According to a “Diversity and Culture” section of the 2017 edition of Nursing: A Concept Based Approach to Learning, I, being of Asian descent, probably “value stoicism as a response to pain.” My Black peers “report higher pain intensity than other cultures,” while my Jewish peers “may be vocal and demanding of assistance.”
The textbook, which also singles out Natives, Hispanics, and “Arabs/Muslims,” reads like a scene out of the famous “Diversity Day” episode of The Office, where boss Michael Scott forces his employees to guess the racial minority card on their forehead based on stereotypes their coworkers act out. This, however, is no NBC sitcom. The “cultural” attitudes described derive from pernicious, destructive stereotypes—that Asians bury their emotions and work in silence, that Black people exaggerate their suffering—and seem to converge on one general conclusion: that minority groups feel pain differently. These tidily bundled packages of minority experiences are supposed to guide health providers entrusted with patients’ lives.
There’s been a lot of talk about racism these past few months. We call it “systemic,” which it is: a set of ideologies, policies, and institutions that influence every aspect of life. But in its ubiquity, “systemic” can also feel impersonal, inadvertently implying a monolithic experience of injustice. The supposed cures, concepts like “diversity and inclusion” and “cultural competence,” often encourage sweeping generalizations of those they seek to protect.
In truth, racism frequently stems from individual bias, wearing a new face for every person it meets. As we confront systemic inequality, we can’t lose sight of what sits at the center of all medicine: patients, each carrying personal fears and wishes, hoping that their providers hear their stories.
I’ll acknowledge that the authors of the nursing textbook, in all likelihood, did not intend to demean. They probably included a “Diversity and Culture” section out of a larger desire to encourage future nurses to recognize the various values their patients might possess. This goal is important, as breakdown in this sort of communication has a well-documented history of creating frustrating and tragic outcomes. But respecting the existence of different cultural beliefs is very different from projecting them onto every patient who happens to come from a marginalized group.
Veering too far into a reliance on “cultural” difference can be just as dangerous as ignorance towards all difference. Anthropologist Khiara Bridges’ 2008 book Reproducing Race documents a women’s health clinic in a New York City public hospital that serves a large poor, BIPOC, and immigrant population. In a particularly damning chapter, Bridges recounts instances of what she terms “culturalist racism,” discrimination that justifies itself with culture instead of biology. In the hospital, employees describe Chinese patients as being more willing to abort their babies due to “a lower level of tolerance for difference and disability” and young women from the “Hispanic crowd” as being promiscuous and having “a bunch of boyfriends.” As a consequence, physicians might more aggressively recommend that their Chinese patients undergo abortions, or suggest that Hispanic women who complain of pelvic pain have STIs rather than endometriosis. The latter, Bridges notes, has already played out in the hypersexualization of Black women.
I’d like to note that though the language in Bridges’ book represents the most blatant forms of bias, prejudice—that oftentimes conflicts with what we consciously believe—can be so deeply embedded in our psyches that we don’t even know it exists. Researchers have found that across specializations and levels of experience, physicians tend to subconsciously harbor negative associations towards darker-skinned patients. This is called implicit bias, and it has measurable impact in the quality of medical care that marginalized communities receive. Patients, for instance, can perceive these biases, which erodes their trust in their providers. Whether or not we actively believe the reckless cultural stereotypes we hear, their very existence—their permeation of the textbooks we read, the conversations we hold—causes harm already.
Biases, whether implicit or overt, has been shown to harm ultimate health outcomes. And in the nursing textbook specifically, we see the direct association between culturalist racism and medical neglect: study after study has shown that communities of color receive substandard pain treatment.
“When we understand that culture can be used to signify fundamental, insurmountable difference (ie., radical Otherness), then cultural stereotypes and assumptions about the way people from/with certain cultures ‘just are’ may produce the same effects produced by racial discrimination,” Bridges writes. Promoting the belief that a prescribed culture accurately defines a marginalized group, whether through “Diversity and Culture” educational material or casual conversation, is ultimately just a continuation of any other form of racism. It is dehumanizing, and it is dangerous.
It is also, more plainly, just incorrect. I constantly reflect upon my position in this country as a Chinese American—particularly in the past few months, when the community has faced COVID-19-related racism while simultaneously being forced to confront its own privileges over Black and brown communities. In health care specifically, I’ve realized that while being Chinese American certainly shapes my personal values and fears, the Chinese American identity is not itself a unifying determinant of experience. For example, though I’ve written about health care inequality throughout the summer, I am fully aware that I’ve personally been endowed with a set of privileges: consistent health insurance, lack of disability, identification with a gender that matches my biological sex, and during the pandemic, an ability to social distance. Many other Chinese Americans do not benefit from these privileges, testament to the heterogeneity within our so-called “cultural” group. And separate from these privileges, even within my own family, attitudes about the health care system vary widely.
As is custom in many Chinese American households, my grandparents have lived with me and my parents for long stretches of time. Often, I’ve watched them interact uncomfortably with the American medical system. They can’t speak English; every interaction with their doctors is mediated through my parents, depriving them of the all-important medical cornerstones of privacy and independence. They trust traditional Chinese medicine, which Western doctors tend to dismiss. More generally, they feel alienated because they long for China, their home.
I have never felt this. I instinctively reject Chinese medicine, in large part due to my Westernized upbringing. I speak English far better than I speak Chinese, and the thought of receiving health care from a doctor in China terrifies me in its unfamiliarity. Once, a dental hygienist casually suggested that I probably got good grades and used tutoring services like all the other Asians in town. My grandparents would probably have been proud at the implication that I was smart and hardworking. I, on the other hand, tried to emphasize that I was different—that I did not care about grades (even though I certainly did), that I would never use tutoring services (even though I had spent a fair amount of time watching Khan Academy videos for the same purposes). I now recognize her words as a symptom of the harmful, divisive model minority myth. Back then, however, alienation for me stemmed from a longing for acceptance.
All this is to say, I would like physicians to understand the values and experiences that guide my grandparents’ fears and wishes. But I would also like them to understand that though I’ve shared a roof with my grandparents, though I bear their genes and carry their ancestry, my own values are drastically different. Our perspectives, which silently shape our interactions with medical providers, approaches to treatment, and ultimate health outcomes, possess far more nuance than can be captured by one sentence in a textbook about a mythical Chinese stoicism.
Shallow attempts at cultural sensitivity might appear to encourage diversity, but in truth, they erase the true diversity that occurs within—not between—different racial, ethnic, and religious groups. The nursing textbook’s “Diversity and Culture” section doesn’t have a section for white patients, or Christian patients. The implication is that those identities are the norm, and that every other group is the Other. White, Christian patients are free to develop their fears and beliefs autonomously, to feel pain and illness individually. Minority patients see their interactions, quality of care, and ultimate health outcomes eroded by the constraints of their “culture.”
While systemic inequality touches every experience of marginalization, a systemic attempt towards cultural competency or diversity will never adequately capture the stories of any marginalized group. Because these stories occur on a personal level—and only careful and thoughtful attention from individual medical providers will uncover them.