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Cross-Cultural Fluency

By Sara Calabro

Medical anthropologist and world-religions scholar Linda Barnes directs the Boston Healing Landscape Project, an initiative that seeks to transform medical practice through educating the biomedical community about culturally diverse and religiously based approaches to healing.

Barnes is an associate professor in the family medicine and pediatrics department at Boston University School of Medicine, and directs BU’s masters program in medical anthropology and cross-cultural practice. She has researched numerous medical traditions around the world and is an expert on Chinese healing modalities, including acupuncture. Her work has been published in leading medical anthropology journals and she is the author of several books, including Needles, Herbs, Gods, and Ghosts: China, Healing, and the West to 1848.

Barnes’s work is vitally important, particularly in big, ethnically diverse cities, where numerous healing traditions are represented within walking distance of leading biomedical teaching hospitals. Patients being seen at these hospitals are often concomitantly utilizing therapies that are not represented or understood within biomedicine. There is a critical imperative for the clinicians in these hospitals to open themselves to the beliefs and practices that motivate their patients.

Barnes says she is noticing a shift in the professional development of biomedical physicians as they become more open minded to ideas that exist outside their own traditions. As we learned from talking with her, she has contributed greatly to this evolution.

AcuTake: You’ve been teaching medical students and physician colleagues for years about cross-cultural healing practices. Since many of these practices are influenced by religion, have you faced a lot of resistance?

Linda Barnes: At least in the U.S., when people are asked to think about religion, the assumption is that you mean Christian traditions. Given that people who enter clinical practice in biomedicine are usually not religion scholars—they come out of the general public—they are as prone as everyone else to making this assumption. You find doctors being apprehensive if you try and talk about religion. There is an assumption that you are going to try and get them to proselytize or pray with their patients.

Given the prevalence of Christian bias in the U.S. even today, was it surprising to you that a prominent medical school like Boston University’s wanted to bring you on board in the 1990s?

Well, around the time that I was invited to join the medical school, some research on religiosity and health had just gotten a lot of press. A number of physicians and psychologists tried to do clinical trials to show that by going to church, listening to religious radio programs, reading the Bible, etc., people had better health outcomes. Those of us trained in world religions looked at that and said, that’s fine if you’re a Protestant Christian in the American Southeast, where those data points reflect religious practice, but they don’t say much if you’re not Christian. In response to those criticisms, the same researchers started asking things like, how often do you go to religious services (opposed to, how often do you go to church)? Or, how often do you read a religious text (opposed to, how often do you read the Bible)? All they did was plug generic terms into categories that were still Christian in nature. It gave the impression of being more open, but it was just as skewed.

I think the media coverage of this research helped me get hired. But it was ironic because I was highly skeptical of these studies. I don’t do them myself and was critical of the ways in which religiosity was being defined. But I got hired anyway. I initially encountered a lot of apprehension on the part of the physicians I was meeting as colleagues. Most of them were concerned I was going to bring a heavily Christian bias into the department and push it down their throats. I had to learn strategies for coming at it from a direction that rang true for me and went across barriers.

Has it gotten easier to broach these topics in recent years?

Physicians today are required to train in some set of cross-cultural practice skills. It is a given now, especially at a teaching hospital like BU’s which is the safety net hospital in the Boston region for underserved populations. That creates a platform for me to say that roughly 40% of people from cross-cultural backgrounds are using other therapeutic interventions in addition to or instead of the interventions they get in the hospital. (That is as true in inner city hospitals as it is in the suburbs.) With that point made, it becomes simpler to suggest that many of those interventions are grounded in patients’ cultural and religious world views. It becomes clear that we are talking about cultural complexity and therapeutic complexity, and in those frames of reference, religious complexity.

What kind of teaching do you offer to medical students?

I teach two courses for med students. One is on cultural self-reflection. It encourages students to reflect on their own foundations and how they might shape their orientation in practice. The reflection focuses on areas of bias that go unexamined and are most likely to lead to health disparities. We look at things such as how someone is socialized into a racial identity, gender identity, sexual orientation, social class, etc. I’ve also taught fourth year med students, an intensive month of reading about and going out and meeting representatives of traditional healing practices in the Boston area. That was usually no more than four or five students at a time, so it wasn’t having as broad an effect as I would have liked. We’ve also given talks to third-year students as they rotate through pediatrics. But if you open all this stuff to med students and the people supervising them are not participating, it’s likely to get squashed. We tried developing some teaching cases for people in the residency program and on faculty. We are trying to figure out how to develop strong teaching units that people will utilize when they’re in the middle of a busy clinical situation. Currently, when they’re busy, they are not inclined to look up cultural information, even though they will run and look up medical data.

Do you talk to students and physicians about specific modalities? How is acupuncture received?

I parse the various interventions according to the cultural communities that the doctors are seeing. For example, plant medicine used by immigrants from the Caribbean: It’s herbal medicine, but it is contextualized in terms of the specific community. In the case of acupuncture, we have partnered with New England School of Acupuncture to set up free clinics in some of the departments at the hospital. It is available in pediatrics, family medicine, oncology, and some of the immigrant and refuge services. For physicians who want to participate in the acupuncture service, my acupuncturist colleague Ellen Highfield has started a continuing education program for doctors who have done a medical acupuncture program but feel ill equipped to go out and practice. It is a combined didactic and supervised clinic program. Physicians learn more foundations than they get in the medical acupuncture program and then see patients under the supervision of a licensed acupuncturist.

So it sounds like receptivity to non-biomedical approaches is pretty strong at BU. Do you attribute that to the new generation of doctors coming down the pike?

It is an easier sell in general at a place like Boston Medical Center because the cultural complexity of the patient population is so rich—you are talking to physicians about the clinical worlds they live in. The new generation of doctors is a funny blend. You don’t get into medical school unless you’re really good at science. Some of these students may have been religion or anthropology majors as undergrads, but a lot of them were biology or biochemistry. There is a mixture in any medical school class, and it really depends on what sector of a class you’re working with. The same is true of residents and faculty. Departments like family medicine and pediatrics are incredibly open. There is some interest from emergency medicine; surgery is a much harder sell. Generally speaking, though, it’s improving: When I first started at the medical school, there was relatively little presence or interest in anthropological research methods, but since then, these have flourished and gotten people thinking about alternative world views.

Regarding acupuncture specifically, has the biomedical community become more embracing?

Relatively speaking, acupuncture is far more accepted than other modalities. It has been around long enough without any major reports of crises or catastrophes that you find physicians being fairly comfortable at least saying that it can’t hurt. We’re still seeing skeptical apprehension leading to real caution, but there’s also an acknowledgment of not understanding something but recognizing that it is effective, safe, and okay to recommend. This is especially true when doctors refer patients to acupuncture and the patients come back saying it’s the only thing that’s worked. Then there starts to be a sense of, “This is our acupuncture clinic that’s helping my patient.” The bottom line is that most physicians and nurses want to see their patients do better. Even if they don’t outright endorse acupuncture, they won’t discourage it if they see it helping.

There seems to be a growing recognition within biomedicine that it has a responsibility to develop awareness around cross-cultural practices. What about the acupuncturists and other non-biomedical practitioners? What is their responsibility in contributing to a more open-minded healthcare system?

The people who were practicing acupuncture during the early years that it was gaining traction in this country were largely devoted to public health. I don’t think that needs to be the exclusive orientation of the acupuncture world, but it has been very encouraging to me to see people coming back around to that. Things like Acupuncturists Without Borders and the Community Acupuncture Network are good examples of ways that people are coming back to thinking about working in minority communities, working in underserved populations, and addressing crises and trauma. The acupuncture community, if it is continuing to move in that direction, also needs to take seriously the sorts of developments we’re seeing in biomedicine in terms of thinking about cross-cultural practice. One of the things I have observed is that people who go into non-biomedical practices think of themselves as alternative and therefore not having some of the common cultural biases possessed by physicians. In other words, “If I practice acupuncture, I’m not racist.” I would say that by nature of growing up in this country, you get painted with various forms of bias, consciously or not. If acupuncturists are going to keep growing in terms of reflective practice, they have as much of a responsibility as biomedical clinicians to take very seriously what it means to become skilled in cross-cultural issues.

Any other advice for acupuncturists?

It behooves people in the acupuncture community to avoid getting trapped in clinical trial models as the only way to study what they do. And to the extent that they do engage in clinical trials, it’s important to rethink those trials in ways that are faithful to the medicine. There also is the issue of developing some fluency in communicating with the biomedical community, but that doesn’t need to be as complicated as it is sometimes made to seem. TCM acupuncturists, for example, talk in terms of syndromes, which is a term that biomedical practitioners are very used to. There are ways of matching things up that don’t have to rely on talking about where and what the meridians are. We just need to get away from thinking that there is a dominant system that forces everyone to talk in its terms, and move toward the idea that there are really interesting things to learn when you are trained to look through various lenses. Having that multilingual fluency is a real gift.

Featured photo by Sara Calabro
Photo of Linda Barnes courtesy of Linda Barnes

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