Where Is the Line Drawn? a Difficulty in Cross-Cultural Health Care

She brought her mom in that morning. Her mother was in her 40s, pregnant, and although her face looked pained, she was complaining of feeling very weak. But being the relatively small township clinic that we were, we couldn’t do anything for her, and we told her this. Her daughter would have to take her to the nearest maternity hospital, not terribly far away, but by no means close. Nurses Announcements Archive Article

Where Is the Line Drawn? a Difficulty in Cross-Cultural Health Care

For whatever reason, they didn't go, because within a couple hours the sick woman was called into the room where I was assisting one of the nurses. Her daughter, in her early 20s, followed. The weakened woman, in her second term of pregnancy, was also HIV positive. On any other day the HIV nurse would have seen her, but on this particular day, Ivy* (the HIV nurse) was busy filling in for the absent pharmacist. This left her in the care of Linde*, a nurse as unpredictable as Cape Town's summer winds.

Her diagnosis of the patient was in no way said in a thoughtful or empathetic manner. Per usual, it was said in a rather belittling tone, "Mommy, the reason you are feeling so sick, and so weak, is because of your HIV, you have had it for a while, but now there is much more HIV in your body. Okay?" The daughter, whose dark facial features were covered with a visible yet translucent layer of white paint, was sitting on the bedside footstool, and her posture seemed to shrink as Sister Linde spoke.

Linde left to consult with Ivy, and I was momentarily left alone with the two women. The only exchanging of words occurred between the mother and her daughter. They spoke in Xhosa, which to the best of my knowledge-explained the painted white face. Their speech was almost at a whisper and succumbed to the return of Sister Linde.

"Mommy, why did you go and get pregnant if you knew you were positive?" she asked while rounding the corner. I was wearing a mask, which would have hidden my dropped jaw, but not the rest of my body, which went from being somewhat relaxed to frozen and tense. As much (or as little) as I knew about HIV care, there was not one part of me that could make sense of her words or her motive for that matter. "Who is going to take care of this baby?" she said to the mother, "You?" But before waiting for an answer she turned to the daughter, "Who is going to take care of this baby? Are you?" The daughter's gaze had moved to the floor tiles, one could only imagine what was going through her mind. The conversation in the room consisted only of Linde's seemingly heartless and nagging questions. "Why are you cross, sissy?" She said to the daughter, "Are you cross at me?" With her head held in her hands, the young woman let out the slightest "no."

"So you're cross at your mommy?" Linde continued. The paint around the young woman's face was cracked, but tears had made their way to her chin, where they collected bits of white pigment before dropping to the floor below. Her questions weren't completely uncalled for; however, the implications paired with them were. She was giving them a false death sentence, especially considering the fact that the women had never been treated for HIV before. She could start antiretroviral medication now that her CD4 count had fallen below 200 and expect to live many more years if all went well. But this wasn't the message that was being conveyed.

When Linde left the room for the second time, every bone in my body was jumping at the opportunity to reverse the bleak prognosis. But I wasn't a counselor, a pharmacist, or even a legitimate nurse. I was a volunteer-a student-so I stepped back from the line that I was about to cross. There was an entire team that would be helping this woman, educating her about her treatment, and encouraging her to stay compliant. They were the professionals, not me.

At the same time, considering the treatment they just received, what was there to convince them to return to the clinic? With that in mind, I reached for a box of tissues and handed it to the daughter. She looked up just enough to grab a handful of tissue. The mother had assumed a similar solemn disposition and had her head hung low, in the direction of her folded hands that rested in her lap.

"I know...I know that some of the nurses may seem..." I started in and then paused. She nodded. "Have you met the HIV nurse yet?" I asked in the nicest way I could. She shook her head. I had been working primarily with Ivy the past few months, and I admired her daily for her sincere kindness toward each and every patient.

Acknowledging the language difference, I said to them the little that I could, "uShe umnandi. She's very nice." Amazingly, at that moment no communication barriers seemed to exist. The daughter looked up at me, and while whipping away the last of her tears she gave me a subtle yet most assuring nod, "Enkosi...thank you."

*Names have been changed to protect privacy

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Specializes in trauma, ortho, burns, plastic surgery.

Very touching story sweety! Thanks so much for sharing!

Specializes in IMCU.

I sure hope Linde learns something from someone. How ignorant and hurtful. Bless you! You truely have the heart of a nurse.


Specializes in Psych, Psych and more Psych.

What a beautifully written piece!

Specializes in OB, HH, ADMIN, IC, ED, QI.

My best friend from Nursing School in Montreal, Canada married a South African man and lived there for over 30 years.

We were discussing racial problems in South Africa that she described, and I said,"good education is the answer". She answered, "you don't understand that our people are like children". In a withering tone of voice, I responded, "You know better than that!"

I visited her in Capetown, before aparteid was vanquished, while her new home was being renovated and we stayed in their rented apartment. They had a worker from their ostrich farm in the rural area where they had resided previously, to help around the house. His papers weren't obtained that allowed him to be there, so they locked him in a space without a bathroom that had dirt "floors" under their new house at night, saying, "If he was free to roam the streets, he would be in trouble without his papers". It wasn't his responsibility to get them...... it was theirs!

Then I asked one day, where there was a laundromat so that I could do my laundry, and my friend said, "He's over there". I cried and said again, "you know better than that!", while realising that her assimilation into that country's ways was complete.

Then I moved to Virginia in the USA many years later, and worked as a supervisor in a Home Health agency where I was told, "They can't learn", as I taught charting to African American Nurses' Aides. 6 months later, their charting brought compliments from company auditors. I was told that my hours were being diminished, by the supervisor, who added, "now they'll want more money!"

With President Barack Obama at the helm of our country, bigots will eat their words! What a wonderful presence he has, and great intelligence. Intolerance is caused by ignorance, and has no place in any society. Yet it lingers as some wait for any indication that he isn't perfect. There is a smug saying that a sign was placed in the White House (would that it could be painted another color) that states: "NO WALKING ON WATER". He doesn't have to do that.......


This sounds more like a ..... good example of what not to do than cross cultural nursing. Were the nurse and the patient of the same culture? Even if they were, I don't think that it would have mattered. Nurses, from any culture, simply should not treat patients that way. From the article I understand that this was a problem with an individual nurse and not necessarily a problem with nurses in general at the clinic. I do not envy you being in that position (having to watch the cruelty with no authority to intervene).

Thank you for sharing.



The President's skin colour has nothing to do with anyone "eating their words". Bigots of all stripes and hues (Joseph Lowery's benediction for example) will simply continue to live on in denial. It's not about how he looks, it's about what he says and what he has done so far in government. As for intolerance, I agree completely with you concerning intolerance based on appearance, but intolerance of certain actions or attitudes is not only good, it is necessary in any society. Like anything else, discretion and moral discrimination are key to maintaining a functional society. Jim Crow has no place in today's America. As for your "friend"... well... some friendships we have to let go for good reasons.


So shines a small act of kindness in a dark world. You remind us that we don't need the "legitimacy" of a license to show compassion.

Specializes in OB, HH, ADMIN, IC, ED, QI.

451F:quote "intolerance of certain actions or attitudes is not only good, it is necessary in any society. Like anything else, discretion and moral discrimination are key to maintaining a functional society. "

I sure don't understand how the above relates to my post!

Being intolerant means "unwilling to endure" according to my huge Random House dictionary. Isn't it better to find common grounds of agreement, and then investigate ways to "endure" differences, starting with those things that are agreed? Accepting what is, simply because that's the situation, is what sponsored Jim Crow laws!

Functional societies rely on similarities, rather than discretion ("the power or right to decide or act according to one's own judgement")and discrimination ("treatment or making a distinction in favor of or against a person or thing based on the group,class or category to which that person or thing belongs rather than on individual merit"). It is dysfunctional of any society to discriminate or exercise discretion, as that promotes inequality, which contradicts America's constitution.

I don't have the American constitution handy at the moment, but the pledge of allegiance has in it, "one nation with liberty and justice for all". Those who composed that and the constitution came from places where inequality reigned, and they wished to live better than that.

what a gift of grace that you were there at the right time and right place,when cruelty is at issue there is no line to cross,we all have permission and a moral duty to stop it or mitigate its effects