By: Claudia R. Sotomayor.
B. was born in Jalisco, Mexico. Her childhood was a typical Mexican lower-income childhood: deprived from many luxuries, but still happy and surrounded by a big and loving family. She attended school until middle school, and after that she helped with the household chores, and participated in the festivities and customs of her town. On a December 12, day of our Lady of Guadalupe, the town had the usual big party, full of music and good food. It was that day when she met N., who was visiting from the United States. N was an undocumented immigrant in the United States, who left his hometown in Mexico to search for a better future for his family. They fell in love and after eight months of knowing each other, they got married. N. wanted to come back to the United States, and so they did.
The experience of crossing the border without legal documents was a shocking experience for B. “No se lo deseo a nadie” (I don’t wish that experience to anyone)-she said- “We went through the desert in May, so it was very hot during the day and very cold at night. We ran out of food and water, and we didn’t bring warm clothes for the night. We even saw a cadaver. I cried I lot.” They finally got to Arizona, where a van picked them up and took them to Chicago, which was a staging area for people to be taken to various states. N. and B. were the second to last to be “delivered” to Atlanta, Georgia.
Once they were settled in their new life in a modest trailer home, N. wanted to start a family, but B. had to break the bad news that according to her doctors in Mexico, she couldn’t have any kids due to severe polycystic ovaries. He felt disappointed, but he never lost hope. Two months later, she noticed that her period was late, but she never thought she was pregnant because she was generally irregular, and she lost a lot of weight during their crossing through the desert. At the time, she weighed 80 pounds and she is about 5’6‘’ tall. N. immediately bought a pregnancy test, and then they found out they were expecting their first child.
She went to a clinic to start her prenatal care with a doctor who spoke Spanish. Due to her weight and hormonal problems, she was under a high risk pregnancy care. She got the prenatal vitamins and all the medication needed. She got an ultrasound by the 5th month of pregnancy, where everything looked normal. Her blood work and other tests were normal too. Everything was going smoothly until the 6th month of pregnancy, when one day she started feeling very sleepy and tired. N. invited her to a restaurant, and during dinner she felt a sharp lower abdominal pain that radiated to her back and was increasing over time. She started vomiting and feeling dizzy. They called her doctor’s office, but it was closed, so they decided to go to the Emergency Room. When they arrived, they tried to communicate their situation the best way they could in English, but there was no interpreter so another Hispanic woman that was at the ER offered her help. Due her low weight, her belly wasn’t big so they didn’t believe she was pregnant. After a long period of time, she was seen in the triage area, where they decided to admit her to the 4th floor (labor and delivery). When she arrived to her room, the nurse that was in charge was an intimidating African-American woman. B. impression of the nurse was that she was dirty: “She had long dirty nails, a lot of rings, smelled funny, and she kept scratching her head”. The nurse told B. that she wasn’t pregnant but rather she was complaining over nothing, “just like a Mexican soap opera actress”, so she asked her for a urine specimen to do a pregnancy test. B. went to the bathroom, when suddenly an even greater pain came and then the baby was born. She asked for help, and the nurse, without gloves or previous sanitation of her hands, grabbed the baby girl, cut the umbilical cord and ran with her, leaving B. unattended on the bathroom floor. No one came back to help B. for a long time. She was feeling terrified because she didn’t hear the baby cry, and didn’t have the chance to see her. Finally someone came to help B. When the nurse came back, she said to her: “You really made a mess on the floor, look at that.” B. felt scared, anxious, and terrified for her baby and for herself. It took a while for her to see her baby, and she was feeling desperate: “Like if my heart was going to stop beating.” When she finally saw her baby girl, she couldn’t believe how small she was: “Her head was soft, her legs were as long as my pinky.” The doctors told her that her baby was in a bad shape, that she was blind, had a heart condition, and needed two blood transfusions. She agreed with any treatment needed to save the life of her baby.
B.’s health was improving, and even though she wasn’t feeling very well, she managed to pump breast milk to be able to feed the baby, but her body couldn’t produce enough milk and it only lasted for a month. She spent as much time as she could with her baby. When I asked her how she felt, she said: “There were times when I thought I couldn’t do it any more, I wasn’t sure If I was going to be able to go to the NICU because the pain of seeing my daughter under those conditions. It broke my heart. Besides, I was all alone. I needed my mom and my family to give me support, but they couldn’t come because they didn’t have the means to do it. I didn’t know anyone but N., and he had to work. I cried every day, almost all day long.”
The baby girl was in the NICU for two months. When she was discharged, a social worker came to B’s house to see their living situation and to see if there was a cause for the premature birth. There was not an apparent cause.
The experience was painful for her, but at the end she feels blessed and happy because her daughter is alive and doing well. She had to go to auditory therapy, and she has her cardiac condition under control. So far, the girl is living a normal life. Although traumatic in the beginning, now she sees it as a precious moment where she learned how frail life is and how important it is to cherish it.When I asked her: “What do you think caused the problem?” She answered: “the poor service at the ER, the incompetence of the nurse and the lack of doctors.”
B’s story is tough to imagine. It made me feel aggravated and with an urgent need to do something to improve the cultural competence in health care services.
There are several healthcare issues in her story that should have been handled differently:
- No Interpreter was provided. The Hispanic lady offered her assistance as an interpreter, but even though it was a good gesture, it is not acceptable according to the National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care. An interpreter should be always be available either by phone, in person or video[i].
- Tervalon and Murray-Garcia shared a similar story where an African-American nurse “knew” that Hispanic patients overexpress their pain B’s nurse probably had the same course as the nurse in Tervalon and Murray-Garcia’s story, and as they noted: “The equating of cultural competence with simply having completed a past series of training sessions is an inadequate and potentially harmful model of professional development.”[ii] There is an urgent need for cultural humility workshops because having stereotypes could put someone’s life in risk.
- Patients are also biased, in this case is evident that B. was really intimidated by the nurse, and that probably exacerbated of the cultural shock. The nurse was probably biased by the “melodramatic Mexican” and Bertha by the “intimidating African-American”. It would be a good exercise for the staff and healthcare providers to see how patients are seeing them and how that impression affects their performance.
- Finally, it is important to address the elephant in the room: the probable bias caused by the fact that B. was an “Illegal” immigrant. Immigrants -regardless their legal status- are specially vulnerable. According to the report on the Principle of Respect for Human Vulnerability and Personal Integrity of UNESCO’s International Bioethics Committee, the Migrants in general, whether within or between States, may find themselves marginalized, because of a lack of knowledge of local language and social and legal entitlements. These situations of social vulnerability may lead to significantly increased exposure to risks caused by social exclusion [iii].
This story shows us the importance of having a department of multicultural affairs in hospitals, especially in those where the population is diverse, so that these cases can be addressed properly and that healthcare providers are constantly trained and reminded about the importance of being culturally competent and humble. It is always challenging to break barriers and ideas, and sometimes there are persons who are not willing to be open to new cultures. However, healthcare institutions should promote cultural competence by making it a core value impressed upon all of its staff and providers.
[i]US Department of Human and Health Services ( 2016) National CLAS Standards, available at:www.thinkculturalhealth.hhs.gov (cited 6/21/2016)
[ii] Tervalon, M, and J Murray-García. “Cultural Humility Versus Cultural Competence: a Critical Distinction in Defining Physician Training Outcomes in Multicultural Education.”Journal of Health Care for the Poor and Underserved. 9.2 (1998): 117-25. Print.
[iii] International Bioethics Committee of UNESCO (2013) THE PRINCIPLE OF RESPECT FOR HUMAN VULNERABILITY AND PERSONAL INTEGRITY Report of the International Bioethics Committee of UNESCO (IBC) . Available at: http://unesdoc.unesco.org/images/0021/002194/219494E.pdf (Cited 6/21/2016)