My Colorful Neighborhood

This post was first published in February of 2011 – it’s one of my favorites, if only because it gives the reader a colorful picture of where we live!

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It’s a 8 am and I’m a kind of drunk and I want you!” were the words sung to me at Central Square, Cambridge.  The truth is – It was 7:30, he was drunk, and he didn’t want me!

But it brought laughter to my heart and I realize how much I love my colorful neighborhood.

While Harvard Square is full of intellectuals of all ages, brain cells abounding with funky stores,coffee shops, and Out of Town News – Central Square is hardcore life. It is dirtier and grittier with a cross-section of people that defies any stereotype. Recent and older immigrants speaking everything from Amharic and Arabic to Portuguese and Punjabi; every age from infants in strollers to the elderly heading to a community center or the library around the corner; and the sassiest and saltiest homeless people you will ever meet, all converge in Central Square.

If you don’t give money, the homeless population have no problem escorting you to the nearest ATM or looking you up and down with derision and the comment “That’s ok! What goes around comes around!” and you are left feeling cursed.

Central Square T Stop
Central Square T Stop

Maybe the reason I feel so at home in this neighborhood, as opposed to Harvard Square with its sophisticated milieu, or Kendall Square filled with Geeky MIT students and biotech engineers, is that I feel like I am a cross-section of worlds and people. The suburbs stifled me as I felt the need to fit in with beautiful homes and more beautiful people, never quite measuring up to what I perceived as the unspoken expectation.

My past of both Pakistan and Egypt didn’t seem important in the suburbs, but in Central Square it feels like my background belongs. Central Square welcomes me with its imperfection and honesty. There is the ability to feel fully alive and authentic, even as I am serenaded by intoxication at 7:30 am.

With burnt orange, brick-redelectric lime, and hot magenta all mixed together in one place, Central square is like a box of crayons that are primary colors – no pastel pinks, light blues, or pale yellows in sight.

End of Life Care and Cultural Competency

I just finished speaking to a group of medical and nursing students on end of life care and cultural competency.

It’s a big topic.

In health care the two areas where cultural beliefs are profoundly obvious are during birth and during death. In other areas the belief systems are more subtle, the differences not always obvious.

But birth and death? These moments of coming into and going out of the world are rich with tradition, ritual, meaning, and emotion.

The first thing I ask people to do is to think back to their first memory of death in their family or community. Who was it? What were the circumstances of the death? What is their most vivid memory? What rituals and behaviors were observed by the family and/or community?

The answers are fascinating, particularly if it’s a diverse group. There are people who remember all the church bells in the town ringing — they knew someone had died because the bells were ringing at a time when they were usually silent. Others remember wailing waking them during the night. Still others will talk about death being a celebration, a party of sorts.

The important piece is that they talk. Most have never thought about this, let alone processed it in a group. And talking about their experience puts us in the best possible place to continue the discussion.

Because telling their stories helps them realize how significant those moments are, and how critical it is for them to hear the stories of their patients, to be fully present with their patients during the end of their lives.

We move forward into the discussion on the western view of the body as a machine, on how culture affects views of illness, expectations of care, and views of the process of death. We look at possible points of cultural collision – patient autonomy, organ donation, body preparation, the differences in both meaning and expression of pain and so much more.

I usually end the time with a short video telling the true story of a gentleman from Afghanistan named Mohammad Kochi. Mr. Kochi immigrated to the United States with his family and settled in California. At the time of the film he was diagnosed with stomach cancer. The film details some of his care and the disconnect and misunderstandings that occurred, resulting in his refusal of chemotherapy through a pump into his body — ultimately his death because of lack of treatment.

It is sobering and hard to watch. We sit somewhat stunned at the end and there is no gap in conversation.

How could this happen?

So preventable!

Such a misunderstanding!

But these types of cultural misunderstandings occur far too often despite the best of intentions.

There are so many things that come up in conversation, and so much to learn from each other. But we end talking about three areas where we can develop skills.

The first is in self-reflection – How do I react to cultural differences? How do I manage my own reactions? How do I negotiate with patients and families in the face of cultural differences?

The second is active listening Listening to and with the body, listening in with self reflection, listening out by learning from others; listening with the mind by hearing facts and stories; listening with the heart by being willing to hear emotions and feelings.

The third is bearing witnessbeing fully present with the person, letting them know they’re not alone, listening to their stories and their symptoms. 

As is usually the case, I leave contemplative, thinking about life in its entirety, life from birth to death. And I also leave with a renewed resolve to continue developing skills in the areas of self-reflection, active listening, and bearing witness.

Skills not only important in end of life but through all of life. 

Cultural Competency & the FBI

Two months ago in Miami, Florida the FBI raided a mosque and arrested two Imams that had been under surveillance for some time. It is remarkable that most of us had no idea it  happened, and it didn’t seem to fuel any anti-Muslim sentiment elsewhere. When I heard the story I was impressed. Not one to praise the FBI or government in general, it was a moment where I was amazed with the thoughtfulness and cultural awareness with which the raid was carried out. All the evidence points to actions that took into account the larger Muslim community and efforts that were taken to inform and involve this community.

The story goes that the activity of the imams had been watched for some time. When the decision was made that an arrest and questioning was warranted, the FBI consulted with a cultural broker of sorts as to the best time to carry out the raid. It is a large and active mosque with prayers going on five times a day and activities in between. It was decided that a Saturday morning would be the ideal time, at 6am. This ensured the fewest number of people and the least amount of chaos. Second, the officers took off their shoes before going into the mosque. They took the effort, despite the obvious seriousness of the situation to display sensitivity to this need and recognition that this was a place of worship and it was important to abide by the rules of the mosque. Third, they spoke to the imams in Pashto, through a translator. It was their native language so there was no ambiguity about the arrest and no miscommunication because of limited English. The Pashto was clear and precise. Fourth – they waited until the prayers had finished, they did not interrupt but surrounded the mosque waiting. Lastly, before the media had any idea that this had occurred, the spokesperson for the FBI contacted leaders in the Muslim community. The neighborhood surrounding the mosque is heavily populated with Muslims and, while an arrest of a religious leader within any religious community would be difficult, given the current attitudes toward Muslims this is one of most difficult and potentially explosive things that can happen. They wanted the community to have an opportunity to frame a response before a media frenzy began inciting fear of all Muslims as well as assumptions that all in the community were involved in suspicious activities linked to terrorism.

This is all quite remarkable. We have all heard of police violence, FBI gaffes, and abuse of power by people in the role of law enforcement. There are horror stories in other countries as well that include raids, torture, and untold abuse by secret police and intelligence people. Yet in this case, the FBI went above and beyond expectations of cultural competency as they carried out this raid. Just days before the operation many of the officers had attended a training program that gave tools on working in a culturally sensitive way with Arab and Muslim communities.

I am well aware of the often valid criticism that is voiced about decisions of the United States government and the many organizations that fall under the auspices of the government, including the FBI.  But this is a time to be impressed and applaud, not criticize. Almost weekly I work with a colleague presenting workshops in healthcare organizations on how to give culturally responsive care to diverse communities. What amazed me about this story is that an organization with intent to arrest did a far better job communicating across cultural boundaries than many healthcare organizations do with intent to heal.

Bloggers note: You can read or listen to the full story on NPR here.

Acculturation or Assimilation?

“Yet, faced with a man clearly in decline, Mrs. Kirschner seemed unmoved. She found him troubling. Though skilled and vastly experienced, a professional who’d helped thousands of immigrants make the transition from the old world, making the transition had been based on the act of letting goabandoning belief systems that were quaint and out of date in favor of the modern, the new, the progressive ideas that were so uniquely American.

That is what assimilation was all about, yet the overly polite genteleman with the vaguely British accent and the severe limp rejected the notion out of hand.

My father was by no means convinced the values of New York trumped those of Cairo. He couldn’t see abandoning a culture he loved and trusted in favor of one he barely knew, and which he instinctively disliked. He preferred being an “old Egyptian” to a “new American”. He had, in short, no desire whatsoever to assimilate. “We are Arab, madame,” he told Mrs. Kirchner. ” It was a tragic clash of cultures….” from “The Man in the White Sharkskin Suit” p. 207

I quoted from “The Man in the White Sharkskin Suit” in the past in my post “Coats Too Big, Shoes Too Small:Shopping as an Immigrant”. It is by far one of the best books I have read that describes the immigrant experience. The quote above comes from a section in the book describing the family’s arrival in New York and their interactions with a social worker at an agency then called the New York Association for New Americans or NYANA. The cultural clash came between the social worker in charge of the case and Leon, the patriarch of this new immigrant family. I believe the quote captures much of what newcomers feel as they embark on the arduous process of adjusting. I don’t think it is a case of people not wanting to live in the United States so much as the fear that those things with which they disagree or find culturally disturbing will make their way into the fabric of the family and community, threatening to destroy that which they hold dear.

The word assimilation sounds exactly like the meaning. To “become or cause to become similar.” Basically it’s the process minority groups or individuals go through to “absorb” culture and take on the culture of the majority of people. As I think about a multicultural society is that really what I want? What we want? It sounds too robotic and sterile.

Acculturation, by contrast, is when behaviors and attitudes of people are adjusted or shaped as a result of contact with a different culture. There is a hypothesis that at least some cultural equality has to exist between cultures for acculturation to occur. Compare this with assimilation where it is the stronger cultural group that influences and compels people to adopt values rather than modify or integrate values.

In an op-ed piece in today’s edition of the New York Times there is piece called “Assimilation’s Failure, Terrorism’s Rise”.  I found it to be an interesting and provocative piece written by a British writer, Kenan Malik. He begins by looking back at the terrorist attack in Britain on July 7th in 2005 where London’s mass transit system was attacked spreading fear and chaos. He makes the distinction that while America’s 9/11 was the work of an outside terrorist group, 7/7 in London was the work of British citizens and that fact has troubled and confounded authorities.

The writer goes on to talk about multiculturalism and it’s two meanings that are rarely distinguished.  He states  “On one hand, it refers to a society made diverse by mass immigration, and on the other to the policies governments employ to manage such diversity. The failure to distinguish between these meanings has made it easier to use attacks on multiculturalism as a means of blaming minorities for the failure of government policy.”

It is an interesting read and I haven’t figured out what my response to his points are, but as I work with immigrant communities on an almost daily basis, I think acculturation is critical. Assimilation? That continues to be a more difficult and controversial issue.