What should be done when skin color is respected over experience and degrees?
“She’s sick,” a woman says, looking pleadingly into my eyes, and then into the eyes of my colleague Maaike. She is holding a little girl, around three years old. The girl’s name is Pinky, a name that stuck in my mind. The name Pinky sounds happy to me, like it would belong to a smiling, exuberant little girl. Yet the Pinky that sat before me had sad droopy eyes and a large frown. Maaike, a midwife from The Netherlands, had helped me take Pinky’s height, weight, z-score, and MUAC. In the end, she did not meet the criteria for malnutrition. She was in the low-average range, but this did not qualify her to receive any porridge, milk, or RUTF (peanut supplement).
“She’s sick,” the woman repeated. “She’s underweight. She needs food.” It tore my heart knowing we could give her nothing. My American cultural context is one of excess, where extra food and resources are freely doled out. This context made me feel guilty for the clinic’s decision to turn the woman away as she pleaded for food. I consoled my own conscience with the knowledge that Noah’s Ark would provide food for Pinky if she did eventually meet the criteria for malnourishment.
The question now became, how can we comfort the aunt? I noticed that Pinky’s aunt continually voiced her pleas to me and Maaike, even though she could clearly see that Rachel, a Ugandan nurse, was the one making the final decisions about nutrition supplements. I recognized the inherent power imbalance in this situation, with Maaike and me as Caucasians and Rachel as a Ugandan. Rachel has over 10 years of experience with malnutrition patients, while Maaike and I have little to none. So why would anyone come to us instead of Rachel? The answer is power, or rather attributed power.
While Maaike and I had no authority to give Pinky milk and food, we were assumed to have this authority. While we continually told the aunt that Rachel was in charge, she did not believe us, thinking we had power and influence over the situation. Finally, Pinky’s aunt accepted that the “muzungus” (foreigners) were not in charge, although she seemed confused by it.
During my semester studying abroad in Uganda, I was taught to engage in several principles, including the following: “Root out superiority/paternalism and reorient to engage as an equal” (a learning goal from a class handout). The situation I described above involves paternalism because there is an assumed authority or superiority of Caucasian clinicians over Ugandan clinicians. This perception is not primarily the fault of Pinky’s aunt but is a result of years of medical intervention and control by Western physicians. They are the experts, people are told. Westerners will teach you how to practice real medicine. Of course, this is entirely misguided, as illustrated by the story above. Even if Maaike and I were trained physicians, we would still not be the “experts” in this situation. Rachel, with her cultural and professional expertise, was most equipped to handle the woman’s concerns. An insightful article on cultural humility reminds readers of the importance of “respecting the skills and abilities of the local people” (Hockett, Samek, & Headley, 2014). While respecting Rachel and other clinicians, I am encouraging others to respect and elevate their positions as well.
During this outreach, I learned to emphasize the positions of Ugandan health professionals, while stressing my role as a student—nothing more. During the rest of my medical internship in Uganda, I aimed to become more aware of ways in which I unintentionally reenforced Western paternalism in front of patients. Emphasizing the authority of Ugandan clinicians encouraged patients to clearly see who the experts were in the field. This requires good cross-cultural skills, since communicating effectively and respectfully amidst cultural and language differences can be challenging, especially in an emotional situation like the story of Pinky and her aunt.
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