Between 1979 and 1982, hundreds of physicians, nurses, social workers, and clinic administrators traveled to Miami to attend the Cross-Cultural Training Institute (CCTI). An eight-day intensive course held six times and designed and operated by faculty at the University of Miami’s Psychiatry Department, the CCTI promised to equip trainees with the expertise necessary to treat a multiethnic patient population. Preceding decades had seen rising distrust in medical authority, an outcome of powerful social movements that challenged the institutional sources of health disparities. At the same time, postwar migration patterns altered the ethnic makeup of American cities, and many professionals were struggling to make health care accessible and meaningful to diverse populations. The CCTI, drawing on Miami’s unique multicultural environment as well as years of experiments in cross-cultural care, offered a unique opportunity for health professionals to expand their expertise into the realm of culture.
Trainees checked into their hotel on Friday for a week of work ahead. Saturday featured introductory lectures and group-building exercises, culminating in the “Community Experience” that evening. In small groups, trainees took to the streets—each touring a different neighborhood. Guided by a staff member, they visited landmarks and parks, ate at local restaurants, and dropped into popular bars and lounges to observe and interact with residents “in their natural Saturday night settings.” At around nine at night, they returned to the classroom to discuss what they had seen. The activity was one of several immersive exercises that anchored the training sequence. Sunday, for instance, involved a “Church Experience,” whereas, later on, groups visited residents in their homes to “share the living environment of an inner-city family.”1
The rest of the week consisted of role-playing exercises and lectures by local cultural experts—including anthropologists, health practitioners, community advocates, and folk healers. Activities were designed to help trainees “understand behavior in cultural context,” the exposure making them intimately aware of the unique stresses faced by minority groups, as well as sources of support and healing within their homes and communities. Among the most memorable sessions was one on “alternate healing systems,” in which a Cuban santera and a Bahamian faith healer came to the classroom to present on and demonstrate their ritual healing practices. One trainee described the session as, “Excellent. I was always resistant to…this area of mysticism…I have been reborn!”2
This mix of didactic and experiential activities reflected the CCTI’s peculiar approach to professional development. It aimed to help trainees unlearn aspects of their formal education, gaining knowledge of other health cultures as well as—more importantly—an awareness of their own cultural biases and the shortcomings of mainstream medicine. Trainees reported coming away from the course with “increased professional competence,” having become more “adept” and “effective” in their ability to treat minority clients. In other words, by recognizing the limits of their expertise, they were in fact enhancing their expertise. This seemingly paradoxical logic will sound familiar to those trained in cultural sensitivity in professional curricula today. In both cases, seminars and workshops that aim to foster a set of skills for dealing with cultural diversity also turn humility into a kind of tool for gaining new forms of knowledge and control.
Now, there were issues with the CCTI and what its curriculum implied about cultures of care. For one, while the program figured Miami as a kind of cultural observatory, the city itself was in the midst of unprecedented levels of migration and racial unrest. An influx of Cuban and Haitian refugees, rising crime rates, and civil disturbances over the 1980 acquittal of police officers accused of murdering Black insurance salesman Arthur McDuffie stirred xenophobic fears and interethnic hostility—and, ultimately, the cancellation of the CCTI in May 1980.3 Figured as disruptions, these events in fact revealed a fundamental issue with CCTI: in order for trainees to take away a set of skills that they could implement at their home institutions, the culture in which they were immersed was extricated from local social and political realities. “Culture” has always been abstracted as it is turned into expertise, allowing those who require it to shed the contexts of that acquisition—along with knowledge of the inequities it entailed.4
In the forty years since the CCTI launched, educators have continually promoted the importance of such training, citing the increasing diversity of patient settings. They have also continually debated how exactly to address such issues in curricula. For many years, institutions focused on so-called cultural competency, which figures cultural differences as one more module trainees must master en route to comprehensive expertise. However, many complained of the inadequacies and perhaps unintended consequences of such training, which often devolved to teaching a laundry list of traits about minority groups that reinforced damaging stereotypes. In response, health professional schools have opted instead for “cultural humility”—encouraging professionals to relinquish the idea of expertise, to accept that matters of culture and health are ones they can never fully master.5 Others have promoted teaching “structural competency,” drawing on the institutionalization of cultural competency in medical curricula to demand closer attention to social and economic forces in health care.6
Still, culture becomes an object of expert training: in teaching professionals how not to be an expert, they are able to more skillfully manage their minority patients. As scholars, activists, and educators continue to articulate and debate the value and limits of such curricular reforms, institutions like the CCTI reveal the contradictions underlying the very premise of cultural sensitivity training. And even as such institutions adapt to the times, they risk practicing and promoting an extractive form of expertise that ignores or elides the fraught politics of place. In doing so, we fail to address the structures of power and race that make such training necessary in the first place.
Harriet Lefley, “Cross-Cultural Training for Mental Health Personnel: Final Report to the National Institute of Mental Health (Grant Number 5-124-MH15429)” (Miami: Department of Psychiatry, University of Miami School of Medicine, 1982).
On twentieth-century Miami, see in particular, Nathan D. B. Connolly, A World More Concrete: Real Estate and the Remaking of Jim Crow South Florida (Chicago: University of Chicago Press, 2014); Monika Gosin, The Racial Politics of Division: Interethnic Struggles for Legitimacy in Multicultural Miami (Ithaca, NY: Cornell University Press, 2019). On the cancellation of CCTI, see Rafael Urrutia, telephone interview by author, 20 Feb 2018.
Ruha Benjamin has perceptively critiqued the deployment of “culture” in the health professions. Ruha Benjamin, “Cultura Obscura: Race, Power, and ‘Culture Talk’ in the Health Sciences,” American Journal of Law & Medicine 43 (2017): 225–38. Also see Angela C. Jenks, “What’s the Use of Culture? Health Disparities and the Development of Culturally Competent Care,” in What’s the Use of Race? Modern Governance and the Biology of Difference, eds. David S. Jones and Ian Whitmarsh (Cambridge, MA: MIT Press), 207–24.
Melanie Tervalon and Jann Murry-García, “Cultural Humility Versus Cultural Competence: A Critical Distinction in Defining Physician Training Outcomes in Multicultural Education,” Journal of Health Care for the Poor and Underserved 9, no. 2 (1998): 117–25.
Jonathan M. Metzl and Helena Hansen, “Structural Competency: Theorizing a New Medical Engagement with Stigma and Inequality,” Social Science & Medicine 103 (2014): 126–33.