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4 Technologies of Culturally Appropriate Health Care I n the mid-1990s in Thornton, Massachusetts, activists and community health leaders worked to establish what would become Thornton Community Health Center (TCHC) as part of a struggle to bring quality, culturally appropriate health care to low-income and minority patients. According to organizers, economically and ethnically marginalized Thornton residents were unable to obtain quality care from existing health care resources (Shaw 2005). When I began my fieldwork there in 1998, TCHC had been caring for patients for two years but still struggled with the best way to reach so-called hardto -serve residents of its surrounding neighborhoods. Building on established models of lay health advisors (Eng, Parker, and Harlan 1997), the Community Health Advocate (CHA) program described in previous chapters mobilized local residents as outreach workers to bring medically underserved residents into the clinic. Once they arrived, however, ethnic, cultural, and linguistic differences between these new patients and TCHC’s staff and health care providers remained an issue, as the clinic struggled to locate medical interpreters or when a patient complained about prejudicial behavior from a physician. George Williams, executive director of TCHC for its first nine years, therefore maintained an active interest in culturally appropriate health care— efforts to tailor health care to the distinctive needs of different cultural groups (Shaw 2005). For example, Williams created a standing committee tasked with designing policies and procedures to foster culturally 104 / Chapter 4 appropriate health care, and the clinic underwent an organizational cultural competence assessment by researchers at Georgetown University. Observing this process prompted me to subscribe to an e-mail discussion list (which I here call the Culture and Health list) where health care administrators, medical interpreters, and other cultural competence (CC) experts use e-mail to share resources and information in a collective yet dispersed effort to address the effects of cultural difference in the clinic. This chapter draws on five years of postings to the Culture and Health list, as well as on participant-observation research at conferences attended by health care administrators and CC trainers, to discover how culturally appropriate health care has emerged as another widely promoted remedy to the same problems of cultural difference that the CHA program, in its inception, sought to overcome. I explore culturally appropriate health care as a novel formation encompassing both face-to-face and electronic technologies that contributes to the development and dissemination of new forms of expertise in health care. Much of the ethnography on which this chapter is based comes not from a particular clinical setting but rather forums such as the Culture and Health list where participants from all over the world discuss topics of culture and health care. I explore the processes through which cultural expertise is being developed , codified, and disseminated through analyses of five years of postings to this moderated e-mail list. The Culture and Health list has nearly two thousand members at last count and is sponsored by an international nonprofit organization that claims a central role in the development of the CLAS regulations and holds a biannual conference that I attended in 2008. Those who post to the list, whom I refer to as posters, include health care administrators, medical interpreters, anthropologists, and cultural competence experts and trainers. Subscribers tend to be those who have been assigned responsibility for ensuring compliance with the CLAS regulations or for handling issues related to cultural diversity in their health care organizations (e.g., diversity officers or directors of medical interpreter departments). While a wide range of e-mail lists, blogs, and Web sites feed the public appetite for information on topics related to culture and health, the Culture and Health list fills a special niche. A forum for the exchange of information (often in the form of links to other Web pages), views, and opinions, the Culture and Health list helps establish and disseminate cultural expertise—both as a group and as individuals—and actively creates a shared, if contested, narrative (Mattingly 1998) about cultural competence programs.1 This chapter traces the emergence of cultural competency as a 1. I was an unannounced “lurker” on this list. As noted previously, all names and identifying features have been changed to maintain anonymity, but it is worth noting that current guidelines indicate that the consensus among scholars is that e-mails to this sort of list are public and therefore not subject to narrower privacy concerns (see Ess and the Association of Internet Researchers 2002). [3...

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