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1 Introduction Members of minority communities who have lived in the United States for generations —Asians,Africans,Latinos,andAmerican Indians—have long complained about being treated as second-class citizens by a health care system that does not understand or meet their needs. The dramatic influx of recent immigrants and refugees, including, among others, Mexicans, Somalis, Ethiopians, Hmong, Cambodians, Bosnians, and Russians, is strengthening the pleas for change in the practice and delivery of health care services. Fleeing war, famine, poverty, and persecution in their homelands, immigrants and refugees continue to arrive in large numbers in search of something better. The 2000 census confirms that the number of foreign-born residents and children of immigrants and refugees as well as the percentage of nonEuropean Americans are the highest they have been in the history of the United States. Demographic projections based on current trends indicate that “minorities” will be in the majority in 2060 (U.S. Census Bureau, 2000). The scale and pace of these demographic changes are leading health care professionals , administrators, and policy makers to recognize with new urgency the inadequacy of rote applications of Western biomedicine to every person who enters a health care facility. Fueled further by recent studies describing racial and ethnic disparities in health status,the constellation of social and historical factors is at last compelling health care professionals, administrators, and policy makers to seek greater cultural awareness and competence (American Medical Association, 1999, 2001; Institute of Medicine, 2001; Smedley, Stith, & Nelson, 2002; U.S. Department of Health and Human Services, 2000, 2002). Delivering culturally responsive health care* is both difficult and rewarding. It requires providers to be self-aware and culturally knowledgeable and to apply complex communication skills and demonstrate attitudes that help build trusting and respectful cross-cultural relationships. Providers want to provide care that is respectful of the patient, medically correct, nondiscriminatory, and consistent with professional integrity. Often providers can achieve these goals. Sometimes, however—espe- *People are using a wide variety of terms, such as “culturally sensitive,”“culturally competent,”“culturally effective ,” “culturally appropriate,” and “culturally congruent” to refer to the obligation health care providers and organizations have to respond to patients’ cultural needs effectively. The phrase “culturally responsive” suggests that clinicians can respond to pertinent aspects of patients’ cultural practices, beliefs, and values in clinical settings and stresses the application of knowledge, skills, and attitudes without requiring that clinicians be“competent ” in other people’s cultures (Goldman, Monroe, & Dube, 1996). 2 Healing by Heart cially in cases involving cultural differences between providers and patients—questions arise about how to balance and prioritize these objectives. Providing health care to patients from diverse cultural backgrounds may generate confusion and conflict, requiring clinicians to make difficult decisions about which objectives to sacrifice when not all can be fully realized. When U.S. providers do not understand the choices and actions of patients and families from diverse cultures, they may inadvertently use their status and power to impose their perspective on patients and families. Alternatively, they can choose to learn about the social issues, core beliefs, moral commitments, and emotions that underlie what seem to them strange choices and actions and remain open to negotiating options that are acceptable to all. Providers who learn more about the perspectives of their patients may also be better able to make creative changes in their practices and the institutions where they work. The results should lead to fewer misunderstandings and conflicts, more satisfied patients, families, and practitioners, and—ultimately—better health outcomes. A comprehensive consideration of how to enhance the delivery of health care across cultures requires attention not only to health care professionals but also to the health care organizations in which they work. An organization’s culture—its policies, practices , and attitudes—affects practitioner-patient relationships and shapes the space within which practitioners may be able to modify their own practices to improve their care of individual patients. State and federal health care policies, for their part, strongly influence the capacity of health care organizations to respond to the needs of all groups they serve. Finally, clinicians, health care organizations, and policy makers are all constrained by historical and current social and economic circumstances . Overview of the Book Based on ethnographically informed reflection on the health-related cultural beliefs and values of the Hmong community, Healing by Heart explores clinical and ethical challenges in cross-cultural health care.It contrasts traditional Hmong health-related moral practices and commitments with those that are widely held by U...

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