Although industrialized nations have always been composed of diverse populations, they are becoming even more diverse as we move into the 21st century. Within 50 years, the United States should have no “majority” population. It will be a society composed of individuals who trace their ancestries to all regions of the world, with no one group dominant over all other groups. This is a desirable future. However, it is one in which the traditional model of medical education in the United States must be radically modified. Physicians cannot assume that they will treat only those with whom they share ancestry and culture. They must assume that the patient population will be diverse. Therefore, it is incumbent on medical educators to train physicians who are capable of interacting appropriately and effectively with a broad array of individuals from a broad array of populations and cultures.
In order to meet this challenge, many medical schools are now offering courses in cultural competency and/or are attempting to embed culturally competent information into the general curriculum. The basic premise of these efforts is to be applauded. The concern arises over how these efforts are implemented. As Núñez points out in her excellent article, the term “cultural competence,” which focuses on the “exotic other” (my term), can simply lead to a perpetuation of existing stereotypes. She would therefore replace “cultural competence” with “cross-cultural efficacy,” which “implies that the caregiver is effective in interactions that involve individuals of different cultures and that neither the caregiver's nor the patient's culture is the preferred or more accurate view.”1,p.1072 I would agree that this is a more desirable outcome than simply being given a set of fascinating tidbits about various “exotic others.” However, the essentialist basis of much of medicine (see the discussion below) must be carefully examined; such an examination should be included in any course that attempts to provide medical students with the tools of cultural competence or cross-cultural efficacy.
Essentialism can be defined simply as “If it looks different, it is different”; i.e., the best method for categorization is to focus on differences. Depending on who does the categorizing, any degree of difference can be cause for considering two things or individuals to be “essentially” different. If essentialism were confined to chemicals and minerals this focus on differences really would not matter, and might often be useful, since chemicals and minerals are not alive and changing. However, the method has been used for living organisms, including humans. When essentialism is used to classify humans, unfortunate consequences can result.
If biologic essentialism is kept at the higher levels of taxonomic organization, the impact is less than if it is allowed to function at the species or below-species levels of organization. For the essentialist, variability in a group of organisms is taken as a sign that the group needs to be subdivided into ever-smaller cohorts. However, this ignores a key component of life: organisms, unlike chemicals, require variability within a group so that at least some individuals in the group will survive the vicissitudes of life. This is true of plankton, fish, elephants, and humans. Progress would be made if the essentialists would understand that variability is essential to a group of humans, not a reason to subdivide them.
Once groups have been defined as essentially different, then all manner of traits found in association with a particular group, whether biologic or not, are considered to be “natural” to that group. In addition, because they are now “natural,” this set of traits is given a historical time depth. The traits are considered to have been part of this group since time immemorial, or at least for a very long time. Such deductions totally ignore what we actually know of history and the interactions of populations. Groups do not live in isolation from other groups. They trade with each other, mate with with other, merge, and separate: populations are constantly in flux. Cross-cultural research “found no ethnically discrete groups. Instead, marriages across what seemed to be the most profound ethnic boundaries were common.”2,p.9 Ethnogenesis, as defined by Moore,3 is a more appropriate and accurate method for understanding groups. A population is like a river with multiple channels. At a particular point in time, the population/river appears to have a certain set of traits, but examined at some other point in time, what appeared immutable now presents a different configuration. Essentialism is a technique of oversimplification leading to false conclusions, whereas ethnogenesis recognizes that complexity is inherent and vital in groups of biologic organisms.
ESSENTIALISM AND MEDICINE
One might ask what this has to do with cultural competency. Whether a course of study explicitly addresses essentialism or not determines whether that course presents material that is truly competent and efficacious or merely reinforces prevailing stereotypes. Essentialism is a core precept of medicine: focusing on deviations from whatever has been defined as “normal.” Until the very recent past, “normal” was based on studies of men of European descent and generally only a narrow subset of that group. This results in obvious problems in determining what is “normal” and what is “deviant.”
In order to appropriately deal with differing populations, some knowledge of the evolutionary history of humans is necessary. I have been disturbed to discover that (at least in the Midwest) many in the medical profession, a field grounded in human biology, have either poor knowledge of and/or disbelief in the organizing principle of biology: evolution. Inadequate understanding of the process of natural selection allows essentialism to flourish. A key necessity for natural selection to function is variability within a population. Without such variability, the population is unable to adapt to a changing environment through differential survival and fertility of individuals. The end result is extinction of the population. But it is this variability that is partitioned up by the essentialists, thereby negating the very structure that makes populations viable.
Curiously enough, this human variability, so assiduously demarcated by the essentialists, is actually quite modest when we humans are compared with our nearest relatives, the chimpanzees. DNA hybridization studies have found that humans and chimpanzees share about 99% of their DNA.4,5,6,7 Only about 1% of our DNA goes into making us distinctively human. And of that 1%, probably less than 0.02% actually differs between any two humans. In contrast, DNA analysis of the various populations of chimpanzees found that one subspecies of chimpanzees, the Central African, has more genetic variability than is found in the entire human species.8
Essentialists from the 18th century (e.g., Linnaeus and Blumenbach9) through the 20th century (Coon,10 Haeckel,11 and Hooton12), focusing on perceived differences, subdivided the human species into “races,” the number of “races” varying depending on the criteria used. An entire suite of psychosocial and cultural traits was deemed to be embedded in the “nature” of the individuals of each “race.” These essentialist divisions are not supported by ethnographic, historic, and archaeologic research, which has shown that ethnic and cultural groups do not now live and have not lived in the past in total isolation from other groups. There were never any “pure” groups. Just as recent genetic research has shown that humans are too similar to be subdivided into racial groups, ethnographic research has shown that cultures are simply a snapshot in time. A snapshot taken at a different point in time would display different features. The description of a culture depends on the time, the place, interactions with neighboring groups, population density, and numerous other factors. Culture is fluid and in flux; therefore, cultural competence/efficacy cannot be based on a trait list or cultural prescription. The core concept and method of cultural competence should be the eradication of essentialist thought and practice.
An essentialist example often used in medical schools in the United States, perhaps even with the thought that this would somehow demonstrate cultural competency, is the association of the sickle-cell trait and anemia with African Americans. It is frequently described as a “black” disease. Therefore, if a patient of “non-black” phenotype is discovered to have sickle cell trait, the immediate presumption is that despite appearances, the patient must have black (West/ Central African) ancestry, which may or may not be the case. If, instead, sickle cell were described as one of several hemoglobinopathies associated with endemic malaria, in particular, P. falciparum, then the physician would accurately assume that the patient was from or had ancestors from a region where malaria was endemic. This could include not only West/Central Africa but Sicily, Saudi Arabia, and India, among other malarial regions.13,14,15 Knowledge that sickle cell is an adaptation to living in a malarial environment16,17 should also spur the physician to further testing of the patient in order to determine whether he or she has any of the other adaptations to malarial environments, such as the thalessemias and G6PD. In addition, knowledge that malarial environments have selected for numerous hemoglobinopathies should encourage the physician to test for these traits in anyone presenting with health problems whose ancestry is found in a malarial region. In contrast, by operating from an essentialist perspective (e.g., sickle cell is a “black” disease), the physician begins with a number of erroneous notions that can easily lead down an incorrect diagnostic path, inhibiting appropriate patient care.
Essentialism ignores the fact that, increasingly, populations are composed of individuals with multi-ethnic back-grounds. The essentialist concept wherein someone identified as “black” is somehow very different physically, behaviorally, and culturally from someone identified as “white” results in difficulties when faced with their offspring. The essentialist “one-drop” rule attempts to force these individuals to truncate their ancestries and their views of themselves physically, behaviorally, and culturally. This truncation may result in medical difficulties when a particular individual is, for example, perceived as “black” and little or no attempt is made to probe beyond this descriptor. In opposition to this essentialism, the ethnogenetic perspective would encourage the physician to discover as much as possible about each individual's ancestry. This information would help not only in diagnosis but also in determining the most effective manner for achieving appropriate patient—physician interactions.
ETHNOGENESIS AND MEDICAL EDUCATION
One way of obtaining adequate information about an individual's ancestry is the use of an “ancestry form,” shown in Chart 1. This form was pilot-tested in Nicodemus, Kansas, at the Emancipation Celebration Homecoming, July 2000. This celebration is for descendants of the original settlers (freed slaves from Kentucky) and anyone else in the surrounding communities who wishes to attend. As part of the celebration, the University of Kansas School of Medicine offers free health screenings. Those who took part in the health screenings during the July 2000 Celebration were also invited to fill out the ancestry form. The form was well received, especially by those who were recent immigrants or who had multiple ancestries. Since many individuals in the United States have poor geographic knowledge, it is useful to have available a map with the regions used in Chart 1 marked on it to aid in determining the locations of the various regions and subregions.
The information obtained from this form gives the physician a more precise understanding of the patient than can be obtained from the usual federal categories, even when modified by the choice on federal forms of “check as many as apply.” For instance, a patient labeled Hispanic by the physician, due to surname, might have quite different genetic and cultural concerns if that person's ancestry were localized in the Caribbean as opposed to Central America. A patient perceived as “black” may have ancestry in the Caribbean, West/Central Africa, South Asia, the U.S. Southwest (i.e., from an American Indian group), and Western and Eastern Europe, while another patient perceived as “black” may have ancestry in East Africa and South Asia. The essentialist, by focusing on a narrow aspect of an individual, ignores the complexity inherent in that individual. Ignorance of this complexity by the physician could result in misdiagnoses and culturally incompetent behavior.
In order to achieve a successful patient outcome, the physician must function from an ethnogenetic perspective rather than an essentialist perspective. Ethnogenesis values the complexity that essentialism ignores. “Populational diversity” requires changes in medical education. However, care must be exercised in how these changes are implemented. Increasing the number of data bits about the “exotic other” in otherwise unaltered course material will simply reinforce the essentialist bias already present in medical education. True cultural competency/efficacy will be achieved only when essentialist biases are exposed and eradicated. The ethnogenetic perspective, with its focus on the complex, fluid interactions that shape and diversify populations and the individuals within those populations, must be fully integrated into medical education if we are to produce physicians who will be truly qualified to give competent patient care in our increasingly complex societies.
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