winter 2007 imq

Intercultural Management Quarterly

Winter 2007Vol. 8, No. 1

Intercultural Management Quarterly: www.imquarterly.orgIntercultural Management Institute: www.imi.american.edu

Integrating Culture and Management in Global Organizations

Hearts, Minds and Schools ................................................... 3by Lawrence E. Harrison

An Interview with Prudence Bushnell ............................. 6by Chris Saenger

The “Dark Side” of Diversity .............................................. 10by Ben Alexander

Globally Responsible Study Abroad ............................. 13by Skye Stephenson

Managing Time Differences ............................................... 17by Erran Carmel and Alberto Espinosa

Cultural Competence in Health Care ............................. 18by Ursula Leitzmann

In This Issue...

2 Intercultural Management Quarterly

From the Editor IMQ STAFFPublisher: Dr. Gary R. WeaverManaging Editor: Chris Saenger

Editorial Review BoardDavid Bachner, Annmarie McGillicuddy, Adam Mendelson, Darrel Onizuka, Karen Santiago, Gary Weaver, Sherry Zarabi

Intercultural Management Quarterly (IMQ) is pub-lished by the Intercultural Management Institute at American University. IMQ combines original research conducted in the field of interculutral man-agement with the applied perspectives of industry experts, professors and students.

SUBMISSION GUIDELINESProfessionals, scholars, and students are invited to submit articles of 1,000-2,000 words on issues related to the study and practice of intercultural management. Articles must be innovative and contribute to the knowledge in the field but should avoid overly academic jargon. Footnotes or endnotes are discouraged except for direct quotes or citations. Each submission is refereed by the members of the IMQ editorial review board. Accepted pieces are subject to editing.

REPRODUCTIONNo part of this publication may be reproduced or transmitted in any form or by any means, without the express written permission of the Publication Manager. Please contact the Managing Editor for reprint availability.

CONTACT IMQIntercultural Management QuarterlyIntercultural Management Institute4400 Massachusetts Avenue, NW

Washington, DC 20016-8177Phone: (202) 885-6436

Fax: (202) [email protected]

© 2007 Intercultural Management Quarterly

As we go to press, the Intercultural Management Institute’s eighth annual conference is around the corner, posing the question, “Does Culture Still Matter?” While there may not be much doubt as to IMI’s answer to the question, the conference promises another round of exploration, discus-sion and debate on culture’s impact on organiza-tions and situations of all stripes.

The conference’s keynote speakers are no strang-ers to controversy. Some interculturalists vehe-mently contest Lawrence Harrison’s belief that certain cultures are more prone to economic and democratic development. Prudence Bushnell, a State Department official before and during the Rwandan genocide and Ambassador to Kenya at the time of the Nairobi embassy bombing, finds an optical theme as she reflects on mistakes and cultural lessons from her decisions in times of cri-sis.

This edition’s other contributors, all conference presenters, shed light on other facets of intercul-tural management, including the potential for painful feelings when opening up to diversity, the challenges of cultural sensitivity in health care and the need for further reflection on the best ways for study abroad programs to support the communi-ties where they work.

I look forward to meeting many of you at the IMI Conference, March 15-16 on the campus of American University. I welcome your comments and criticism on all parts of IMQ. Please send your letters to [email protected].

Chris Saenger Managing Editor

W A S H I N G T O N , D CAMERICAN UNIVERSITY

3Winter 2007

Hearts, Minds and Schools

The war in Iraq has produced many casualties. One lesser-noticed one may be the death of an idea—the idea that the culture of a nation or

region can be transformed quickly by well-intentioned foreigners. The recent report of the Iraq Study Group scarcely mentions the grand goals of bringing democracy to Iraq, and instead contemplates a drawdown of U.S. combat troops. It seems that the notion of transforming the political culture of the Middle East has been drawn down as well.

“Are the people of the Middle East somehow beyond the reach of liberty?” President Bush asked in 2003. “Are millions of men and women and children condemned by history or culture to live in despotism? I, for one, do not believe it.” As his audience applauded, he went on to criticize the “cultural condescension” of skeptics who believe that Islam and democracy don’t mix.

The president was, at best, half right. In the long run, the values of freedom may be right and true for all people in all societies. But the cultural values favorable to plural-ism and entrepreneurship are indispensable to building democracy and capitalist prosperity.

For the past half-century, politicians and experts in rich countries have tried to improve living standards and build democracy in Africa, Asia and Latin America. Early on, they, too, were convinced that tyranny and poverty could be defeated, that democracy and capitalism were rooted in human nature. With a few exceptions, such as South Korea and Taiwan, meaningful progress has not materialized.

Some cultures and some religions clearly do better than others in promoting democracy and prosperity. Iraq and Afghanistan show that, where culture is adverse, a blind belief in the power of freedom is a frail foundation for U.S. policy.

But culture is not destiny. The failures in Iraq and in-

stability in Afghanistan do not prove that these or other countries are condemned to stagnation and political op-pression. For politics to change, however, culture must change, too—and that takes much more than dispatch-ing troops, holding elections and writing constitutions.

During my 20 years (1962-82) with the U.S. Agency for International Development, I directed five missions in Central America and the Caribbean. Like other young idealists, I believed that President John F. Kennedy’s Al-liance for Progress—a “Marshall Plan” for Latin Ameri-ca—would make the region safe for democracy.

But as I encountered daily the intractability of Latin America’s problems, it became clear to me that poverty and injustice were rooted in the region’s values. I was learning what Federal Reserve Chairman Alan Greenspan would articulate years later, after the Russian economy collapsed in the late 1990s. “I used to think that capital-ism was human nature,” he reflected. “But it isn’t at all. It’s culture.” The same is true of democracy.

In the late 1970s, I worked in Haiti, which shares the island of Hispaniola with the Dominican Republic. In 1804, when Haiti became independent, it was vastly richer and more powerful than the Spanish colony to the east. But today Haiti is by far the poorest country in the hemisphere—in 2003, its per capita income was $1,740, compared with $6,820 for the Dominican Republic, ac-cording to U.N. estimates. Adult literacy was 51 percent in Haiti, vs. 88 percent in the Dominican Republic. And while Dominicans have experienced substantial demo-cratic continuity in the past 40 years, authoritarianism has been the norm for Haiti.

The Dominican Republic’s evolution has been typical of Latin America, while Haiti’s has been typical of Af-rica. Why the difference? The dominant religion in Haiti is voodoo, which nurtures mistrust and irrationality. Its roots are in the Dahomey region of West Africa—what is today Benin. The levels of income, child malnutrition, child mortality, life expectancy and literacy are virtually identical today in Haiti and Benin.

Some religions and cultures do better than others at promoting personal responsibility, education, entrepre-neurship and trust—all values that shape political and

by Lawrence E. Harrison

Lawrence E. Harrison is Senior Research Fellow and Adjunct Lecturer at the Fletcher School at Tufts University.


Enlightened policies can, over time, produce cultural change—change that spurs pluralism and development.

economic development. When it comes to democracy, prosperity and rule of law, Protestant societies—above all, the Nordic countries of Denmark, Finland, Iceland, Norway and Sweden—have generally done better than Catholic nations, particularly those of Latin America. Confucian societies such as Japan, Singapore, South Ko-rea, Taiwan and now China have produced transforming economic growth. Islamic countries, even those with oil, have not.

The late senator Daniel Patrick Moynihan once stated: “The central conservative truth is that it is culture, not politics, that determines the success of a society. The cen-tral liberal truth is that politics can change a culture and save it from itself.”

With these words in mind, I’ve spent the past four years leading the Culture Matters Research Project at the Fletcher School at Tufts University, where I am a senior research fellow. The effort has involved 65 social

scientists, journalists, politicians and development prac-titioners from 25 countries. We undertook case studies of more than two dozen countries in Africa, the Ameri-cas, Asia and Europe, several of which had experienced or were undergoing transformations from traditional to modern societies.

Our goal was to capture the role of culture and cultural change in a society’s evolution. We found that Confu-cian values of education, achievement and merit played a central role in the economic “miracles” in East Asia. Open economic policies and the welcoming of foreign investment triggered several transformations, including in India, Ireland and Spain. Visionary leadership was crucial in the cases of Botswana, Turkey and Québec. In Ireland, Italy, Spain and Québec, modernization was also accompanied by decline in the influence of the Catholic Church.

We concluded that enlightened policies can, over time, produce cultural change—change that in turn spurs po-litical pluralism and economic development. However, it is extremely difficult to impose such changes from out-side; war is not a helpful instrument. Better tools include education that inculcates democratic and entrepreneurial values; improved child-rearing practices; religious reform; and development assistance keyed to cultural change.

The first step is to end illiteracy, which is the greatest obstacle to progressive cultural change. It impedes the human capacity to learn and perpetuates fatalism and superstition. Human progress lags most in societies in which illiteracy is highest, above all in Islamic countries and Africa. Literacy among women may be even more important than literacy among men because of the cru-cial role women play in child-rearing.

A second, longer-term goal is ensuring a high school education for all. Spain offers a telling example: In 1965,

during the Franco dicta-torship, 38 percent of the country’s high school-age population was in school; in 1982, seven years af-ter Spain’s transition to democracy, it was 88 per-

cent.

Child-rearing techniques must also be rethought. Tra-ditional child-rearing patterns are sustained from genera-tion to generation, yet in many countries such customs may instill values that impede progress for individuals and for society. For example, Costa Rican psychiatrist Luis Diego Herrera argues that child rearing in his coun-try typically upholds shrewdness over honesty. “Children are taught contradictory standards of behavior,” he said. “They are supposed to abide by the rules, but if they break them, the important thing is to get away with it.”

Reducing the role of religion in politics and religious reform more broadly may also be crucial, particularly in the case of Islam. The groundbreaking U.N. Arab Hu-man Development Reports stress openness to the values, ideas and institutions of the non-Islamic world, includ-ing tolerance of other religions and commitment to edu-

Hearts, Minds and Schools...

5Winter 2007

© 2006, The Washington Post. Reprinted with Permis-

cation and gender equality. The advocacy group Freedom House judges not one Arab country to be free, and that has much to do with a culture that nurtures authoritari-anism, discourages dissent and places a lower priority on education.

Catholic ambivalence about free markets has contrib-uted to Latin America’s costly dalliances with socialism, a point stressed by Catholic writer Michael Novak. Ortho-dox Christianity’s similar ambivalence has contributed to anti-capitalist currents in Russia and elsewhere in Eastern Europe. Support of democratic capitalism by both reli-gions, coupled with their concern about injustice, cor-ruption and crime, could play a key role in progressive cultural change.

Finally, aid agencies and universities must take cul-ture seriously. Because their staffs include professionals committed to cultural relativism, such institutions have largely avoided confronting cultural obstacles to prog-ress. However, they can play an important role in support of reform-minded national leaders by integrating culture into their research, strategies and projects.

Culture does matter. But politics can change culture and enable more rapid progress, substantially transform-ing societies within a generation. The anguish of the U.S. adventure in Iraq, genocide and famine in Africa, and the huge flow of poor people seeking a better life in rich countries are among the vivid reminders of how diffi-cult it is to create a more democratic, just and prosper-ous world. Confronting culture can make that challenge more manageable. i

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A keynote speaker at the 2007 IMI Conference, Prudence Bushnell served in the U.S. State De-partment as Principal Deputy Assistant Secretary

of State for African Affairs from 1993 to 1996, a peri-od that was marked by great tension between the USA and several African countries. In 1993, 18 U.S. soldiers were killed in Mogadishu, Somalia in what has come to be known as the “Blackhawk Down” incident. In April 1994, genocide erupted in Rwanda and led to the kill-ing of an estimated 600,000 people. Bushnell served as a primary conduit of information between embassy staff in Kigali and the State Department leadership in Wash-ington, DC. She also helped coordinate the evacuation of embassy personnel from Rwanda.

She served as Ambassador to Kenya from 1996 to 1999 and was in the Nairobi embassy compound when it was bombed by al-Qaeda in 1998.

She was Ambassador to Guatemala from 1999 to 2002 and Dean of the Leadership and Management School at the State Department’s Foreign Service Institute from 2002 to 2005. After leaving public service in 2005 she founded Sage Associates and now works with senior ex-ecutives to enhance leadership performance, particularly during crises.

IMQ Managing Editor Chris Saenger spoke with her about her experiences.

• • •

IMQ: My first question is about Rwanda. You said in another interview that America and others missed warn-ing signs of the genocide because we were “wearing the wrong glasses.” What did you mean?

PB: We were focused on the peace accords and saw ev-erything through those glasses. That is, we said to our-selves, “What is it that we can do to get people behind the peace accord? Doing so will resolve the problems of the killings that have been going on,” rather than saying, “Wait a minute, the point may not be the peace accords, the point may be the killings and we may need to put the glasses on and focus on the killing rather than the peace accord.”

So it was the chicken and the egg in some respects and we decided that implementing the peace accord would resolve all of the other issues, when it fact it was the other way around. The other issues killed the peace accords and created the genocide.

IMQ: You also talked about how Americans couldn’t grasp a slaughter at that scale, that there was nothing in our history that would prepare us for that. Is there any-thing that can be done to prevent that kind of failure of imagination in the future?

PB: I think that we may be a little more attentive to what is going on in the rest of the world now than we used to be. But this kind of genocide is still pretty un-fathomable. And it was not just the genocide itself, but it was the participation of such huge numbers of people, using farm implements and making the killing a person-al experience for everyone—those who were killed and those who were doing the killing. We are not talking a Nazi-like concentration camp, separate from the popula-tion at large. We are talking about people picking up an ax and going to slaughter their neighbors.

What exacerbated our inability to react was the stereo-typic notion we had of ethnic conflict in Africa: “Well, there they go again. You know, Africans just do this now and then.” And that’s what I think we need to get over, the idea that somehow a group of people has in them a greater inherent ability to do horrible things to their neighbors than we do. I hear that attitude now, and I think it is very dangerous. I hear people who read about the killing going on in Iraq, and say, “Well, gee, it’s ter-rible, but you know, they just don’t value human life like we do.” That is not true. It’s a rather smug form of self-protection when we engage in the “we” and the “they” attitude: “It’s what they do. We wouldn’t do it.” That’s where I think it is dangerous and where I hope we are getting smarter.

IMQ: You have also talked about going to Rwanda be-fore the genocide began and initially not being able to grasp the level of mistrust that existed between Hutus and Tutsis.

PB: Right.

An Interview with Prudence Bushnellby Chris Saenger

7Winter 2007

IMQ: And you said there was “no way to gauge the ve-racity of someone’s words.” I wonder how do you operate as a diplomat in an environment where, at some point, you realize, “I don’t know how to tell what the truth is”?

PB: What the Rwanda experience taught me, and I went on to serve as ambassador in Kenya and then Gua-temala, both countries where conflict was a real issue… What Rwanda taught me was: don’t forget that there is a difference between theater and what goes on behind the stage. That means don’t misinterpret what you are seeing as being reality. Be aware that what you see is not neces-sarily what you get. Now, you have to be very culturally sensitive, and I think Rwandan culture and Guatemalan culture—well, all cultures—are very complicated. It is difficult for an American to walk into another culture and understand what is going on behind the stage. But you can at least understand that what you see is not nec-essarily evidence of what is going on behind the stage.

IMQ: How does crisis leadership differ when you are outside of your own culture? I am trying to imagine the moments after the explosion at the em-bassy in Kenya. Sudden-ly all the formal systems that exist to mediate between American culture and Kenyan culture are gone. How did you go about leading people in that environment?

PB: Well, I can tell you that the difference between Kenyan and American culture was very apparent from the very beginning, from the first few seconds after [the bombing]. I actually got into a lot of trouble because of my culture, the clash of my culture with their culture. So let me tell you what happened.

The bomb exploded—a thousand pounds of explo-sives—in a small parking lot that was surrounded on three sides by buildings; that is why the force of the bomb was so horrific. And 213 people were killed in-stantly. Five thousand people were wounded from the chest area up—a lot of facial wounds and head wounds, which of course are very, very bloody. The American em-

bassy was destroyed on the back side, but, on the front side, except for all the windows having been blown out, it looked pretty intact. In part this is because it was built to American standards to survive earthquakes, so it was a building that could withstand a lot of impact. The build-ing next door to us was a seven-story office building and that pancaked—it just collapsed, with many, many peo-ple inside of it. We lost half of the people in the embassy building either to immediate death or injury. So we were dealing with a lot of people who had just been blown up, in a country long, long ways away from any 9-1-1 emer-gency phone number. There was no fire department or ambulance—nothing except us.

The Kenyans did not see that from the outside because, as I said, the [embassy] building did not look nearly as bad on the outside, even though it was devastated on the inside. Our security personnel went immediately into

standard operating procedure, which was to create a se-curity cordon around the building—to keep people from coming in and also to escort people out of the building, some of whom had come with good intentions and some to loot. Thousands of Kenyans rushed to the street cor-ner, and what they found were grim, white-faced men with guns yelling at them to stay away.

Now, in Kenyan culture, when there is crisis, they come together. They don’t move apart. We don’t do the same thing. We all say, “OK, what is my job? What do I do here?” It was so upsetting to the Kenyans to see what they perceived to be culturally insensitive attitudes at the mo-ment of their greatest need, because we were not able to come to their rescue. We were struggling so fiercely to save our own colleagues that what they saw, again, were men with guns and everybody scurrying around, taking care of the Americans and no one taking care of the Ke-

Rwanda taught me that there is a difference between the-ater and what goes on behind the stage. It is difficult for an American to walk into another culture and understand what is going on behind the stage.


nyans.

That created and fueled an anger that is inevitable and completely justified when a mass murder of this propor-tion takes place. People feel angry. How do you direct your anger? Well, it was easy for the Kenyans to direct the anger at us because, after all, we were the targets. And where were we when they needed us?

I went on television and radio three or four days after the bombing to explain why it was that we had set up the security cordon. I explained the fact that the build-ing was very dangerous, that we were overwhelmed with trying to take care of people and that there were loot-ers in the building. That part ended up igniting another firestorm. The next day the newspapers were filled with stories about how the U.S. ambassador has accused Ke-nyans of looting. So, then, in the Kenyan imagination, not only were we a catalyst for a terrible bombing, a na-tional tragedy, but the U.S. ambassador then turned around and said, on top of it all, “You are all a bunch of thieves.” It was awful. The profound lesson I learned is that sometimes you do not tell the whole truth; some things you just shouldn’t say. And it’s very American to come out and try to explain fully.

IMQ: It seems that there is almost a third culture, in that the Marines in the embassy’s security detail may have had a different sense of how to operate than the other embassy staff and certainly the Kenyans…

PB: Right, I mean, here you have Marines, a small de-tachment of Marine security guards, and it just so hap-pens the bombing occurred during their shift change. So there was a van full of Marines outside the building waiting for one of their colleagues to cash a check when the embassy blew up. In fact, their colleague was killed. This is where their training came in. They rushed in and they put on their helmets and flak jackets, grabbed their guns and created a security cordon. They faced thousands and thousands of panicked people. Now, from my end, I was so proud and grateful that they didn’t kill anybody.

Because these guys were in shock and not knowing what was going to come next. Nobody knew that it was a sin-gle attack.

So, you have three very, very different perspectives of exactly the same situation, with very different conclu-sions. And no one is wrong.

IMQ: Another thing that has struck me in reading some of the things that you have said in the past is the balance that you seem to find between saying, and I’m paraphrasing, “these things happened; we need to move on” and going back into these terrible events enough to learn something from them…

PB: Oh, I chose not to move on. I had a fork in the road presented to me three years after the bombing when I was in Guatemala as ambassador. I received an invita-tion from the Oklahoma City National Memorial and

Museum to be one of their keynote speakers when they opened the museum. I was either going to revisit the [Ke-nya] experience and relive it and talk about it, which was going to be exceedingly painful for me, or I was going to say no and move on. I decided that I was going to talk about it.

When I went, never having been to Oklahoma City… I knew, of course, about Timothy McVeigh and his blow-ing up the Murrah Building, but I didn’t know anything about how the community had reacted in the longer term. I was astounded at the number of people who came up to me after I told the story of what we went through in Nairobi and said, “That is exactly what happened with us.”

That led me into work on crisis leadership. I have four speeches next week and all of them are dealing with what I learned from Nairobi and Rwanda, but particularly the

Kenyans rushed to the scene and found grim, white-faced men with guns yelling at them to stay away. That created an anger that was completely justified.

Prudence Bushnell...

9Winter 2007

Nairobi bombing. So I can’t say that I have moved on at all.

Actually, this reminds me of another cultural difference. I went back to Kenya for the opening of the Memorial Peace Park on the site of what had been our embassy. I had breakfast with a man who was the head of Kenya’s National Council of Churches, whose headquarters had been across the street from our building that was blown up. In the months after the attack we would get together periodically, because he lost some people also, and we would talk about what we were doing for our respective communities. Three years later, one of the things that he noted was that Kenyans don’t move on nearly as quickly as Americans do. I talked with some of the Kenyan em-ployees at the embassy who said exactly the same thing. [The church leader and I] had a discussion about wheth-er that is good or bad, but the fact was the Americans moved on much, much faster, to the consternation of a lot of Kenyans.

IMQ: How do you teach from these experiences? You were Dean of the Leadership and Management School at the State Department’s Foreign Service Institute, where you have career State Department staff, non-career staff who may not have had as much overseas experience…

PB: Well, I think everyone, if you’ve reached a certain age, has faced a crisis. Now, it might not be the magnitude of a terrorist attack, but living is a dangerous thing—we get into car accidents, people we love die, fire destroys homes, etc. So the training involves engaging them in experiences they have had. I try to help them explore what was important in their response to the crisis they experienced. What was it that you needed? What was it that the leader did that was helpful? What did the leader do that was not helpful? Just delving into their own life experience.

What I found was that of the many, many tools of lead-ership that people use, some are far more important in times of crisis than others. And that, to me, is terribly important for us to start talking about in mainstream leadership forums, because it is absolutely un-essential and ridiculous to reinvent the wheel in a time of crisis and put people through further pain because we remain

clueless as to what to do. As you can see, it really irritates me.

IMQ: Then what are the right qualities that people don’t emphasize enough in crisis leadership and what are the wrong qualities they should leave aside when disaster strikes?

PB: First let me say that I have done a lot a lot of re-search and I am absolutely appalled at the dearth of lit-erature on this topic. I would have thought that every Tom, Dick, and Rudy would have written a book. Only Rudy [Giuliani] did (laughs)…

Character is terribly important in times of crisis. It’s not just leadership skills, it’s character. Part of that character is showing empathy. You have to understand what is hap-pening with your people. Being physically present is part of showing empathy. One of the reasons I think Giuliani did such a good job was that he was there—he saw, he knew what was happening and he was communicating.

You also have to create your team, grow your team ahead of time around meaningful purpose and goals because these are all mutually reinforcing elements: the team, purpose, and goals. The team has to be the one to decide what the goal is or else they’re not going to work toward it. They have to have a real stake in the goal.

Then you foster a culture of leadership and you mind your own business—passionately. If you are minding your business, you are creating a culture in which people can exercise their leadership. Then the next thing is, you had better jolly well take care of your people. That means sometimes giving them really wonderful feedback and sometimes really painful feedback and doing what it is they need you to do.

You also need to take care of yourself physically and in-tellectually. When I was moving on from Kenya to Gua-temala, I needed to learn Spanish. I bought a Danielle Steel book in Spanish, figuring it would be a lot easier than Cervantes. Every night I would sit with a Spanish-English dictionary and look up every single word until I could read a paragraph. I’m not that disciplined or intel-lectual, but what my mind really needed was to get away from what I was dealing with at work everyday because

Continued on page 22


“I have learned to endure the humiliation of these stereotypes about my religion, but I will not shame myself by colluding with them.”

His name was Mustafa, a participant in one of my diver-sity workshops. These were the words that he used to ex-plain his sharp reaction to a colleague who had essentially told him that he needed to be “less sensitive and try to be more understanding” of why people who appear to be Is-lamic or Middle-Eastern sometimes encounter higher lev-els of suspicion and scrutiny in airports and other places where security may be an issue. The colleague’s statement was made in response to Mustafa’s description of the dif-ficulties that he frequently encounters when traveling. Frustrated by his inability to get an empathic response, Mustafa suddenly found himself walking away angrily while shouting, “I am not stupid; I understand the logic of it. I just want you to understand how it makes me feel. All you seem to care about is what makes sense to your prejudiced thinking about Islamic people.”

According to Mustafa, the incident, which was witnessed by several people, has had a negative impact on his rela-tionship with the colleague and has created an image of Mustafa as someone who must be “handled with care.” Although his employer never discussed it with him, he was concerned that the incident may have affected his career.

Embedded within this exchange is an important truth about diversity that is not addressed by the “let’s all feel good” approach to diversity training that has become standard in many organizations. The truth is that the awareness of diversity that enables us to explore our posi-tive differences has another side. There is a “dark side” of diversity that has to do with the humiliation and shame felt by some groups because their differences have been used to justify practices of inequality and exclusion to-

wards them.

For the purposes of this discussion I define humilia-tion as an experience that lessens a person’s dignity or sense of self-pride. Shame, which often flows from hu-miliation, is a more intense and lasting sense of unwor-thiness. In the case of Mustafa, the feeling of humiliation came from being treated as a potential terrorist simply because the combination of his name and physical char-acteristics suggested that he was a Muslim. His name and faith, which are points of pride and dignity for him, be-came the basis for distinguishing him from his colleagues and other travelers and treating him with suspicion. The threat of shame emerged when he perceived that his co-worker, and possibly his employer, wanted him to accept this treatment as something that was justified by the be-havior of certain extremists who did not represent him at all. For Mustafa there was no way that he could shrug off his mistreatment without dishonoring his religion and his lowering his standing in his family and social groups.

It did not surprise me that Mustafa, who takes great pride in maintaining his composure and professional im-age, was unable to do so in this case. Many studies of the impact of humiliation and shame suggest that these powerful emotions can diminish the skills needed for in-terpersonal effectiveness.

During the course of our discussion I was able to help Mustafa accept the legitimacy of his feelings of humili-ation and the impact those feelings may have had upon his ability to deal with the situation in a manner that would have satisfied his own standards of professional-ism. From that point he became willing to go to his co-worker and make an appropriate apology for his strong reaction with an offer to explain why this situation had been so difficult for him. He also gave me permission to talk with his supervisor, who I found to be most accept-ing of my suggestion that he support Mustafa by having a similar conversation with him and expressing apprecia-tion for Mustafa’s efforts to resolve the matter positively. We knew that while these steps would not magically cre-ate a perfect solution, they did offer a good start toward repairing the damage done to relationships.

In a somewhat different situation Greg, an African-

The “Dark Side” of Diversityby Ben Alexander

Ben Alexander is Senior Partner at Alexander Con-sulting & Training, Inc. He has designed and pre-sented workshops in human resources management, workforce diversity and dispute resolution to thousands of participants in over two-hundred private and pub-lic organizations.

11Winter 2007

American executive in a large financial organization, spoke at a diversity workshop that I was facilitating. Hoping to make a point about how the racial makeup of a key sector of the company’s staff had not changed dur-ing his 20-year career, he asked all the people in that staff category to stand up and look around. They did and after a very long, silent minute he asked, “What do you see?” After another long silence someone said, “Nothing but white people.” “That’s what I am talking about and that is not diversity,” was Greg’s response. The next day he was shocked to find that large numbers of employees had registered complaints about the incident. The majority of the complaints conveyed feelings of humiliation at be-ing used as examples of racism within the organization. It took a few cups of cof-fee to get Greg to see that even though his inten-tions were honorable, he left the group with a sense that they had been manipulated into being blamed for something that was not their fault. How was this different from the feelings that people from minority groups and women express when they feel that they are being judged on the basis of stereotypes? We agreed that it was not.

What appeared to be a setback was turned into a break-through by having the manager address the group in a subsequent session with an acknowledgement of the mistake. This was followed by a request that they talk in small groups and then individually about how it felt for them to stand up and, in the words of one participant, “be made to feel like we were party to some racist con-spiracy.” The fact that their feelings were acknowledged and honored then made it possible for the discussion to move toward its intended purpose of exploring ways to create higher levels of diversity in the organization.

In both of these scenarios, the conflict across lines of cultural difference was driven by feelings of humiliation and possible shame resulting from misunderstandings. Given that higher levels of diversity in organizational set-tings may cause these situations to occur more frequently now than in the past, it is important for organizations

to develop the capacity to deal with them effectively. I would like to offer the following suggestions for move-ment in that direction:

1. Accept the facts of diversity. Many of the differences that comprise diversity are based upon groups’ efforts to disassociate themselves from negative beliefs and ste-reotypes that lead to inequality and exclusion for them. When individuals from these groups encounter what they consider to be expressions of those beliefs, they may experience feelings of humiliation and even shame. Tell-ing people that they are being too sensitive or that they are mistaken in their perceptions is not a good way to begin the process of reconciliation.

2. Listen for understanding. When misunderstandings and conflicts arise, ask the people involved how they feel about what they have encountered. Demonstrate that you have heard them by acknowledging what they have said without making judgments or questioning the legiti-macy of their statements. One effective way of doing this is to repeat what you think you have heard back to the person with a request for them to correct anything that may be inaccurate or incomplete.

3. Acknowledge what is important to the people in-volved. If they haven’t told you, ask them. Simple ques-tions such as, “Could you tell me what is most important to you in this situation?” or “What do I need to know so that I can understand what is most important to you?” are good ways of getting to the issues and feelings that may be driving the conflict. Before moving on to the next step try using this question: “Is there anything else that would be helpful for me to know?” Many people are amazed by the amount of additional, highly relevant information that sometimes flows from this ending question.

4. Explore possibilities for resolving the conflict. The

The “let’s all feel good” approach to diversity can fall short. Awareness of diversity can also expose feelings of humiliation and shame.


information that you have gained and the concern that you have demonstrated up to this point should provide a foundation that will support additional questions such as, “How can I support you on this?” and “What are you willing to do?”

5. Reach agreement as to what will be done. Create agreements on how and when any next steps will be tak-en.

6. Express appreciation for the assistance that the indi-vidual has given you. Let the person know that you value their cooperation and input. In addition to diffusing feel-ings of anger that may be lingering from the conflict, this step can help reduce the anxiety that may exist around the possibility of negative consequences.

As a practitioner in the area of diversity training and consulting, I try to use upbeat, so-called “feel-good” ap-proaches as much as possible so that people will be more comfortable as they expand their awareness of a difficult topic. However, knowing that the discomfort and even humiliation of diversity’s “dark side” can appear sud-denly, I feel more confident knowing that the techniques outlined above can help me handle the situation.

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IMQ publishes book reviews, case studies and other

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organziations.

13Winter 2007

The U.S. Congress’s declaration of 2006 as the year of Study Abroad presents us with an ideal opportunity to examine U.S.-based education

abroad and its global implications with a critical eye.

Beyond the burgeoning attention and expectations surrounding education abroad these days, how is inter-national education faring as a field that not only contrib-utes to forming global citizens but also functions in a way that is globally responsible in word and deed? With ever more producers of all types engaging in “fair trade” prac-tices, are international educators doing all that they can to ensure that education abroad is functioning in a “fair trade” manner? How can international educators actively shape the future direction of education abroad in ways that resonate with the kind of world we hope will emerge in the twenty-first century and beyond?

With this article, I hope to begin a widespread dialog around these seminal questions and to posit some initial thoughts concerning what should be incorporated into the concept and practice of globally responsible study abroad.

Cross Currents in Education Abroad

To start this discussion, we need to take a critical look at the various types of cross currents buffeting education abroad these days. Three of the most salient are 1) mis-sion and values; 2) power and privilege and 3) inclusive-ness of host country collaborators and consideration of host country impact.

Mission and Values

From the start of student exchanges in the United States

through to the present day, there have been two different visions regarding the purpose and intended outcomes of education abroad. The first is the “global community and peace promotion” paradigm, sometimes referred to as the “idealist” perspective. Its underlying assumptions are that student exchange = more intercultural contact = greater understanding of the other and cross-cultural deepening = greater policies of tolerance and less ten-dency to engage in ethnocentric-behavior toward other peoples = more peaceful world. Several of the key people involved in the early establishment of student exchange organizations were vocal proponents of this perspective, and many were strongly influenced by Quaker principles and practices. Their legacy as well as the work of many other like-minded international educators in subsequent years still reverberates and shapes many organizations and programs today.

A different way of envisioning education abroad is the “growth and benefit” paradigm, in which the primary in-tention of education abroad is for personal benefit and, secondarily, national enhancement. This paradigm can be characterized as: student exchange = greater skills and knowledge = enhancement of professional possibilities = contributing to a more competent national workforce = helping the nation become stronger and maintain its competitive position in the world.

These two different views of the meaning and purpose of education abroad are not necessarily mutually exclu-sive. In fact, over the years they have interwoven-some-times compatibly, sometimes with a certain amount of tension and often with a bit of each. That said, in re-cent years there has been a generalized shift in empha-sis toward the “growth and benefit” paradigm. Several scholars have noted this trend. For instance, Edwards, Hoffa and Kanach write that by the end of the 1980s, globalization impacted U.S. higher education in ways that focused upon “the lack of preparation among U.S. undergraduates for entering and competing successfully in an increasingly interdependent and ever-more global-ized world economy and political order.”

The education abroad field is both responding to and shaping this shift. More focus is being given to assessing participant outcomes, proving the importance of educa-

Globally Responsible Study Abroadby Skye Stephenson

Skye Stephenson is director of Latin American and Caribbean Studies at SIT Study Abroad and formerly served as a program director in Santia-go, Chile for a decade. She is the author of The Spanish-speaking South Americans: Bridging Hemispheres (Intercultural Press) as well as sev-eral articles.


Globally Responsible Study Abroad...

tion abroad to the participants’ future career path and demonstrating how education abroad helps the United States create a more globally competent workforce. Sig-nificantly less discussion is devoted to how education abroad may contribute to a better and more peaceful world. All this is taking place against a backdrop of of-ficial U.S. policies that are exacerbating resentment and ill will towards the United States in many places around the world. Given this current configuration, it behooves us to raise the difficult question of whether these two different visions of education abroad—the idealist and the growth and benefit perspectives—are always mu-tually compatible. Is it possible that in some contexts, promoting what is essentially U.S. professional training and what are officially deemed short-term U.S. “national interests” may actually clash with peace promotion and global community enhancement? If so, then how do we with ethical sensitivity and intellectual rigor promote dialogue around these (sometimes) conflicting paradigms in applied settings?

Privilege and Power

Education abroad as practiced in the United States is sui generis due to several factors, including the tremen-dous resources—financial and otherwise—that institu-tions and students in the United States have access to. This implicit undercurrent subtly permeates the nature of many of our activities abroad. At many sites, U.S. edu-cation abroad students have the opportunity to under-take activities and meet people that most host national students would never be able to avail themselves of, a re-ality that some local students and host culture providers feel most keenly.

The increasing perception of education abroad (as well as many other aspects of the higher educational ex-perience) as a type of “commodity” that has been “pur-chased” and that consequently entitles one to “quality service” as the “consumer” adds yet another dimension to the already privileged stance of education abroad in many parts of the world. The U.S. legal environment and fear of lawsuits exacerbates this tendency even more in some cases. As Jenkins and Skelly so cogently put it, “In addition to the idealist assumptions that inform educa-tion abroad, it has, in the main, become another service

industry that contributes in its own way to a consumerist orientation towards other cultures and societies.”

In truth, culture shock is sometimes felt not just by program participants but also by host nationals who have to deal with them. A prominent Northern European in-ternational educator once told me that U.S. education abroad students typically needed 50 to 70 percent more time and attention than exchange students of any other nationality.

How can we, assuming we want to, encourage program participants to shift from a “consumer” focus regarding their education abroad expectations and experience? And how should international education as a field deal with the real privileges and, at times, sense of implicit entitle-ment embedded in some education abroad practices?

Inclusiveness of Host Country Collaborators and Impact

While education abroad could not exist without host country collaborators, from the stateside vantage point, these people often seem distantly vague; their voices are not frequently heard and their importance is not of-ten overtly acknowledged. Speaking in general terms, U.S.-based education abroad to date has been strongly “self-centered,” focusing nearly exclusively upon the par-ticipants and the U.S.-based institutions that support and send them. Typically, the host culture members are viewed as a “pleasant backdrop” who enjoy receiving the students and find the monetary and other compensation adequate and appropriate for their efforts.

Few probe much more deeply. While many have exam-ined how the education abroad experience may impact the participants, only a handful have considered how education abroad might impact the host culture. In some locales and situations, education abroad participants and programs can have a much broader impact than upon those who have consciously decided to collaborate, af-fecting host nationals whom may never have even heard of studying abroad.

Without making any judgments regarding the implica-

15Winter 2007

tions of this impact, it is important to at least acknowl-edge that this impact does exist and can be notable in some cases. As more and more education abroad provid-ers strive to set up programs overseas, especially in the developing world, it is imperative that we consider more systematically host culture impact as a factor in shap-ing program placement and implementation choices. To date, this area has received little systematic research and attention from the education abroad community.

Another slant on program impact has to do with knowledge generation and the validity accorded to di-verse modes of learning and instruction. One of the most eye-opening aspects of an education abroad ex-perience for many par-ticipants is realizing how different educational systems and pedagogi-cal styles may be from what they were accus-tomed to in the United States. However, implicit in many of education abroad programs is the assumption that what has been learned abroad has to somehow match what the sending school offers. Might it not be more enriching for all to consider how to facilitate a reciprocal dialog and discussion be-tween sending campuses and host country scholars and academics engaged with the program, rather than trying to fit the overseas learning experiences “more or less” into the sending schools’ curriculum?

Looking Toward Globally Responsible Education Abroad

How we respond to these cross currents blowing through education abroad these days will profoundly im-pact how education abroad evolves in the upcoming de-cade, and beyond. We have now circled back to the issue raised at the start of this article, which is a call for discus-sion concerning what globally responsible study abroad should encompass. As a tentative first step, let me posit some general tenets for consideration.

1. Expand the Education Abroad Community

Globally responsible education abroad needs to con-sciously incorporate more host nationals into the inter-national education fold. The collective “we” of education abroad should encompass all those who collaborate with education abroad. To accomplish this, U.S.-based international education professional organizations and structures should strive for greater inclusion in their membership base as well as in their research agendas. Ad-ditionally, the current dialog around standards needs to incorporate standards that deal not only with what pro-grams should provide to the participants but also how ed-ucation abroad programs should function en sitio. Host

country standards should include, at a minimum, the stipulation that permanent education abroad programs overseas need to be legally compliant. They should also incorporate consideration of education abroad program impact in regards to both program setup and delivery.

2. Consider Fair Trade Policies Regarding Education Abroad Funds

Globally responsible education abroad needs also to en-compass the financial implications of education abroad programming. Education abroad programs are usu-ally moneymaking ventures for the program providers, whatever other intentions might also be involved. In fact, education abroad is a business that is getting larger, more lucrative and more competitive all the time. What do these financial realities imply for those of us engaged in education abroad, both stateside and at program lo-cales scattered around the world? If producers of prod-ucts such as coffee and cocoa are flaunting their ethical practices of reinvesting a portion of their profits in host country projects, should we consider similar policies in

If producers of coffee and cocoa are flaunting their ethical practices of reinvesting in host country projects, should we consider similar policies in education abroad?


education abroad?

Whatever the overall position of the education abroad community in the United States will be around this con-troversial issue in the upcoming period, it is quite likely that there will be an increasing number of requests for such “reinvestment” and/or “reciprocity” from host coun-try collaborators as they become more experienced and knowledgeable in dealing with U.S. education abroad program providers, and as demand expands for educa-tion abroad opportunities around the world.

3. Reinforce Education Abroad Experience Outcomes

Globally responsible education abroad should push all of us to acknowledge in word and deed our mutual privi-leges and responsibilities to one other as members of a large network that includes education abroad providers, sending colleges and universities, in-country collabora-tors as well as program participants themselves. Educa-tion abroad students need to be made more aware of the real privilege their experience implies, and pushed to consider the responsibilities inherent in such privilege. This might include yet another slant on why culturally appropriate behavior is so critical when engaging in edu-cation abroad as well as more specific activities such as encouraging education abroad students to engage not only in community welfare projects and service learning while abroad, but to also do so in their local communi-ties upon returning back to the United States. In fact, several sponsoring nonprofit organizations abroad have now made student commitment to working in the Unit-ed States in a similar capacity upon their return a condi-tion of accepting them in country.

Parting Thoughts

These rather tentative guidelines need to be taken up and further developed by committed individuals based both “in the field” and the United States, bringing to-gether voices and perspectives from both sides of the education abroad program cycle. Articulating and imple-menting a conscious practice of globally responsible edu-cation abroad stands to benefit all of us, whatever our connection to education abroad may be. As more people become involved in education abroad and demands for

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programs and internships continue to expand, it be-hooves us as committed global citizens to ensure that we are carrying out our work in a way that is responsible to all parties involved. The implications extend beyond the circle of education abroad participants and contributors, for their decisions will play a role in shaping the future development of international education and, in a broader sense, the global community.

Copyright 2006. Reprinted with permission of NAFSA: Association of International Educators. This article originally appeared in International Educator, NAFSA’s bimonthly magazine, in the November/December 2006 issue. For more infor-mation about International Educator, please visit www.nafsa.org/ie.

Globally Responsible Study Abroad...

17Winter 2007

Focus on: Managing Time Differencesby Erran Carmel and Alberto Espinosa

Sitting here in Washington, India is 10.5 hours away. I am stuck on a difficult problem with the proj-ect, so I write an email. Then the delay begins. My colleague, in India, asks for clarification the next day and then she has to wait. I clarify the following day. Then I wait.

The problems posed by time zones are inherently not solvable. Human beings work during the day-light hours and sleep at night. Ironically, because of expectations of instant global communication, time differences have become a principal obstacle to effi-cient coordination across distances. We have found that experienced global workers have strategies to deal with this and we share them here.

Synchronous Strategies

Time-shifting work hours increases overlap. For ex-ample, European staff may start late and work late, in order to create overlap with their American coun-terparts. Conversely, the Americans may start early, perhaps every day, but on at least some weekdays, in order to expand the overlap time with Europe.

Time-shifting solves some of the problems associ-ated with temporal differences, but it can also create others. For example, one multi-site team we studied spanned seven time zones. This required so much time-shifting that the co-located teammates in the home location never saw each other!

Asynchronous Strategies

A silver lining of time differences is that workers gain “quiet time” conducive to reflection and productivity. There are fewer telephone calls, meetings and instant message requests. This seems to work well for simple, routine tasks.

We found that because of lack of overlap talk time, the tasks that global workers perform need to be formalized. Workers try to craft messages so that the text conveys information unambiguously so that there will not be a need for clarification.

Awareness Strategies

Newer team members are often unfamiliar with work-ing across time zones and require mentoring. They are not used to computing the direction of the time differ-ence (“Is it +7 hours or -7 hours?”). A simple tactic is to post hours and time differences on the common team web site.

Other Strategies

An important skill is knowing when to break the “e-mail chain” that begins when one worker sends a message and the receiver, on the other side of the globe, asks for clarification. The next day, the sender responds... and so on until an entire week has gone by. Experienced global-ists stop this chain early by picking up the phone or find-ing another real-time communication method to clarify the message.

Other popular practices are very effective but often in-volve “heroics” that can cause team burnout. These in-clude: being available around the clock, carrying mobile communication devices at all time and frequent travel to resolve critical issues.

The strategies outlined above offer a place to start when confronting time zone differences in global projects and teams.

Erran Carmel is Associate Professor of Infor-mation Technology and Alberto Espinosa is As-sistant Professor of Information Technology at the Kogod School of Business at American University.


Cultural Competence in Health Careby Ursula Leitzmann

Ursula Leitzmann serves as manager for Train-ing and Development at IOR Global Services in Northbrook, Illinois. She has conducted inter-cultural communication seminars and diversity training programs for the National Institutes of Health.

During the past decade, the health care system in the United States has experienced significant changes. Health care institutions face increas-

ingly severe economic pressures and health care consum-ers are becoming more value conscious. Hospital ratings, based on patient satisfaction surveys, are forcing hospitals to think more like retailers and re-evaluate their relation-ship with their patient population as well as with their medical staff.

At the same time, the demographic characteristics of the United States are rapidly changing, with the number of minority groups steadily increasing. As a result, both the provider and patient populations have become in-creasingly diverse. American providers see patients from a broad range of socio-cultural backgrounds on a daily basis. Likewise, nurses, administrators and doctors from varied cultural backgrounds serve American patients. Cultural competence is therefore an indispensable ingre-dient in delivering appropriate and culturally sensitive health care.

Background

The concepts of health, the body and acceptable medi-cal practices vary considerably from culture to culture. For example, western patients and practitioners tend to see the body as consisting of individual organs or sys-tems (cardiovascular, reproductive, skeletal, etc.) that can be replaced or repaired by surgery without threaten-ing our survival. In stark contrast, the eastern view, as embodied in traditional Chinese medicine, conceptual-izes the body’s organs as integrated symbolic links to the universe. Invisible energy channels—meridians—are re-sponsible for the vital energy flow in the body and if they are blocked, (somatic) illness might result. Acupuncture is an example of a treatment that is based on such a view

of the body. Fine needles are applied to specific anatomic points in the body to balance the movement of energy (qi) and to restore health. The eastern holistic approach of symbolic mapping of the human body differs mark-edly from the scientifically-rooted medicine taught and practiced in western societies.

Cultural groups throughout the world have unique health care beliefs and practices which are rooted in early childhood. People learn how to label their experience of illness, how to express their conditions and make the dis-tinction between normal and abnormal states. The health beliefs and linguistic needs of clients with a cultural im-print different from that of their providers may affect the diagnosis, treatment and overall health outcome. The ability to provide quality care thus depends on the skill of the provider in communicating effectively with patients from diverse cultural backgrounds.

Cultural Competence in Health Care

A culturally competent health care professional will fol-low the principles of patient-centered care, exploring a patient’s values, needs and preferences while striving to reconcile them with institutional demands and existing health care practices. Although it might not always be possible to comply with the patient’s wishes—such as taking the placenta home after giving birth in order to bury it under the bed for good luck, a tradition found among the Hmong population of Laos—knowledge of those practices provides opportunity for learning, empa-thy and understanding.

Ideally, medical interventions will follow the United States Department of Health and Human Services’ CLAS (National Standards for Culturally and Linguistically Ap-propriate Services in Health Care). The Office of Minor-ity Health at HHS has developed fourteen standards, which serve primarily as recommendations for health care management organizations but are also aimed at health care providers (see box on p. 20 –Ed.). The stan-dards revolve around three themes: culturally competent care, access to language services, and organizational sup-port to implement the recommendations.

One CLAS recommendation involves access to inter-

19Winter 2007

preters for clients who don’t speak English well enough to understand and follow prescribed treatment. The crucial role of language is made clear by the following incident: A Latin American patient with poor English language skills was admitted to a hospital emergency room. An in-terpreter helped clarify the nature of the emergency. The instructions on the medicine read, “take once every day,” indicating that the patient was supposed to take one tab-let per day. However, in Spanish, “once” means eleven, so he took the prescribed dose eleven times in one day, which caused a severe reaction resulting in his visit to the ER.

Ideally, the cultural make-up of the provider popula-tion should reflect that of the patient population. Any mismatch may cause dissatisfaction among both groups as the patients don’t feel they are well cared-for and pro-viders may not feel appreciated. This can result in a poor evaluation in a patient satisfaction survey, affecting the popularity of a hospital and leading to a decline in pa-tients.

On the clinical level, educational and training inter-ventions are recommended in the CLAS standards to improve provider-client encounters in diverse and mul-ticultural health care organizations. It is well researched (by J. Betancourt, among others) that effective commu-nication leads to increased patient satisfaction, which in turn has positive effects on patient compliance and mea-surable improvements in health outcomes.

Examples of Patient-Provider Cultural Encounters

“Have you taken your medication?” might elicit a nod and a “Yes, doctor” across most cultures. In a culture with a pervasive direct communication style, the mean-ing is in the words and the patient has indeed taken the medicine. In contrast, in cultures with indirect commu-nication styles, the meaning is in the context and the pa-tient’s answer is an acknowledgment of what the doctor said, maintaining harmony and respect. Thus the cultural translation might read more like, “Yes, doctor, I have not taken the medicine.”

The degree to which emotional expression is tolerable may also vary significantly across cultures. Consider the

case of a patient from Mexico who suffered from multi-ple bone fractures following a car accident. He repeatedly summoned the German nurse to his bedside, moaning and complaining about his pain. The nurse became in-creasingly stern, frustrated and angered by his “needy” demeanor. What is the cultural rationale behind this con-flict? Being stoic and strong when ill is a common Ger-man trait that is instilled at a very young age. Therefore, the nurse treated her patient in an unemotional manner, which she considered to be appropriate. She discredited his behavior as weak and became increasingly emotion-ally restrained as he became more and more emotionally expressive. To articulate pain openly is a common be-havioral trait in Mexico and pampering the patient is a sign of good care and humane concern. In the example, the patient felt lonely and not well cared-for because the emotional component of the care was missing. Once the nurse understood the cultural roots of his behavior she attended to his needs in a more personal manner.

Additional Cultural Causes for Disparities in Health Care

Besides the examples above, explaining how verbal communication styles differences can potentially affect patient-provider relationships, non-verbal behavior pat-terns, such as facial expressions, touching, physical pos-tures and hand gestures are also culturally-bound and hold different meaning attributions that may lead to mis-understandings. For example, signaling with the right in-dex finger to come closer is used in the Philippines only with animals and thus may be perceived as a personal offense if used to summon a person.

Other examples relate to the role of family and author-ity. Who makes the decisions pertaining to the patient’s treatment? In individualistic cultures such as the United States, it is expected that an adult patient is the sole de-cision maker. In relationship-oriented cultures, particu-larly in rural areas, often the head of the family negotiates the treatment. Similar patterns hold true when it comes to disclosure of bad news. Should the patient be told the full truth about the diagnosis? Whereas this is often considered best practice in many individualistic cultures, there are many collectivistic cultures, such as Italy, Japan, or Middle Eastern cultures where relatives insist that care-


The Office of Minority Health at the U.S. Depart-ment of Health and Human Services has developed fourteen standards, which serve primarily as recom-mendations for health care management organiza-tions but are also aimed at health care providers. The standards revolve around three themes: culturally competent care, access to language services, and or-ganizational support to implement the recommen-dations.

• • •

1. Health care organizations should ensure that patients/consumers receive from all staff mem-bers effective, understandable, and respectful care that is provided in a manner compatible with their cultural health beliefs and practices and preferred language.

2. Health care organizations should imple-ment strategies to recruit, retain, and promote at all levels of the organization a diverse staff and leadership that are representative of the demo-graphic characteristics of the service area.

3. Health care organizations should ensure that staff at all levels and across all disciplines receive ongoing education and training in culturally and linguistically appropriate service delivery.

4. Health care organizations must offer and provide language assistance services, including bilingual staff and interpreter services, at no cost to each patient/consumer with limited English proficiency at all points of contact, in a timely manner during all hours of operation.

5. Health care organizations must provide to patients/consumers in their preferred language both verbal offers and written notices inform-ing them of their right to receive language as-sistance services.

6. Health care organizations must assure the competence of language assistance provided to limited English proficient patients/consumers by interpreters and bilingual staff. Family and friends should not be used to provide interpreta-tion services (except on request by the patient/consumer).

7. Health care organizations must make avail-able easily understood patient-related materials and post signage in the languages of the com-monly encountered groups and/or groups repre-sented in the service area.

8. Health care organizations should develop, implement, and promote a written strategic plan that outlines clear goals, policies, operational plans, and management accountability/oversight mechanisms to provide culturally and linguisti-cally appropriate services.

9. Health care organizations should conduct initial and ongoing organizational self-assess-ments of CLAS-related activities and are en-couraged to integrate cultural and linguistic competence-related measures into their internal audits, performance improvement programs, patient satisfaction assessments, and outcomes-based evaluations.

10. Health care organizations should ensure that data on the individual patient’s/consumer’s race, ethnicity, and spoken and written language are collected in health records, integrated into the organization’s management information systems, and periodically updated.

11. Health care organizations should maintain a current demographic, cultural, and epidemio-logical profile of the community as well as a needs assessment to accurately plan for and implement services that respond to the cultural and linguis-tic characteristics of the service area.

National Standards for Culturally and LinguisticallyAppropriate Services in Health Care

21Winter 2007

givers not disclose the diagnosis to the patient, as they are convinced that doing so would negatively affect his or her health outcome.

Conclusion

There is a growing need for cultural competence in health care order to provide optimal care for diverse pa-tient populations. Once health care providers understand their own perceptional frameworks and gain further in-sights into the frameworks of the cultures they are serv-ing, they will be much better able to achieve the goal of providing high-quality care to all patients. In the words of Sir William Osler: “It is much more important to know what sort of a patient has a disease than what sort of disease a patient has.”

12. Health care organizations should devel-op participatory, collaborative partnerships with communities and utilize a variety of formal and informal mechanisms to facilitate community and patient/consumer involve-ment in designing and implementing CLAS-related activities.

13. Health care organizations should ensure that conflict and grievance resolution pro-cesses are culturally and linguistically sensi-tive and capable of identifying, preventing, and resolving cross-cultural conflicts or com-plaints by patients/consumers.

14. Health care organizations are encour-aged to regularly make available to the pub-lic information about their progress and successful innovations in implementing the CLAS standards and to provide public notice in their communities about the availability of this information.

Source: US Department of Health and Hu-man Services, Office of Minority Health http://www.omhrc.gov/clas/ (emphasis added)

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it was so difficult. Things like su-do-ku or crossword puzzles that require mental concentration very different from what you are doing are very useful. Using tools like these is taking care of yourself intellectually.

Taking care of your spirit, however you do that, wheth-er it is through family, church, meditation… is very im-portant. So: spiritual, physical, intellectual and fun. And the last thing is perseverance. Those are my lessons [in crisis leadership].

IMQ: Did those thoughts crystallize in time for you to bring to them to your post as ambassador in Guatemala?

PB: Oh no, they crystallized two weeks ago (laughs). I’ve been talking a lot and doing a lot of research and I think I have it down now.

IMQ: I have one last question. It goes back to Rwanda but it could be applied anywhere. You said that the ques-tion for the State Department shouldn’t have been, “How do we stop the violence?” but rather “How do we save lives?” The difference between the two is subtle, but very important. Lots of organizations face situations where, in hindsight, it is clear that they were asking the wrong questions. Do you have thoughts about how organiza-tions can avoid that sort of mistake?

PB: I think changing the prism is really important.

I have come to the conclusion since I left public ser-vice a year and a half ago that it is absolute folly to focus on conflict resolution. What we need to do is focus on developing peace, because as long as you’re dealing with conflict, you’re dealing with the so-and-sos with the guns and everyone else is marginalized. What if you dealt with everybody else? What if you picked up the phone and called the mother of these—sometimes—little boys and said, “Take your child and put him in the corner and take his gun away. And no, we’re not going to take him to a five-star hotel [for negotiations] and wine and dine him until he’s up to going and slaughtering more people” in Darfur or wherever it is. So it’s that: change in your prism.

IMQ: Well, we started with the wrong glasses and end-ed up with the need for a new prism. Thanks for talking

with me.

PB: Thank you.

Prudence Bushnell...continued from page 9

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