section six

This page forms part of the Transcultural Health resource, published in 2004, and is preserved as a historical document for reference purposes only. Some information contained within it may no longer refer to current practice. More information

This module has introduced quite a range of concepts, each of which carries within it a route to a particular way of seeing the world.

The concept of a nation suggests that, as human beings, we have ways of identifying with others which can powerfully tie us to a particular view of history, and of territory. The collective we of 'the nation' has become one of the most potent ways of linking people together:

In sport, whether football, the Olympic Games or golf we are invited to find some competitor's success more fulfilling and important than that of other equally committed competitors; because they represent our nation
As a country, we enter into morally ambiguous liaisons with other political regimes because it is 'in the national interest'
The same national interest has shaped Government policy over a wide range of internal policies - including freedom of information, the rights of people to co-ordinate pickets, the subsidising of particular industries and the building of the Millennium Dome

Across Europe, the idea of a nation has impacted upon people's entry into the legal status of citizen and their access to their substantive rights within the state. In all states, it is possible to see a highly developed exploitation of nationalism within party politics. Typically, this has had a far right; 'extremist' form which has dragged behind it a 'mainstream' variation upon the same theme.

Importantly, for the analysis you have been encouraged to develop, both in its history and currently, the concept of ethnicity has been intimately linked with national identity construction. Either explicitly (as in the German case) or implicitly (as in the English case), membership of the nation has been defined through possession of a common ethnic identity, or core identities and non-members of the nation have been identified by their lineage and their culture.

Over the last five decades, the process of immigration in Europe has been a focus for the identity politics of ethno-nationalism. At the same time, the reality of migration and settlement has created de facto multi-ethnic national demographies. In reality, virtually all European countries were already both multi-national and polyethnic (see Kymlicka page 70). The new migrations of the last half century have produced increased ethnic diversity - and a diversity that has created new inter-ethnic contacts. Migration has become global, rather than just cross-border.

However, you have learnt that the history of British migration includes centuries of global migration. The 'Anglo-Fragment' societies in America, Australasia and Africa are a testimony to the massive migration that has taken place from England, Ireland, Scotland and Wales. All 'Britons', then, have reason to be self-conscious about the easy acceptance of contemporary anti-immigrant rhetoric. Regrettably, your reading and reflection will have indicated how, in Britain's responses to migration and ethnic diversity, racism is a system of thought and action that has a long tradition in British thought and culture.

The successful anti-immigrant politics of the 1960's and 70's produced both policies and argument that reflected the entry of 'race' into the heart of British contemporary thought. This racialisation of the practical realities of Britain's multi-ethnic demography was continued through the politics of Thatcherism and continues to be expressed in current debates around asylum seeking. The success of race thinking is partially founded upon its ability to be expressed in forms of language that have about them a taken-for-granted reasonableness. 'Discursive deracialisation' - the ability to invoke race thinking without employing an explicit language of 'race' - has been central to the resilience of racism in British society.

In nursing, the racism that has been recorded in clinical practice is not dependent upon vulgar expressions of racist hostility for its survival. On the contrary, a cultural racism in which there is a collusive practical acceptance of everyday racism, is the greater challenge. There are individuals who are actively prejudiced and have a personal satisfaction in their discriminatory behaviour. And some are the nursing profession's share of the "unlovely ten per cent" of extreme bigots who are maliciously racist. However, the module teaches the limitations of equating racism with prejudice. Bigots cannot be tolerated in health care practice. In nursing, they are inevitably incapable of delivering individualised holistic care in multi-ethnic Britain. They have placed themselves outside of the core values of nursing. But prejudice alone is not the sole target of creating culturally safe practice.

The discussion of communities of practice has revealed that health and social care takes place in specific institutional settings, for example, nurses' subjective 'consciousness of kind' provides them with an identity, values and professional aspirations which shape their strategies in seeking to sustain high standards of nursing care within this system.

However, the institutional axis of these communities of practice plays a pivotal role in determining the framework of power, time, space and resources that shape practice. It is this institutional framework, and the routine practices that it facilitates, which create the areas of practice within which institutional racism operates.

Institutional racism provides a very different challenge from the one presented by personal prejudice within health care delivery. Even 'nice people' can be participants in processes that come to be revealed as discriminatory. Nor will adherence to professionalism be an adequate defence. For you will have seen that processes of racial discrimination can be aided by ideologies other than those of 'race'. Professionalism can be such an ideology. Institutional racism demands a wide ranging and systematic response if it is to be eliminated.

Throughout this module, you have been repeatedly invited to reflect upon how you respond to the implications of the arguments as they are developed. This is seldom a simple task, and occasionally an uncomfortable one. We each of us come to our commitment to justice, and opposition to discrimination, from a unique biographical perspective. The values that we draw upon, in explaining our position in relation to multicultural policies, may have quite different philosophic and personal roots - for example:

For some people, a theological faith in a greater being may provide a belief in the fundamental equal worth of us all. Such religious convictions may provide a moral basis for opposing discrimination and unequal treatment
For others, secular political beliefs may fuel the same drive toward decency and fairness between all people.

These different sources of values sit more, or less, comfortably with the actions demanded by our membership of other value communities. As members of a nation, a gender, or an ethnic community, we may feel called to pursue policies that protect these special identity groups. It may easier for us, then, to be committed to tolerance than to equality. Tolerance, of its nature, tends to remind us of our generosity toward others. And, it reminds us of their difference. However, toleration does require a generosity of spirit, since it means in many instances a restraint from imposing our wishes or views. To be tolerant of others does not require us to have no personal values; it may, however, require us to constrain them in respecting the values and cultures of others.

For some, the demands of toleration - particularly if linked with the expectation that we show 'sensitivity' to others - is seen as an assault upon the integrity of their own values; whatever they may be. For being sensitive invites us to go beyond the restraint of tolerance, and to have an affirmative judgement toward other cultures: to show a positive appreciation of the other culture. This demand can easily be presented as being a necessary extension to the empathy and respect that is inherent to delivering individualised holistic care.

The ambiguity surrounding this question of how we demonstrate respect for other cultures has proved unnerving and distressing to many health and social care professionals. Not wishing to be accused of being racist or ethnocentric, and accepting the core values of individualised holistic care, they do wish to demonstrate respect, understanding and empathy with patients from other cultures. There are, however, cultural practices which individual nurses and midwives find contrary to their own values, and, therefore, objectionable. But, believing that cultural relativism is the expected professional posture, they then find themselves unclear about what they may legitimately do with their own feelings. This scenario is almost certainly guaranteed to create anxiety, frustration and resentment. However, the problem was created by the professional ambiguity that allowed for the belief that absolute cultural relativism was a requirement of transcultural practice to exist in the first instance.

As Hylland Eriksen (1995:11-12) demonstrates, cultural relativism is a valuable tool of anthropological research: not an essential under-pinning of multicultural policy:

"Cultural relativism is sometimes posited as the opposite of ethnocentrism. This is the doctrine that societies or cultures are qualitatively different and have their own unique inner logic, and that it is therefore scientifically absurd to rank them on a scale. If one places a San group, say, at the bottom of a ladder where the variables are, say, literacy and annual income, this ladder is irrelevant to them if it turns out that the San do not place a high priority on money and books. It should also be evident that one cannot, within a cultural relativist framework, argue that a society with many cars is 'better' than one with fewer, or that the ratio of cinemas to population is a useful indicator of the quality of life.

Cultural relativism is an indispensable and unquestionable theoretical premise and methodological rule-of-thumb in our attempts to understand alien societies in an as unprejudiced way as possible. As an ethical principle, however, it is probably impossible in practice, since it seems to indicate that everything is as good as everything else, provided it makes sense in a particular society. It may ultimately lead to nihilism. For this reason, it may be timely to stress that many anthropologists are impeccable cultural relativists in their daily work, while they have definite, frequently dogmatic notions about right and wrong in their private lives.

Cultural relativism cannot, when all is said and done, be posited simply as the opposite of ethnocentrism, the simple reason being that it does not in itself contain a moral principle. The principal of cultural relativism in anthropology is a methodological one - it helps us investigate and compare societies without relating them to an intellectually irrelevant moral scale; but this does not logically imply that there is no difference between right and wrong".

Reflecting cultural relativism as a necessary element in transcultural practice helps to clarify matters, but it does not make life easy. Absolute cultural relativism invites a suspension of moral judgement - which may be consistent with a fascination with the variety of forms of human solutions to the act of living, but hardly sustains a viable social order.

In this module, you have looked at individuals living together within a state bound by rules of citizenship and enmeshed in a framework of social policy. Such liberal democracies require a moral order to provide meaning and legitimacy for this political arrangement. Absolute cultural relativism is not consistent with shared citizenship, nor with the commitment to caring which resides at the heart of nursing and social care. In rejecting such cultural relativism we are all required to consequently remain in touch with our own moral sensibilities.

In essence, there is no easy fix to the challenge of transcultural practice. So much of health and social care draws upon an engagement with one's own inner self. The compulsion to care, the capacity to empathise and an ability to engage with the emotional labour of caring all require that practitioners stay in touch with their inner self. Their personal authenticity is integral to their ability to be a practitioner. Their moral sensibilities are fundamental to this personal authenticity.

The politics of difference invites us all to recognise difference, and to be prepared to treat each other equally through respecting that difference. The first task is to understand the difference. And ethnic diversity is always interactive: we are different because I differ from you and you differ from me. This is an appropriate relativism, for it rejects the distorting normative assumptions of ethnocentrism. From an understanding of the difference we can all then move to demonstrating respect between equals. No one who has isolated themselves from their own identity and values can do this. Holistic care requires holistic carers: rounded, complex, whole persons. Thus, transcultural practice challenges us to live and practice through respect for difference, and to learn how to negotiate difference appropriately. The core values of British health and social care professions provide a positive platform for pursuing this goal.

However, there appears to be no easy formula that will enable all of us to negotiate easily the policies that must be developed, to guarantee health care that is appropriate for a multi-ethnic society. We live in an age when we all feel the power of the politics of identity. We too have identities, we too are able to claim our distinct location within the access to rights and resources offered by differentiated citizenship.

In a polyethnic society we are all ethnic and, therefore, all capable of claiming our own polyethnic rights. Multiculturalism is about recognising ethnic diversity and in Britain our experience of living with multicultural policies is not yet sufficiently mature for the majority ethnic community to resist the emotive comforts of buying into the 'victimisation of the majority' rhetoric. Nor do all minority ethnic claims to polyethnic rights avoid the divisive politics of essentialism, whereby some members of their community are more real than others. And there is, as yet, no easy calculus that allows us to easily, and with certainty, distinguish between a legitimate statement of ethnic pride and an ethnocentric piece of xenophobia that may well be racist. There is a struggle within the United Kingdom for equal treatment for all ethnic communities. Where this struggle focuses upon particular resources, such as health care, it is not difficult to find evidence of tactics of resistance to change from the majority ethnic group and increasing frustration from minority ethnic communities. It is appropriate to see this as a situation of conflict in which feelings may be heightened, and ethnic boundaries are made explicit and strongly defended. It is useful in this context to remember two realities:

that despite any ethnic difference the very great majority of health care user are citizens - they have an absolute right to appropriate healthcare and that:
individual practitioners committed to high quality transcultural health care cannot adequately compensate for a health care system that has failed to develop, and resource, policies that will guarantee a flexible culturally safe health care system.

The first statement reminds us all that culturally safe health care is not a generous addition to current health care practice; it is fundamental to a NHS for 21st century Britain. It is integral to individualised holistic care.

The second statement reminds us that individual practitioners cannot practice appropriately in a health care system that has not, at an institutional level, developed systematic policies to guarantee culturally safe practice. This underlines the fact that if practitioners have not been educated to deliver culturally safe care they can hardly be blamed for their inadequacies. And, it underscores the necessity of communities of practice having a shared commitment to monitoring and developing transcultural skills.

If we can be more open about, and comfortable with the ambiguity and anxiety that is attached to this developmental phase of changing health care practice, then we may all be more receptive to recognising change and to consolidating progress.