Dr. Crampton is senior lecturer, Department of Public Health, and Dr. Dowell is professor and Mr. Parkin is senior teaching fellow, Department of General Practice, Wellington School of Medicine and Health Sciences, Wellington, New Zealand; Ms. Thompson is Kaitiaki/Manager Community Health Teams, Ngati Porou Hauora, East Cape, New Zealand.
Correspondence and requests for reprints should be addressed to Dr. Crampton, Department of Public Health, Wellington School of Medicine and Health Sciences, PO Box 7343, Wellington, New Zealand.
The authors thank Ngati Porou Hauora for organizing the cultural immersion program, Otago University for funding it, Denis Simpson for supporting it, and the students for immersing themselves in it.
This paper provides a perspective from New Zealand on the role of medical education in addressing racism in medicine. Coker states “Racism and oppression are about the abuse of power that denies people dignity and choice.”1,p.xix Racism may take the form of ideological conviction that certain races are superior to others.1,2 However, racism may be more insidious if the abuse of power and the denial of dignity and choice do not flow from ideological conviction, but are mediated non-consciously through inherited mores and institutional structures. The consequences for the oppressed group may be similar regardless of the form of racism, but the attitudes, beliefs, and conscious motivations lying beneath the two forms may differ markedly and in ways that are relevant to medical educational goals and strategies. For example, although it is unlikely that many medical students are ideologically racist, all the same it is probable that their attitudes, beliefs, and prejudices regarding minority groups broadly reflect those of the societies in which they have been raised or are located (inherited mores and institutional structures).2,3,4
THE PROBLEM—RACISM IN MEDICINE
There is increasing recognition of racism in health care2,3,5 and ample evidence that racism adversely affects the health status of ethnic minority populations in many Western industrialized countries.6 For example, using Jones'7 schema for categorizing racism (institutional, personally mediated, and internalized), institutional racism may be expressed in the failure of medical schools to recruit students reflecting the ethnic composition of the groups they aim to serve8 and personal racism may be reflected in the failure of clinicians to adequately investigate disease and treat people from certain ethnic groups.9
Despite the work of various researchers and educators concerned with the teaching of medical students in racially and ethnically diverse settings in Australia, Canada, the United States, and the United Kingdom,10,11,12 there is little to suggest that undergraduate medical curricula pay much attention yet to the impact of racism on medical education and medical practice. Based on the New Zealand experience, it seems likely that countries with sizeable indigenous populations are exploring solutions to racism that differ from solutions being explored in countries that have indigenous populations as well as large non-indigenous minority populations (e.g., African American, Latino, Asian, Pacific Island, etc.). Insights from countries with minority indigenous peoples such as New Zealand may prove helpful for these other countries. Specifically, this paper considers whether cultural immersion exercises in medical education can help to address the problem of non-conscious inherited racism in medical training. We present the example of a cultural immersion program for third-year medical students in New Zealand and discuss some of the strengths and weaknesses of such an approach. Our recommendation is that undergraduate medical education engage more enthusiastically with indigenous peoples and racial and ethnic minority groups.
FRAMEWORKS—DIFFERENCES BETWEEN CULTURAL COMPETENCE AND CULTURAL SAFETY
Discourses about concepts of culture, race, and ethnicity differ significantly among the United Kingdom, the United States, and New Zealand. Medical educators in the United Kingdom, for example, tend to use terms such as cultural and ethnic diversity, which indicate that ethnic minority groups exist within the context of a multicultural society. Nursing and medical literature from the United States, on the other hand, refers to the concept of cultural competence—the ability to work effectively with a range of different cultural groups.13 The discourses in New Zealand, by contrast, emphasize the concepts of biculturalism and cultural safety. Maori are the indigenous people of New Zealand, constituting about 15% of the total population. Constitutionally, the rights and obligations of the (British) Crown and Maori are enshrined in the Treaty of Waitangi, signed in 1840. In the discourses in New Zealand, biculturalism reflects the primacy of the relationship between the indigenous people and the Crown, and multiculturalism is subsumed within the Crown's side of the relationship.
Despite the importance of the treaty in protecting the interests of Maori, in common with other colonized indigenous peoples Maori experience markedly poorer health and social outcomes compared with the dominant (colonizing) ethnic groups.14,15,16 In response to racism and the poor health status of Maori, the concept of “cultural safety” was developed for nursing curricula. Cultural safety is a powerful means of conveying the idea that cultural factors critically influence the relationship between carer and patient. Cultural safety focuses on the potential differences between health providers and patients that have an impact on care and aims to minimize any assault on the patient's cultural identity.17,18 Specifically, the objectives of cultural safety in nursing and midwifery training are to educate students to examine their own realities and attitudes they bring to clinical care, to educate them to be open-minded towards people who are different from themselves, to educate them not to blame the victims of historical and social processes for their current plight, and to produce a workforce of well-educated and self-aware health professionals who are culturally safe to practice as defined by the people they serve.19
CULTURAL IMMERSION AS A RESPONSE TO RACISM IN MEDICINE
Increasing attention is being paid in undergraduate medical courses to the knowledge, attitudes, and behaviors required for the effective and culturally safe practice of medicine in culturally diverse settings,10,11,12,20 and a range of approaches to educating medical students to work in culturally diverse settings has been recorded, including experiential seminars.12,21 Cultural immersion, an approach based on the principle that immersion in culture and language is an effective means of learning about oneself and about another culture, provides opportunities for students to learn some of the principles associated with cultural safety. There are very few recorded examples of cultural immersion in medical and nursing education.13,22 Kavanagh22 provides an in-depth description from the United States of a six-week nursing cultural immersion program with the High Plains Oglala Lakota and notes, “Immersion, by its very nature, provides nearly limitless ‘teachable moments’.”22 The principles and content of cultural immersion within medical education are similar to those identified by Kai et al.11 in the context of teaching medical students the value of diversity and include encouraging students to critically reflect on their own and others' attitudes towards differences, assisting them to acquire generic skills that will improve their ability to work in culturally diverse settings, and providing them with insights and knowledge about specific cultures including their own. A further aim is to counter negative racial stereotypes that may interfere with the doctor–patient relationship.23
THE CULTURAL IMMERSION PROGRAM AT THE UNIVERSITY OF OTAGO
The cultural immersion week for third-year medical students at the University of Otago has run for four years. A general description and evaluation of it are provided elsewhere.24 In brief, the program is convened in the rural and remote East Cape region, in collaboration with the local tribally-based community-controlled primary health care provider, Ngati Porou Hauora. Prior to the project's commencing, consultation was undertaken with each of the local hapu (subtribes) to gain their approval. The East Cape region has a largely Maori population and is economically depressed, with high unemployment and poor health status among residents. Primary care services are provided through outreach clinics located in small, remote, rural communities and are coordinated through a small rural hospital. The students are divided into groups of eight to 15 and are hosted by hapu-based communities dotted up and down the East Cape. The role of the program's tutors varies from year to year, the chief difference being whether or not the tutors stay with the student groups in the local communities.
The educational objectives of the week can be grouped into two categories—those related to cultural immersion and those related to health needs assessment. Although the educational objectives include performing health needs assessments, it should be emphasized that the defining feature of the week for the students is their cultural immersion experience. This commences from the moment they step on to the marae (traditional Maori meeting place), where they are given a formal welcome and are advised of the tikanga (etiquette) of that particular marae. As in the nursing cultural immersion program with the High Plains Oglala Lakota in the United States,22 students are “inducted” into the Maori world of the East Cape according to a protracted and clear entry protocol; there is no attempt at assimilation, rather the students and tutors are treated as guests. Students sleep and eat in marae and are cared for by kaiawhina (local health care workers).
In a very real sense the local communities and health care workers become medical educators for the duration of the week. The university contracts with Ngati Porou Hauora to organize the cultural immersion week and recompense the local communities for the time and resources involved in hosting the students. We believe that the contract fairly reflects the costs of running the week and provides a useful adjunct to the income of East Cape communities.
It's the best way to teach. If you're going to have Maori cultural components [in the undergraduate course] this is one of the best ways to do it. You can't teach it out of a book. [Student comment]
We believe the consciousness-raising dimension of cultural immersion has value in combating racist attitudes of the non-conscious inherited type. Students are encouraged to critically reflect on their own and others' attitudes towards racial and ethnic differences, assisting them to acquire generic skills that will improve their ability to work in culturally diverse settings and providing them with insights and knowledge about a specific culture. Students' evaluations of their participation in the cultural immersion program have been extremely positive and have strongly reflected the students' raised awareness of cultural differences.
There are a number of risks associated with running a program such as this. They include managing the relationship with the host community in instances where a student behaves in a rude, arrogant, or offensive manner. This risk is amplified where a student adopts the closed and defensive role of “cultural tourist” rather than an open and empathic role as learner. Although such instances have occurred rarely in our experience and have been resolved through tact and diplomacy on the part of the hosts, students, and tutors, there is clearly potential for the host communities to become disaffected with the task of hosting students—particularly when the students' tasks include exploring health status and health services. As one student commented, “It seemed a bit rich, like they had been feeding us all this food all week and then we say you eat way too much fat. It was a bit inappropriate …”
There are clearly limits to what can be achieved in a one-week cultural immersion program. Although the students appear to value the week highly and gain considerable knowledge, many aspects of their educational experience are necessarily relatively superficial. Kavanagh22 refers to the “paralyzed paradigm effect” whereby students may have difficulty understanding and valuing different cultural norms because of their lack of awareness of—and strong prior socialization in—their own cultures. Although students are exposed to a range of opportunities for gaining cultural competence in the undergraduate curriculum, ideally more time would be devoted in the curriculum for students to reflexively examine their personal values and those associated with the subculture of medicine and forms of racism and their impact on health and health care, which underlie the concept of cultural safety. The undergraduate curriculum could better prepare the students for the experience-based educational content of the cultural immersion exercise and ensure that learning taking place during the cultural immersion week is systematically reinforced and built upon and important linkages to other components of the curriculum are fully explored.
The educational benefits of cultural immersion exercises such as this may be compromised if they are combined with other educational activities such as health needs assessment because the requirements of the two sets of educational objectives may conflict with one another. For example, in the program we describe, the health needs assessment requires the students to be occupied with collecting epidemiologic and other data related to health status and health services. There is a risk that this process itself may prompt racial stereotyping, undermining cultural safety, unless the process of health needs assessment is critically examined by the students.
Even taking into account the above-mentioned risks and limitations with cultural immersion, we believe the approach has great potential as a method of consciousness raising to counter the insidious effects of non-conscious inherited racism. Apart from the educational benefits, the program has fostered a strong working relationship between an indigenous health care organization and the medical school, thus providing a platform for further developments. In general, we hope that medical educators—and hospitals and primary care providers—will more actively engage with the issue of racism and be prepared to experiment with novel approaches to teaching and learning. More specifically, we are hopeful that the principles of cultural immersion, informed by the concept of cultural safety, could be adapted to indigenous and minority groups in urban settings to provide medical students with the foundations for a life-long commitment to practicing medicine in a culturally safe manner.
1. Coker N. Editor's introduction. In: Coker N (ed). Racism in Medicine: An Agenda for Change. London, U.K.: King's Fund, 2001.
2. Bhopal R. Racism in medicine. BMJ. 2001;322:1503–4.
3. Bhopal R. Spectre of racism in health and health care: lessons from history and the United States. BMJ. 1998;316:1970–3.
4. Atkin K. Community care in multi-racial Britain: an introductory note. Critical Public Health. 1994;5:7–13.
5. Coker N (ed). Racism in Medicine: An Agenda for Change. London, U.K.: King's Fund, 2001.
6. Krieger N. Discrimination and Health. In: Berkman L, Kawachi I (eds). Social Epidemiology. New York: Oxford University Press, 2000:36–75.
7. Jones C. Levels of racism: a theoretical framework and a gardener's tale. Am J Public Health. 2000;90:1212–5.
8. McManus I. Factors affecting likelihood of applicants being offered a place in medical schools in the United Kingdom in 1996 and 1997: retrospective study. BMJ. 1998;317:1111–6.
9. Canto J, Allison J, Kiefe C, et al. Relation of race and sex to the use of reperfusion therapy in Medicare beneficiaries with acute myocardial infarction. N Engl J Med. 2000;342:1094–100.
10. Kai J, Bridgewater R, Spencer J. “‘Just think of TB and Asians’, that's all I ever hear”: medical learners' views about training to work in an ethnically diverse society. Med Educ. 2001;35:250–6.
11. Kai J, Spencer J, Wilkes M, Gill P. Learning to value ethnic diversity—what, why and how? [see comments]. Med Educ. 1999;33:616–23.
12. Louden R, Anderson P, Gill P, Greenfield S. Educating medical students for work in culturally diverse settings. JAMA. 1999;282:875–80.
13. Jones M, Bond M, Mancini M. Developing a culturally competent workforce: an opportunity for collaboration. J Prof Nurs. 1998;14:280–7.
14. Howden-Chapman P, Tobias M. Social Inequalities in Health: New Zealand 1999. Wellington, New Zealand: Ministry of Health, 2000.
15. Hogg R. Indigenous mortality: placing Australian aboriginal mortality within a broader context. Soc Sci Med. 1992;35:335–46.
16. Kunitz S. Disease and Social Diversity, The European Impact on the Health of Non-Europeans. New York: Oxford University Press, 1994.
17. Ramsden I. Cultural safety. New Zealand Nursing J. 1990;83:18–9.
18. Papps E, Ramsden I. Cultural safety in nursing: the New Zealand experience. Int J Qual Health Care. 1996;8:491–7.
19. Ramsden I. Cultural safety: implementing the concept, the social force of nursing and midwifery. In: Te Whaiti P, McCarthy M, Durie A (eds). Mai i Rangiatea. Auckland, New Zealand: Auckland, University Press, Bridget Williams Books, 1997,113–25.
20. Prideaux D, Edmondson W. Cultural identity and representing culture in medical education. Who does it? Med Educ. 2001;35:186–7.
21. Dogra N. The development and evaluation of a program to teach cultural diversity to medical undergraduate students. Med Educ. 2001;35:232–41.
22. Kavanagh K. Summers of no return: transforming care through a nursing field school. J Nurs Educ. 1998;37:71–9.
23. Levy DR. White doctors and black patients: influence of race on the doctor–patient relationship. Pediatrics. 1985;75:639–43.
24. Dowell A, Crampton P, Parkin C. The first sunrise: an experience of cultural immersion and community health needs assessment by undergraduate medical students in New Zealand. Med Educ. 2001;35:242–9.