taryn Pittman, mentioned that she had just come from a cultural competency training for health care professionals in Seattle. She was modeling the training at MGH after the Seattle model, called Cross Cultural Health Care Program (CCHCP), Taryn explained that one valuable piece of the training was the sharing of "cultural bumps."

Cultural Bumps
A cultural bump is an occurrence when an individual finds himself or herself in a situation (that is) different, strange, or uncomfortable when interacting with persons of a different culture. This phenomenon results from a difference in the way people from one culture behave from people in another culture (Archer, 1986). Taryn shared her own example of a cultural bump when she worked as a naval officer aboard an all-male ship. For several months at sea she was the only woman. She said this was one of the most terrifying tasks she ever had to face in her life. "Cultural Competency involves recognition and respect for differences among patients in terms of their values, expectations, and experiences with healthcare, while at the same time recognizing the culture-based practices and dictates of organized medicine, and the values, expectations, and experiences of the providers who practice it" (CCHCP's Cultural Competency Curriculum, 1999). Taryn's training was designed to help doctors and other health care professionals become aware of their own cultural identity and then to slowly move toward understanding others. She emphasized that the process of cultural competency starts and navigates from a greater sense of self awareness. After this visit, I understood the stories that I heard at Centro Latino to represent cultural bumps, or in the worst-case scenarios, cultural clashes.

At the end of the year, I presented a workshop, "Cultural Clashes in the Health Care System," at the Statewide Health conference. After my workshop ended a woman came up to me and said that her daughter was a 15-year-old nurses' aide in a local hospital outside of Boston. Her daughter was asked to translate, in high school Spanish, the procedure for a kidney transplant to a young Spanish-speaking woman whose surgery was due the next day. I found it hard to believe that a hospital so near to Boston would not be able to find a qualified Spanish- speaking interpreter at any time of the day. At the same workshop a Chinese woman spoke of the terror and vulnerability she felt when she went to a hospital in Boston not knowing one word of English. These stories call out to our community of ESOL for support and awareness on how destructive cultural incompetence is both on an individual and institutional level. In the U.S. we have medical treatment and preventative care far ahead of most other countries in the world. However, in Massachusetts, many immigrants and refugees are given substandard care because their health care provider is unable to communicate with them. Many times, family members may act as interpreters of highly specialized information and children used as interpreters are thrown into the role of adults way before their time. Cultural values are inherent in our beliefs around health. As adult literacy practitioners, we need to educate ourselves about how different cultures view health and illness and how they practice health care so we can be more empathetic and less judgmental in our discussions with our students. Our ESOL training should prepare us, not only to teach language, but to ask questions and probe these issues without perpetrating stereotypes or creating wider gaps between cultures.

Notes
Archer, C. ( 1986). "Culture bump and beyond." In: Culture bound: Bridging the cultural gap in teaching, Joyce Merrill Valdez, ed. London: Cambridge University Press.

The CCHP curriculum can be found at www.culture.org/training/overview/cultural/index.html.

Katy Hartnett is the ESOL coordinator at the Adult Literacy Resource Institute/Greater Boston Regional SABES Center. She can be reached at 617-782-8956 or by e-mail at katy@alri.org