Shattering Culture: American Medicine Responds to Cultural Diversity

The editors of Shattering Culture explain that their ideas for the book emerged from conversations on medical anthropology, culture, and psychiatry in weekly seminars held over two decades at the Harvard Training Program in Culture and Mental Health Services Research. The book reports on findings gathered over several years from a study in Boston and the surrounding area in which the role of culture in medicine and psychiatry was explored. Two major questions are asked: How does American medicine respond to cultural diversity? And does culture make a difference in health care provision?

The book is divided into two parts. Chapter 1 provides a needed orientation to the book and its philosophic directions along with an outline of what the reader has in store. Ethnographic interviews, observations, and narrative analysis of staff, patients, and families provide a useful backdrop for each chapter. Part 1 takes on the complex issue of culture as seen in the medical and psychiatric settings in the Boston area. Over the four chapters of this part we learn that culture is not a constant variable but changes within each person, whether patient or staff. The communities of ethnic and racial diversity are changing over time, as is the health care delivery system. Language, religion, and social change are thoughtfully analyzed and viewed as contributing factors in making more complex our efforts to provide fair and balanced health care for all people.

Part 2, with six chapters, examines the clinical cultures and realities of health care provision from the perspective of the patient, staff, and community. Chapter 6 describes an interesting personal journey of a psychiatrist from the former Soviet Union who moves through immigration, retraining, and relocation in a new clinical setting, where she sees a broad range of patients from around the world. This chapter conveys the message to the reader that culture is a two-way street between the patient and the psychiatrist. Of course all relationships are complicated by the vagaries and demands of the health care system and the local community. Hence the new word “hyperdiversity,” which the authors use to reflect on the tremendous cultural, ethnic, and racial changes going on in the Boston area. Incoming new populations are changing the makeup of health care networks, and the health care systems are scrambling to keep up with the new patients coming in. This point is one all our readers can appreciate.

Shattering Culture is a good read for those of us who want to take some time to understand the complexities of our patients and the health care system with which we all work. For me, culture and individual variation are the wonderful and challenging parts of medicine. Because a patient comes from one culture does not mean that he or she is constant or predictable. Long ago, a mentor shared with me, “All Indians walk single file—at least the one I saw did.” We are students of our profession and, in this case, always looking to understand the “newness” we all see daily.