Promoting skill-building in cultural competence: A must for paediatricians who care for socially vulnerable populations

Abstract

The demographics of Canadian society have evolved significantly over the past 40 years. The switch in immigration policy from a geopolitical quota-based system to a points-based system of immigration in the mid-1960s has contributed to an unprecedented cultural and ethnic diversity in this country. There is increasing recognition among health science educators that there is a specific skill set that tomorrow’s (and today’s) health care professionals will require to practice effectively in this exciting new reality. Canada’s largest city, Toronto, Ontario, is second in the world after Miami (USA) in having the largest number of foreign-born residents on earth (43.7% at the 2001 census; the geographical origins of Toronto’s foreign-born are much more diverse than in Miami) (1). Immigration has contributed to the significant cultural diversity that exists in all major urban centres in Canada, and newly arrived Canadians are often faced with downward mobility that increases the risk of marginalization through poverty (30% of immigrants versus 21.6% of all Canadians were living below the poverty line in 1995) (2). Canada’s First Nations peoples represent another important, culturally diverse and severely marginalized population. Significant and discouraging health status disparities are well-documented among these diverse cultural groups (reviewed and referenced below). These populations are not only affected by geographical isolation, but also by chronic poverty, under- or unemployment, substance use and abuse, and limited opportunities for education and social advancement (to give but a few examples of observed social determinants of health among Aboriginal populations in Canada) (3). It is, thus, important to recognize that the efficacious medical practitioner who cares for populations that are socially vulnerable and marginalized by poverty needs competence in caring for patients from a diverse set of backgrounds, including cultural and socioeconomic diversity. As paediatricians, we have long recognized that children fundamentally exist within the context of a family and a community, and that practicing effectively in the care of children means incorporating these realities into therapeutic decision-making. If we are to train tomorrow’s paediatricians to care and advocate for Canada’s most vulnerable children and to view working toward eliminating health care delivery biases as a part of the social accountability of the profession, we will need to promote the development of skills in negotiating culture in the clinical encounter, as well as an understanding of broader issues, such as discrimination and bias, in the way health care is experienced by marginalized populations such as our oldest (First Nations) and newest (recently arrived Canadians) cultural groups.