Cultural competence: what effect on reducing health disparities?

The National Center for Cultural Competence (2000) has linked the cultural competence of researchers and practitioners to the elimination of health disparities among various racial/ethnic groups when compared to Anglo groups in the U.S. In addition there are institutional requirements for cultural competence in providing health care and conducting research. Cultural competence may be a needed component of health care and research, but can we really expect individual practitioners and researchers to have sufficient capacity or scope to eliminate or reduce health disparities by becoming culturally competent? Is there not a societal context to the existence of health disparities that cultural competence alone can not address? These are not new questions. Florence Nightingale’s dilemma during the Crimean War concerned a central problem in public health: What could be done about the unyielding connections among poverty, sickness, and early death (Small, 1998). Nightingale linked the societal conditions of poverty to illness and death and proposed societal options: charity, technology (sanitation), and social change. It has long been recognized that there is a consistent, global relationship between socioeconomic status and health status (World Development Report, 1993). Socioeconomic status operates as a fundamental cause of disease by allowing people with high socioeconomic status to use broadly serviceable resources such as money, power, and knowledge to avoid risks and to minimize the consequences of disease once it occurs (Link & Phelan, 1996). Mann (1998) also recognized the societal context to the taxonomy of health and noted that a lack of resources and power, discrimination, and violations of human rights are primary pathogenic forces in the formation of health disparities. In the context of the AIDS epidemic, Mann and Tarantola (1996) demonstrated that regardless of where and among whom the epidemic began in a given region, the brunt of the epidemic gradually and inexorably turned to those who bear the societal burden of marginalization, stigmatization, discrimination, and poverty. Unfortunately, the identification of poverty and discrimination as important contextual factors for understanding social vulnerability to