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  • Writer's pictureH. M. Truog

Being A Culturally Competent OT in a Historically Racist System of Healthcare

Updated: Sep 26, 2021

The conversation about racial and ethnic disparities in the United States health system is enormously relevant in the current climate of outrage and fear. It is impossible to ignore the tidal outpour of individuals, communities, and organizations demanding change, begging for help – but above all else, simply calling for awareness.

Let’s begin with awareness.

As a healthcare community, and as contributing members of that established healthcare industry, how aware are we of what is transpiring within our own ‘home turf’?

I am writing these words after reflecting deeply on what it means to be in this authoritative role as a ‘healthcare provider’ – because whether we see ourselves in this light or not, we are. We have authority over our patients in the care we deliver, and as participating members of larger organizations. We are all accountable to the American Occupational Therapy Association (or to whichever national governing body you may affiliate with) to both represent the agenda and cultural values of the organization, and to demand progress in areas that we see are lacking.

Am I doing enough as an OT?

The American Occupational Therapy Association issued a formal Statement on Justice and Systemic Racism on May 31st, 2020. In this statement, they declare, “We acknowledge and condemn the multifaceted aspects of systemic racism and oppression”…”Justice is a core value of occupational therapy and the responsibility of all practitioners,” and “…we must endeavor to eliminate occupational injustice, occupational alienation, and occupational deprivation. Equity, inclusion, and diversity is a critical pillar of our Vision.”

These are wonderful sentiments. And I am happy to call myself a member of this organization, who takes a stand on these topics and speaks to the value of what we as a profession have to offer in this movement for systemic change. But I always find myself coming back to the same question… aside from saying the right things, are we, as a profession, doingthe right things.

According to [the famous] Immanuel Kant’s philosophical take on moral ethics: non-maleficence is not synonymous withbeneficence. Translation: doing ‘no-harm’ does not equal ‘doing good’…. Or, more colloquially… simply not being a shitty person does not qualify you as a good person.

And this is where my mind keeps coming back to. Have I DONE enough? Or… anything? Have I actually done a damn thing to HELP – or have I (like so many others) simply held tight to the knowledge that I am not a ‘bad person,’ I am not a 'hateful racist’… but…. Am I actually (truly) an ally?

I can do more. I can absolutely be doing more.

Women’s health equality is synonymous with racial equality – and it’s a double-fronted battle for women of color.

Much of my professional voice is utilized in speaking to the importance of advancing awareness and care pertaining to women’s health topics. I, as a therapist, as a woman, and as a member of my national community, feel deeply that we, occupational therapists, have a role to play in advancing the health outcomes of the girls and women within our communities – but to ignore the disparities of race and ethnicity in that campaign would be drastically negligent. Racial and ethnic inequality within the healthcare system is rampant. The health disparities of women of color absolutely cannot go unaddressed if we are going to achieve better outcomes for women as a whole.

In this regard, I can absolutely be doing more. I can emphasize in my research, my writing, and in every platform of my professional practice – black lives not only matter… they need us to do more than ‘not be a shitty person’… they need us to do good. Do better. Do more.

Our entire healthcare system needs to be doing more. We, as an institution of care, have a long way to go. The gap is enormous.

Looking back in order to look forward…

I want to underscore two historically relevant texts that highlight the breadth and depth pertaining to the gap in our healthcare industry on the topic of race and ethnicity:

The first is the initial acknowledgment by the United States federal government of the existence of racial and ethnic health disparities in morbidity, mortality, and many indicators of health for African Americans, Native Americans, Hispanics, and Asians/Pacific Islanders:

Report of the Secretary’s Task Force on Black and Minority Health (Heckler, 1985).

The second, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, published by the Institutes of Medicine (IOM; 2003) in follow-up and response to this revelation.

It has only been since the (then) shocking 1985 report that requisite data collection upon black and minority members of the population has been undertaken. And, as all other aspects of care, data recording of these populations are rife with disparities and subsequent inaccuracies.

The 2003 report by the IOM outlines a historical anthology of origins and evolution of inequities and bias in western and U.S. healthcare and health systems, spanning from ancient origins; the Middle Ages; the Renaissance; the Age of Science and Enlightenment; the Civil War; the Reconstruction, Gilded Age, and “Progressive” Eras; the Early 20th Century; the Great Depression and World War II; Groundwork for Civil Rights in Healthcare; a Civil Rights Era in Healthcare; a Retrenchment Era in Healthcare; Failed Reform and Corporate Takeover; to a Health System Shedding Some Negative Aspects of Its Past?.

This report provides insights and analysis that articulates the deep roots of American racial and ethnic health and healthcare disparities that span over 2,000 years. Read it.

The American federal government has only acknowledged the existence of a problem pertaining to these racial and ethnic disparities in the most recent 35 years!

On the path of increasing awareness, aiding in efforts to advocate for and promote change, and achieve systemic outcomes at the organizational levels – we are in our relative infancy. Thirty-five years is so very little in the over 2,000-year history of systemic racial and ethnic inequality within the sphere of medicine.

The fight for equality is happening NOW.

The generation of our predecessors collected the information, presented it to the general population, and demanded a call to action. It has taken over three decades to build upon, expound upon, and articulate clearly through the qualitative and quantitative research the complex facets of this systemic injustice.

If we wish to further the efforts of those who came before us, we must act upon the information that we now have at our disposal. We must seek solutions and implement strategies for change at a system-wide level.

This is not solely necessary at the institutional level of the American healthcare system – but broadly across the nation. The 2013 U. S. census indicated that of the United States population 316,128,839, the ‘white majority’ accounted for 77.7%. But statistical growth in minority groups projects that the days of ‘white majority’ are coming to an end.

In the next 50 years, the U.S. is projected to be a plurality nation, where the non-Hispanic white population will be the largest single group, but no group will be in the majority.

Cultural competency and health equality is imperative.

Seeking ‘Cultural Competency’ as a Healthcare Provider…

What exactly does this mean?

The American Hospital Association – which provides a published guideline – articulates,

Cultural competency in health care describes the ability of systems to provide care to patients with diverse values, beliefs and behaviors, including the tailoring of health care delivery to meet patients' social, cultural and linguistic needs. A culturally competent health care system is one that acknowledges the importance of culture, incorporates the assessment of cross-cultural relations, recognizes the potential impact of cultural differences, expands cultural knowledge, and adapts services to meet culturally unique needs.”

Understanding how to create a culturally competent organization begins first by acknowledging that there is a need to implement change. And I firmly believe that this must be initiated with an honest and authentic look inward.

Changes at the micro-level (the individual) must always be addressed synonymously with the macro-level (the organization).

We all have biases.

The field of social psychology posits that “stereotyping is an almost universal human cognitive function,” and that it occurs automatically, has been shaped and reinforced unconsciously by society, and it undoubtedly shapes our personal interactions producing “self-fulfilling prophecies.” Stereotyping helps people to organize a very complex world, and can give us more confidence in our abilities to understand a situation and respond to it, particularly when we lack information” (IOM, 2002, p.4).

Even healthcare providers who strongly believe that they are ‘not racist’ were found to demonstrate racially and ethnically biased behaviors severely impacting their medical decision making and the course of the patient’s outcomes of care (IOM, 2002).

Be a part of the solution in your healthcare organization.

As a provider, you can investigate what policies and training opportunities are the standards of practice within your specific healthcare organization. If you find that your organization is lacking a comprehensive protocol for educating and reinforcing cultural competency, advocate to your healthcare administrator to look into an established resource for implementation.

Advancing health equity, improving quality, and helping to eliminate disparities in healthcare by establishing a blueprint for organizations to follow is what The National Culturally and Linguistically Appropriate Services (CLAS) Standards strives to accomplish.

Specific for occupational therapists...

For those of us practicing in the United States, the Coalition of Occupational Therapy Advocates for Diversity (COTAD) and the Multicultural, Diversity, and Inclusion (MDI) Network are organizations to familiarize yourself with, follow, and participate in as able. The later provides a published ‘Cultural Competency Tool Kits’ reference for occupational therapists.

Let us not allow the words within the AOTA’s statement on Justice and Social Racism be empty words. Let them be a springboard for action.


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