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Sunday, August 25, 2024

Voyages of Christopher Columbus

From Wikipedia, the free encyclopedia
 
The Voyages of Christopher Columbus
Part of the Age of Discovery
The four voyages of Columbus (conjectural)
Date1492, 1493, 1498 & 1502
LocationThe Americas
ParticipantsChristopher Columbus and Castilian crew (among others)
OutcomeEuropean discovery and colonization of the Americas

Between 1492 and 1504, the Italian navigator and explorer Christopher Columbus led four transatlantic maritime expeditions in the name of the Catholic Monarchs of Spain to the Caribbean and to Central and South America. These voyages led to the widespread knowledge of the New World. This breakthrough inaugurated the period known as the Age of Discovery, which saw the colonization of the Americas, a related biological exchange, and trans-Atlantic trade. These events, the effects and consequences of which persist to the present, are often cited as the beginning of the modern era.

Born in the Republic of Genoa, Columbus was a navigator who sailed in search of a westward route to India, China, Japan and the Spice Islands thought to be the East Asian source of spices and other precious oriental goods obtainable only through arduous overland routes. Columbus was partly inspired by 13th-century Italian explorer Marco Polo in his ambition to explore Asia. His initial belief that he had reached "the Indies" has resulted in the name "West Indies" being attached to the Bahamas and the islands of the Caribbean.

At the time of Columbus's voyages, the Americas were inhabited by Indigenous Americans, and Columbus later participated in the beginning of the Spanish conquest of the Americas. Columbus died in 1506, and the next year, the New World was named "America" after Amerigo Vespucci, who realized that it was a unique landmass. The search for a westward route to Asia was completed in 1521, when the Magellan expedition sailed across the Pacific Ocean and reached Southeast Asia, before returning to Europe and completing the first circumnavigation of the world.

Background

Many Europeans of Columbus's day assumed that a single, uninterrupted ocean surrounded Europe, Asia and Africa, although Norse explorers had colonized areas of North America beginning with Greenland c. 986. The Norse maintained a presence in North America for hundreds of years, but contacts between their North American settlements and Europe had all but ceased by the early 15th century.

Until the mid-15th century, Europe enjoyed a safe land passage to China and India—sources of valued goods such as silk, spices, and opiates—under the hegemony of the Mongol Empire (the Pax Mongolica, or Mongol Peace). With the Fall of Constantinople to the Turkish Ottoman Empire in 1453, European countries sought to compete with the Silk Road dominated by the gunpowder empires through expanded use of ocean voyages to scope out and establish new trade routes.

Portugal was the main European power interested in pursuing trade routes overseas, with the neighboring kingdom of Castile—predecessor to Spain—having been somewhat slower to begin exploring the Atlantic because of the land area it had to reconquer from the Moors during the Reconquista. This remained unchanged until the late 15th century, following the dynastic union by marriage of Queen Isabella I of Castile and King Ferdinand II of Aragon (together known as the Catholic Monarchs of Spain) in 1469, and the completion of the Reconquista in 1492, when the joint rulers conquered the Moorish kingdom of Granada, which had been providing Castile with African goods through tribute. The fledgling Spanish Empire decided to fund Columbus's expedition in hopes of finding new trade routes and circumventing the lock Portugal had secured on Africa and the Indian Ocean with the 1481 papal bull Aeterni regis.

In response to the need for a new route to Asia, by the 1480s, Christopher and his brother Bartholomew had developed a plan to travel to the Indies (then construed roughly as all of southern and eastern Asia) by sailing directly west across what was believed to be the singular "Ocean Sea," the Atlantic Ocean. By about 1481, Florentine cosmographer Paolo dal Pozzo Toscanelli sent Columbus a map depicting such a route, with no intermediary landmass other than the mythical island of Antillia. In 1484 on the island of La Gomera in the Canaries, then undergoing conquest by Castile, Columbus heard from some inhabitants of El Hierro that there was supposed to be a group of islands to the west.

A popular misconception that Columbus had difficulty obtaining support for his plan because Europeans thought the Earth was flat can be traced back to a 17th-century campaign of Protestants against Catholicism, and was popularized in works such as Washington Irving's 1828 biography of Columbus. In fact, the knowledge that the Earth is spherical was widespread, having been the general opinion of Ancient Greek science, and gaining support throughout the Middle Ages (for example, Bede mentions it in The Reckoning of Time). The primitive maritime navigation of Columbus's time relied on both the stars and the curvature of the Earth.

Diameter of Earth and travel distance estimates

Columbus's geographical conceptions (beige) compared to the known landmasses and their demarcation by Juan de la Cosa (black)

Eratosthenes (who assumed three variables he had not proved: the distance of the sun, parallel light rays, and that the earth was spherical) had measured the diameter of the Earth with good precision in the 2nd century BC, and the means of calculating its diameter using an astrolabe was known to both scholars and navigators. Where Columbus differed from the generally accepted view of his time was in his incorrect assumption of a significantly smaller diameter for the Earth, claiming that Asia could be easily reached by sailing west across the Atlantic. Most scholars accepted Ptolemy's correct assessment that the terrestrial landmass (for Europeans of the time, comprising Eurasia and Africa) occupied 180 degrees of the terrestrial sphere, and dismissed Columbus's claim that the Earth was much smaller, and that Asia was only a few thousand nautical miles to the west of Europe.

The "Columbus map", depicting only the Old World, was drawn c. 1490 in the workshop of Bartolomeo and Christopher Columbus in Lisbon.
Handwritten notes by Christopher Columbus on the Latin edition of Marco Polo's Le livre des merveilles

Columbus believed the incorrect calculations of Marinus of Tyre, putting the landmass at 225 degrees, leaving only 135 degrees of water. Moreover, Columbus underestimated Alfraganus's calculation of the length of a degree, reading the Arabic astronomer's writings as if, rather than using the Arabic mile (about 1,830 m), he had used the Italian mile (about 1,480 meters). Alfraganus had calculated the length of a degree to be 56⅔ Arabic miles (66.2 nautical miles). Columbus therefore estimated the size of the Earth to be about 75% of Eratosthenes's calculation, and the distance from the Canary Islands to Japan as 2,400 nautical miles (about 23% of the real figure).

Trade winds

There was a further element of key importance in the voyages of Columbus, the trade winds. He planned to first sail to the Canary Islands before continuing west by utilizing the northeast trade wind. Part of the return to Spain would require traveling against the wind using an arduous sailing technique called beating, during which almost no progress can be made. To effectively make the return voyage, Columbus would need to follow the curving trade winds northeastward to the middle latitudes of the North Atlantic, where he would be able to catch the "westerlies" that blow eastward to the coast of Western Europe.

The navigational technique for travel in the Atlantic appears to have been exploited first by the Portuguese, who referred to it as the volta do mar ('turn of the sea'). Columbus's knowledge of the Atlantic wind patterns was, however, imperfect at the time of his first voyage. By sailing directly due west from the Canary Islands during hurricane season, skirting the so-called horse latitudes of the mid-Atlantic, Columbus risked either being becalmed or running into a tropical cyclone, both of which, by chance, he avoided.

Funding campaign

Around 1484, King John II of Portugal submitted Columbus's proposal to his experts, who rejected it on the basis that Columbus's estimation of a travel distance of 2,400 nautical miles was about four times too low (which was accurate).

In 1486, Columbus was granted an audience with the Catholic Monarchs, and he presented his plans to Isabella. She referred these to a committee, which determined that Columbus had grossly underestimated the distance to Asia. Pronouncing the idea impractical, they advised the monarchs not to support the proposed venture. To keep Columbus from taking his ideas elsewhere, and perhaps to keep their options open, the Catholic Monarchs gave him an allowance, totaling about 14,000 maravedís for the year, or about the annual salary of a sailor.

In 1488 Columbus again appealed to the court of Portugal, receiving a new invitation for an audience with John II. This again proved unsuccessful, in part because not long afterwards Bartolomeu Dias returned to Portugal following a successful rounding of the southern tip of Africa. With an eastern sea route now under its control, Portugal was no longer interested in trailblazing a western trade route to Asia crossing unknown seas.

In May 1489, Isabella sent Columbus another 10,000 maravedis, and the same year the Catholic Monarchs furnished him with a letter ordering all cities and towns under their domain to provide him food and lodging at no cost.

As Queen Isabella's forces neared victory over the Moorish Emirate of Granada for Castile, Columbus was summoned to the Spanish court for renewed discussions. He waited at King Ferdinand's camp until January 1492, when the monarchs conquered Granada. A council led by Isabella's confessor, Hernando de Talavera, found Columbus's proposal to reach the Indies implausible. Columbus had left for France when Ferdinand intervened, first sending Talavera and Bishop Diego Deza to appeal to the queen. Isabella was finally convinced by the king's clerk Luis de Santángel, who argued that Columbus would bring his ideas elsewhere, and offered to help arrange the funding. Isabella then sent a royal guard to fetch Columbus, who had travelled several kilometers toward Córdoba.

In the April 1492 "Capitulations of Santa Fe", Columbus was promised he would be given the title "Admiral of the Ocean Sea" and appointed viceroy and governor of the newly claimed and colonized for the Crown; he would also receive ten percent of all the revenues from the new lands in perpetuity if he was successful. He had the right to nominate three people, from whom the sovereigns would choose one, for any office in the new lands. The terms were unusually generous but, as his son later wrote, the monarchs were not confident of his return.

History

First voyage (1492–1493)

Captain's ensign of Columbus's ships

For his westward voyage to find a shorter route to the Orient, Columbus and his crew took three medium-sized ships, the largest of which was a carrack (Spanish: nao), the Santa María, which was owned and captained by Juan de la Cosa, and under Columbus's direct command. The other two were smaller caravels; the name of one is lost, but it is known by the Castilian nickname Pinta ("painted one"). The other, the Santa Clara, was nicknamed the Niña ("girl"), perhaps in reference to her owner, Juan Niño of Moguer. The Pinta and the Niña were piloted by the Pinzón brothers (Martín Alonso and Vicente Yáñez, respectively). On the morning of 3 August 1492, Columbus departed from Palos de la Frontera, Huelva, going down the Rio Tinto and into the Atlantic.

Three days into the journey, on 6 August 1492, the rudder of the Pinta broke. Martín Alonso Pinzón suspected the owners of the ship of sabotage, as they were afraid to go on the journey. The crew was able to secure the rudder with ropes until they could reach the Canary Islands, where they arrived on 9 August. The Pinta had its rudder replaced on the island of Gran Canaria, and by September 2 the ships rendezvoused at La Gomera, where the Niña's lateen sails were re-rigged to standard square sails. Final provisions were secured, and on 6 September the ships departed San Sebastián de La Gomera for what turned out to be a five-week-long westward voyage across the Atlantic.

As described in the abstract of his journal made by Bartolomé de las Casas, on the outward bound voyage Columbus recorded two sets of distances: one was in measurements he normally used, the other in the Portuguese maritime leagues used by his crew. Las Casas originally interpreted that he reported the shorter distances to his crew so they would not worry about sailing too far from Spain, but Oliver Dunn and James Kelley state that this was a misunderstanding.

On 13 September 1492, Columbus observed that the needle of his compass no longer pointed to the North Star. It was once believed that Columbus had discovered magnetic declination, but it was later shown that the phenomenon was already known, both in Europe and in China.

First landing in the Americas

First voyage (conjectural): modern place names in black, Columbus's place names in blue

After 29 days out of sight of land, on 7 October 1492, the crew spotted "[i]mmense flocks of birds", some of which his sailors trapped and determined to be "field" birds (probably Eskimo curlews and American golden plovers). Columbus changed course to follow their flight.

On 10 October, Columbus quelled a mutiny by sailors who wanted to abandon the search and return to Spain. On the next day, they saw several artifacts floating up the sea, which caused them to believe that land was nearby. Columbus changed the fleet's course to due west, and sailed through the night, with many sailors looking for land. At around 10:00 pm on 11 October, Columbus thought he saw a light "like a little wax candle rising and falling". Four hours later, land was sighted by a sailor named Rodrigo de Triana (also known as Juan Rodríguez Bermejo) aboard the Pinta. Triana immediately alerted the rest of the crew with a shout, and the ship's captain, Martín Alonso Pinzón, verified the land sighting and alerted Columbus by firing a lombard. Columbus would later assert that he had first seen land, thus earning the promised annual reward of 10,000 maravedís.

They landed on the morning of 12 October. Columbus called this island San Salvador; its indigenous name was Guanahani. The modern San Salvador Island in the Bahamas is considered to be the most likely candidate for this island. Columbus wrote of the natives he first encountered in his journal entry of 12 October 1492:

Many of the men I have seen have scars on their bodies, and when I made signs to them to find out how this happened, they indicated that people from other nearby islands come to San Salvador to capture them; they defend themselves the best they can. I believe that people from the mainland come here to take them as slaves. They ought to make good and skilled servants, for they repeat very quickly whatever we say to them. I think they can very easily be made Christians, for they seem to have no religion. If it pleases our Lord, I will take six of them to Your Highnesses when I depart, in order that they may learn our language.

A depiction of Columbus claiming possession of the land in caravels (the Niña and the Pinta)

Columbus called the indigenous Americans indios (Spanish for 'Indians') in the mistaken belief that he had reached the East Indies; the islands of the Caribbean are termed the West Indies because of this error.

Columbus initially encountered the Lucayan, Taíno, and Arawak peoples. Noting their gold ear ornaments, Columbus took some of the Arawaks prisoner and insisted that they guide him to the source of the gold. Columbus noted that their primitive weapons and military tactics made the natives susceptible to easy conquest.

Columbus observed the people and their cultural lifestyle. He also explored the northeast coast of Cuba, landing on 28 October 1492, and the north-western coast of Hispaniola, present day Haiti, by 5 December 1492. Here, the Santa Maria ran aground on Christmas Day, 25 December 1492, and had to be abandoned. Columbus was received by the native cacique (chieftain) Guacanagari, who gave him permission to leave some of his men behind. Columbus left 39 men, including the interpreter Luis de Torres, and founded the settlement of La Navidad. He kept sailing along the northern coast of Hispaniola with a single ship, until he encountered Pinzón and the Pinta on 6 January.

On 13 January 1493, Columbus made his last stop of this voyage in the Americas, in the Bay of Rincón at the eastern end of the Samaná Peninsula in northeast Hispaniola. There he encountered the Ciguayos, the only natives who offered violent resistance during this first voyage. The Ciguayos refused to trade the amount of bows and arrows that Columbus desired; in the ensuing clash one Ciguayo was stabbed in the buttocks and another wounded with an arrow in his chest. Because of the Ciguayos' use of arrows, Columbus named the inlet the Bay of Arrows (or Gulf of Arrows).

Four natives who boarded the Niña at Samaná Peninsula told Columbus of what was possibly the Isla de Carib, which was supposed to be populated by cannibalistic Caribs, as well as Matinino, an island populated only by women, which Columbus associated with an island in the Indian Ocean described by Marco Polo.

First return

Depiction of Columbus before the Catholic Monarchs of Spain upon his first return (1874)

On 16 January 1493, the homeward journey was begun.

While returning to Spain, the Niña and Pinta encountered the roughest storm of their journey, and on the night of 13 February, lost contact with each other. All hands on the Niña vowed, if they were spared, to make a pilgrimage to the nearest church of Our Lady wherever they first made land.

On the morning of 15 February, land was spotted. Columbus believed they were approaching the Portuguese Azores Islands, but others felt that they were considerably north of the islands. Columbus turned out to be right. On the night of 17 February, the Niña laid anchor at Santa Maria Island, but the cable broke on sharp rocks, forcing Columbus to stay offshore until morning, when a safer location was found nearby. A few sailors took a boat to the island, where they were told by several islanders of a still safer place to land, so the Niña moved once again. At this spot, Columbus took aboard several islanders with food. When told of the vow to Our Lady, the islanders directed the crew to a small shrine nearby.

Columbus sent half of the crew to the island to fulfill their vow, but he and the rest stayed on the Niña, planning to send the other half later. While the shore party were in prayer, they were taken prisoner by order of the island's captain, João de Castanheira, ostensibly out of fear that they were pirates. Castanheira commandeered their shore boat, which he took with several armed men to the Niña, planning to arrest Columbus. When Columbus defied him, Castanheira said he did not believe or care about Columbus' story, denounced Spaniards, and went back to the island. After another two days, Castanheira released the prisoners, having been unable to get confessions from them or to capture his real target, Columbus. Some claimed that Columbus was captured, but this is contradicted by Columbus's log book.

Leaving the island of Santa Maria in the Azores on 23 February, Columbus headed for Castilian Spain, but another storm forced him into Lisbon. He anchored next to a king's harbor patrol ship on 4 March 1493, where he was told a fleet of 100 caravels had been lost in the storm. Astoundingly, both the Niña and the Pinta had been spared. Not finding King John II of Portugal in Lisbon, Columbus wrote to him and waited for a reply. The king agreed to meet Columbus at Vale do Paraíso, despite the poor relations between Portugal and Castile at the time. Upon learning of Columbus's discoveries, the Portuguese king informed him that he believed the voyage to be in violation of the 1479 Treaty of Alcáçovas.

After spending more than a week in Portugal, Columbus set sail for Spain. He arrived back in Palos on 15 March 1493 and later met with Ferdinand and Isabella in Barcelona to report his findings.

Columbus showed off what he had brought back from his voyage to the monarchs, including a few small samples of gold, pearls, gold jewelry from the natives, a few Taíno he had kidnapped, flowers, and a hammock. He also brought the previously unknown tobacco plant, the pineapple fruit, and the turkey. He did not bring any of the precious East Indies spices such as black pepper, ginger or cloves. In his log, he wrote "there is also plenty of 'ají', which is their pepper, which is more valuable than black pepper, and all the people eat nothing else, it being very wholesome".

Columbus brought captured Taínos to present to the sovereigns, never having met the infamous Caribs. In Columbus's letter on the first voyage, addressed to the Spanish court, he insisted he had reached Asia, describing the island of Hispaniola as being off the coast of China. He emphasized the potential riches of the land, exaggerating the abundance of gold, and that the natives seemed ready to convert to Christianity. The letter was translated into multiple languages and widely distributed, creating a sensation:

Hispaniola is a miracle. Mountains and hills, plains and pastures, are both fertile and beautiful ... the harbors are unbelievably good and there are many wide rivers of which the majority contain gold. ... There are many spices, and great mines of gold and other metals...

Upon Columbus's return, most people initially accepted that he had reached the East Indies, including the sovereigns and Pope Alexander VI, though in a letter to the Vatican dated 1 November 1493, the historian Peter Martyr described Columbus as the discoverer of a Novi Orbis ("New Globe"). The pope issued four bulls (the first three of which are collectively known as the Bulls of Donation), to determine how Spain and Portugal would colonize and divide the spoils of the new lands. Inter caetera, issued 4 May 1493, divided the world outside Europe between Spain and Portugal along a north–south meridian 100 leagues west of either the Azores or Cape Verde Islands in the mid-Atlantic, thus granting Spain all the land discovered by Columbus. The 1494 Treaty of Tordesillas, ratified in the next decade by Pope Julius II, moved the dividing line to 370 leagues west of the Azores or Cape Verde.

Second voyage (1493–1496)

Columbus's second voyage

The stated purpose of the second voyage was to convert the indigenous Americans to Christianity. Before Columbus left Spain, he was directed by Ferdinand and Isabella to maintain friendly, even loving, relations with the natives. He set sail from Cádiz, Spain, on 25 September 1493.

The fleet for the second voyage was much larger: two naos and 15 caravels. The two naos were the flagship Marigalante ("Gallant Mary") and the Gallega; the caravels were the Fraila ('the nun'), San Juan, Colina ('the hill'), Gallarda ('the gallant'), Gutierre, Bonial, Rodriga, Triana, Vieja ('the old'), Prieta ('the brown'), Gorda ('the fat'), Cardera, and Quintera. The Niña returned for this expedition, which also included a ship named Pinta probably identical to that from the first expedition. In addition, the expedition saw the construction of the first ship in the Americas, the Santa Cruz or India.

Lesser Antilles and Puerto Rico

On 3 November 1493, Christopher Columbus landed on a rugged shore on an island that he named Dominica. On the same day, he landed at Marie-Galante, which he named Santa María la Galante. After sailing past Les Saintes (Todos los Santos), he arrived at Guadeloupe (Santa María de Guadalupe), which he explored between 4 November and 10 November 1493. The exact course of his voyage through the Lesser Antilles is debated, but it seems likely that he turned north, sighting and naming many islands including Santa María de Montserrat (Montserrat), Santa María la Antigua (Antigua), Santa María la Redonda (Saint Martin), and Santa Cruz (Saint Croix, on 14 November). He also sighted and named the island chain of Santa Úrsula y las Once Mil Vírgenes (the Virgin Islands), and named the island of Virgin Gorda.

On Santa Cruz, the Europeans saw a canoe with a few Carib men and two women. They had two male captives, and had recently castrated them. The Europeans pursued them, and were met with arrows from both the men and women, fatally wounding at least one man, who perished about a week later. The Europeans either killed or captured all aboard the canoe, thereafter beheading them. Another was thrown overboard, and when he was spotted crawling away holding his entrails, the Arawaks recommended he be recaptured so he would not alert his tribe; he was thrown overboard again, and then had to be shot down with arrows. Columbus's childhood friend Michele da Cuneo—according to his own account—took one of the women in the skirmish, whom Columbus let him keep as a slave; Cuneo subsequently beat and raped her.

The fleet continued to the Greater Antilles, first sighting the eastern coast of the island of Puerto Rico, known to its native Taino people as Borikén, on the afternoon of 17 November 1493. The fleet sailed along the island’s southern coast for a whole day, before making landfall on its northwestern coast at the Bay of Añasco, between the towns of Mayagüez and Aguadilla, early on 19 November 1493. Upon landing, Columbus christened the island San Juan Bautista after Saint John the Baptist, preacher and prophet who baptized Jesus Christ, and remained anchored there for two days, 20 and 21 November 1493. Fleet member Diego Álvarez Chanca recounts that as they sailed along the southern coast of Puerto Rico, a Taino woman and boy, who had volunteered to join them on-board in Guadeloupe, after having been rescued together with a group of at least 20 women the Caribs had been keeping as sex slaves, swam ashore, having recognized their homeland. The women rescued in Guadeloupe explained that any male captives were eaten, and that their own male offspring were castrated and made to serve the Caribs until they were old enough to be considered good to eat. The Europeans rescued three of these boys.

Hispaniola and Jamaica

On 22 November, Columbus sailed from San Juan Bautista (present-day Puerto Rico) to Hispaniola. The next morning, a native taken during the first voyage was returned to Samaná Bay. The fleet sailed about 170 miles over two days and discovered, at Monte Cristi, decomposing bodies of four men; one had a beard implying he had been a Spaniard. On the night of 27 November, cannons and flares were ignited in an attempt to signal La Navidad, but there was no response. A canoe party led by a cousin of Guacanagari presented Columbus with two golden masks and told him that Guacanagari had been injured by another chief, Caonabo, and that except for some Spanish casualties resulting from sickness and quarrel, the rest of his men were well. The next day, the Spanish fleet discovered the burnt remains of the Navidad fortress, and Guacanagari's cousin admitted that the Europeans had been wiped out by Caonabo. Other natives showed the Spaniards some of the bodies, and said that they had "taken three or four women apiece". While some suspicion was placed on Guacanagari, it gradually emerged that two of the Spaniards had formed a murderous gang in search of gold and women, prompting Caonabo's wrath. The fleet then fought the winds, traveling only 32 miles over 25 days, and arriving at a plain on the north coast of Hispaniola on 2 January 1494. There, they established the settlement of La Isabela. Columbus spent some time exploring the interior of the island for gold. Finding some, he established a small fort in the interior.

Columbus left Hispaniola on 24 April 1494, and arrived at the island of Cuba (which he had named Juana during his first voyage) on 30 April and Discovery Bay, Jamaica, on 5 May. He explored the south coast of Cuba, which he believed to be a peninsula of China rather than an island, and several nearby islands including La Evangelista (the Isle of Youth), before returning to Hispaniola on 20 August.

Slavery, settlers, and tribute

Columbus had planned for Queen Isabella to set up trading posts with the cities of the Far East made famous by Marco Polo, but whose Silk Road and eastern maritime routes had been blockaded to her crown's trade. However, Columbus would never find Cathay (China) or Zipangu (Japan), and there was no longer any Great Khan for trade treaties.

In 1494, Columbus sent Alonso de Ojeda (whom a contemporary described as "always the first to draw blood wherever there was a war or quarrel") to Cibao (where gold was being mined), which resulted in Ojeda's capturing several natives on an accusation of theft. Ojeda cut the ears off of one native, and sent the others to La Isabela in chains, where Columbus ordered them to be decapitated. During his brief reign, Columbus executed Spanish colonists for minor crimes, and used dismemberment as another form of punishment. By the end of 1494, disease and famine had claimed two-thirds of the Spanish settlers. A native Nahuatl account depicts the social breakdown that accompanied the pandemic: "A great many died from this plague, and many others died of hunger. They could not get up to search for food, and everyone else was too sick to care for them, so they starved to death in their beds."

By 1494, Columbus had shared his viceroyship with one of his military officers named Margarit, ordering him to prioritize Christianizing the natives, but that part of their noses and ears should be cut off for stealing. Margarit's men exploited the natives by beating, raping and enslaving them, with none on Hispaniola being baptized for another two years. Columbus's brother Diego warned Margarit to follow the admiral's orders, which provoked him to take three caravels back to Spain. Fray Buil, who was supposed to perform baptisms, accompanied Margarit. After arriving in Spain in late 1494, Buil complained to the Spanish court of the Columbus brothers and that there was no gold. Groups of Margarit's soldiers who remained in the west continued brutalizing the natives. Instead of forbidding this, Columbus participated in enslaving the indigenous people. In February 1495, he took over 1,500 Arawaks, some of whom had rebelled against the oppression of the colonists, and many of whom were subsequently released or taken by the Caribs. That month, Columbus shipped approximately 500 of these Americans to Spain to be sold as slaves; about 40% died en route, and half of the rest were sick upon arrival. In June of that year, the Spanish crown sent ships and supplies to the colony on Hispaniola, which Florentine merchant Gianotto Berardi had helped procure. In October, Berardi received almost 40,000 maravedís worth of slaves, who were alleged to be either cannibals or prisoners.

Columbus's tribute system was described by his son Ferdinand: "In the Cibao, where the gold mines were, every person of fourteen years of age or upward was to pay a large hawk's bell of gold dust; all others were each to pay 25 pounds of cotton. Whenever an Indian delivered his tribute, he was to receive a brass or copper token which he must wear about his neck as proof that he had made his payment; any Indian found without such a token was to be punished." The monarchs, who suggested the tokens, called for a light punishment, but any Indian found without a copper token had their hands cut off, which was a likely death sentence. Since there was no abundance of gold on the island, the natives had no chance of meeting Columbus's quota and thousands are reported to have committed suicide. By 1497, the tribute system had all but collapsed.

Columbus became ill in 1495, and during this time, his troops acted out of order, enacting cruelties on the natives, including torturing them to learn where the supposed gold was. When he recovered, he led men and dogs to hunt down natives who fled their forced duties, killing them or cutting off their hands as a warning to others. Brutalities and murders were carried out even against natives who were sick and unarmed. In addition, Spanish colonists under Columbus's rule began to buy and sell natives as slaves, including children.

The Spanish fleet departed La Isabela on 10 March 1496. Again set back by unfavorable trade winds, supplies began to run low; on 10 April, Columbus requested food from the natives of Guadeloupe. Upon going ashore, the Spaniards were ambushed by arrows; in response, they destroyed some huts. They then held a group of 13 native women and children hostage to force a sale of cassava. The Niña and India left Guadeloupe on 20 April. On 8 June, the fleeted landed at Portugal, near Odemira, and returned to Spain via the Bay of Cádiz on 11 June.

Third voyage (1498–1500)

Location of Sanlúcar de Barrameda, the starting point for Columbus's third journey
Third voyage

According to the abstract of Columbus's journal made by Bartolomé de Las Casas, the objective of the third voyage was to verify the existence of a continent that King John II of Portugal suggested was located to the southwest of the Cape Verde Islands. King John reportedly knew of the existence of such a mainland because "canoes had been found which set out from the coast of Guinea [West Africa] and sailed to the west with merchandise." Italian explorer John Cabot probably reached the mainland of the American continent in June 1497, although his landing site is disputed.

On 30 May 1498, Columbus left with six ships from Sanlúcar, Spain, for his third trip to the Americas. Three of the ships headed directly for Hispaniola with much-needed supplies, while Columbus took the other three in an exploration of what might lie to the south of the Caribbean islands he had already visited, including a hoped-for passage to continental Asia. Columbus led his fleet to the Portuguese island of Porto Santo, his wife's native land. He then sailed to Madeira and spent some time there with the Portuguese captain João Gonçalves da Camara, before sailing to the Canary Islands and Cape Verde.

On 13 July, Columbus's fleet entered the doldrums of the mid-Atlantic, where they were becalmed for several days, the heat doing damage to their ships, food, and water supply. An easterly wind finally propelled them westwards, which was maintained until 22 July, when birds flying from southwest to northeast were sighted, and the fleet turned north in the direction of Dominica. The men sighted the land of Trinidad on 31 July, approaching from the southeast. The fleet sailed along the southern coast and entered Dragon's Mouth, anchoring near Soldado Rock (west of Icacos Point, Trinidad's southwesternmost point) where they made contact with a group of Amerindians in canoes. On 1 August, Columbus and his men arrived at a landmass near the mouth of South America's Orinoco river, in the region of modern-day Venezuela. Columbus recognized from the topography that it must be the continent's mainland, but while describing it as an otro mundo ('other world'), retained the belief that it was Asia—and perhaps an Earthly Paradise. On 2 August, they landed at Icacos Point (which Columbus named Punta de Arenal) in modern Trinidad, narrowly avoiding a violent encounter with the natives. Early on 4 August, a tsunami nearly capsized Columbus's ship. The men sailed across the Gulf of Paria, and on 5 August, landed on the mainland of South America at the Paria Peninsula. Columbus, suffering from a monthlong bout of insomnia and impaired vision from his bloodshot eyes, authorized the other fleet captains to go ashore first: one planted a cross, and the other recorded that Columbus subsequently landed to formally take the province for Spain. They sailed further west, where the sight of pearls compelled Columbus to send men to obtain some, if not gold. The natives provided nourishment including a maize wine, new to Columbus. Compelled to reach Hispaniola before the food aboard his ship spoiled, Columbus was disappointed to discover that they had sailed into a gulf, and while they had obtained fresh water, they had to go back east to reach open waters again.

Making observations with a quadrant at sea, Columbus inaccurately measured the polar radius of the North Star's diurnal motion to be five degrees, double the value of another erroneous reading he had made from further north. This led him to describe the figure of the Earth as pear-shaped, with the "stalk" portion ascending towards Heaven. (In fact, the Earth ever so slightly is pear-shaped, with its "stalk" pointing north.) He then sailed to the islands of Chacachacare and Margarita (reaching the latter on 14 August), and sighted Tobago (which he named Bella Forma) and Grenada (which he named Concepción).

In poor health, Columbus returned to Hispaniola on 19 August, only to find that many of the Spanish settlers of the new colony were in rebellion against his rule, claiming that Columbus had misled them about the supposedly bountiful riches they expected to find. A number of returning settlers and sailors lobbied against Columbus at the Spanish court, accusing him and his brothers of gross mismanagement. Columbus had some of his crew hanged for disobedience. He had an economic interest in the enslavement of the Hispaniola natives and for that reason was not eager to baptize them, which attracted criticism from some churchmen. An entry in his journal from September 1498 reads: "From here one might send, in the name of the Holy Trinity, as many slaves as could be sold ..."

Columbus was eventually forced to make peace with the rebellious colonists on humiliating terms. In 1500, the Crown had him removed as governor, arrested, and transported in chains to Spain. He was eventually freed and allowed to return to the Americas, but not as governor. As an added insult, in 1499, the Portuguese explorer Vasco da Gama returned from his first voyage to India, having sailed east around the southern tip of Africa—unlocking a sea route to Asia.

Governorship

Colonist rebellions

After his second journey, Columbus had requested that 330 people be sent to stay permanently (though voluntarily) on Hispaniola, all on the king's pay. Specifically, he asked for 100 men to work as wood men, soldiers, and laborers; 50 farmers, 40 squires, 30 sailors, 30 cabin boys, 20 goldsmiths, 10 gardeners, 20 handymen, and 30 women. In addition to this, plans were made to maintain friars and clergymen, a physician, a pharmacist, an herbalist, and musicians for entertaining the colonists. Fearing that the king was going to restrict money allotted for wages, Columbus suggested that Spanish criminals be pardoned in exchange for a few years unpaid service in Hispaniola, and the king agreed to this. A pardon for the death penalty would require two years of service, and one year of service was required for lesser crimes. They also instructed that those who had been sentenced to exile would also be redirected to be exiled in Hispaniola.

These new colonists were sent directly to Hispaniola in three ships with supplies, while Columbus was taking an alternate route with the other three ships to explore. As these new Colonists arrived on Hispaniola, a rebellion was brewing under Francisco Roldán (a man Columbus had left as chief mayor, under his brothers Diego and Bartolomew). By the time Columbus arrived on Hispaniola, Roldán held the territory of Xaraguá, and some of the new colonists had joined his rebellion. Over months, Columbus tried negotiating with the rebels. At his behest, Roldán tried the other rebels, ordering his former partner, Adrián de Mújica, to be hanged.

Columbus was physically and mentally exhausted; his body was wracked by arthritis and his eyes by ophthalmia. In October 1499, he sent two ships to Spain, asking the Court of Castile to appoint a royal commissioner to help him govern. On 3 February 1500, he returned to Santo Domingo with plans to sail back to Spain to defend himself from the accounts of the rebels.

Bobadilla's inquiry
Bobadilla Betrays Columbus by Luigi Gregori, c. 1883 (Columbus murals at the University of Notre Dame)

The sovereigns gave Francisco de Bobadilla, a member of the Order of Calatrava, complete control as governor in the Americas. Bobadilla arrived in Santo Domingo in August 1500, where Diego was overseeing the execution of rebels, while Columbus was suppressing a revolt at Grenada. Bobadilla immediately received many serious complaints about all three Columbus brothers, including that "seven Spanish men had been hanged that week," with another five awaiting execution. Bobadilla had orders to find out "which persons were the ones who rose up against the admiral and our justice and for what cause and reason, and what ... damage they have done," then "detain those whom you find guilty ... and confiscate their goods." The crown's command regarding Columbus dictated that the admiral must relinquish all control of the colonies, keeping only his personal wealth.

Bobadilla used force to prevent the execution of several prisoners, and subsequently took charge of Columbus's possessions, including papers that he would have used to defend himself in Spain. Bobadilla suspended the tribute system for a twenty-year period, then summoned the admiral. In early October 1500, Columbus and Diego presented themselves to Bobadilla, and were put in chains aboard La Gorda, Columbus's own ship. Only the ship's cook was willing to put the shamed admiral in chains. Bobadilla took much of Columbus's gold and other treasures. Ferdinand Columbus recorded that the governor took "testimony from their open enemies, the rebels, and even showing open favor," and auctioned off some of his father's possessions "for one third of their value."

Bobadilla's inquiry produced testimony that Columbus forced priests not to baptize natives without his express permission, so he could first decide whether or not they should be sold into slavery. He allegedly captured a tribe of 300 under Roldán's protection to be sold into slavery, and informed other Christians that half of the indigenous servants should be yielded to him. Further, he allegedly ordered at least 12 Spaniards to be whipped and tied by the neck and feet for trading gold for something to eat without his permission. Other allegations include that he: ordered a woman to be whipped naked on the back of a donkey for lying that she was pregnant, had a woman's tongue cut out for seeming to insult him and his brothers, cut a Spaniard's throat for being homosexual, ordered Christians to be hanged for stealing bread, ordered a cabin boy's hand cut off and posted publicly for using a trap to catch a fish, and ordered for a man to have his nose and ears cut off, as well as to be whipped, shackled, and banished. Multiple culprits were given a potentially fatal 100 lashes, sometimes while naked. Some fifty men starved to death on La Isabela because of tight control over the ship's rations, despite there being an abundance.

Trial in Spain
Columbus Before the Queen by Emanuel Gottlieb Leutze, 1843 (probably after an earlier work, Brooklyn Museum of Art)

A number of returned settlers and friars lobbied against Columbus at the Spanish court, accusing him of mismanagement. By his own request, Columbus remained in chains during the entire voyage home. Once in Cádiz, a grieving Columbus wrote to a friend at court:

It is now seventeen years since I came to serve these princes with the Enterprise of the Indies. They made me pass eight of them in discussion, and at the end rejected it as a thing of jest. Nevertheless I persisted therein... Over there I have placed under their sovereignty more land than there is in Africa and Europe, and more than 1,700 islands... In seven years I, by the divine will, made that conquest. At a time when I was entitled to expect rewards and retirement, I was incontinently arrested and sent home loaded with chains... The accusation was brought out of malice on the basis of charges made by civilians who had revolted and wished to take possession on the land... I beg your graces, with the zeal of faithful Christians in whom their Highnesses have confidence, to read all my papers, and to consider how I, who came from so far to serve these princes... now at the end of my days have been despoiled of my honor and my property without cause, wherein is neither justice nor mercy.

Columbus and his brothers were jailed for six weeks before the busy King Ferdinand ordered them released. On 12 December 1500, the king and queen summoned the Columbus brothers to their presence at the Alhambra palace in Granada. With his chains at last removed, Columbus wore shortened sleeves so the marks on his skin would be visible. At the palace, the royal couple heard the brothers' pleas; Columbus was brought to tears as he admitted his faults and begged for forgiveness. Their freedom was restored. On 3 September 1501, the door was firmly shut on Columbus's role as governor. From that point forward, Nicolás de Ovando y Cáceres was to be the new governor of the Indies, although Columbus retained the titles of admiral and viceroy. A royal mandate dated 27 September ordered Bobadilla to return Columbus's possessions.

Fourth voyage (1502–1504)

Columbus's fourth voyage

After much persuasion, the sovereigns agreed to fund Columbus's fourth voyage. It would be his final chance to prove himself and become the first man ever to circumnavigate the world. Columbus's goal was to find the Strait of Malacca to the Indian Ocean. On 14 March 1502, Columbus started his fourth voyage with 147 men and with strict orders from the king and queen not to stop at Hispaniola, but only to search for a westward passage to the Indian Ocean mainland. Before he left, Columbus wrote a letter to the Governors of the Bank of Saint George, Genoa, dated at Seville, 2 April 1502. He wrote "Although my body is here my heart is always near you." Accompanied by his stepbrother Bartolomeo, Diego Mendez, and his 13-year-old son Ferdinand, he left Cádiz on 9 May 1502, with his flagship, Capitana, as well as the Gallega, Vizcaína, and Santiago de Palos. They first sailed to Arzila on the Moroccan coast to rescue the Portuguese soldiers who he heard were under siege by the Moors.

After using the trade winds to cross the Atlantic in a brisk twenty days, on 15 June, they landed at Carbet on the island of Martinique (Martinica). Columbus anticipated that a hurricane was brewing and had a ship that needed to be replaced, so he headed to Hispaniola, despite being forbidden to land there. He arrived at Santo Domingo on June 29, but was denied port, and the new governor refused to listen to his warning of a storm. While Columbus's ships sheltered at the mouth of the Haina River, Governor Bobadilla departed, with Roldán and Columbus's gold aboard his ship, accompanied by a convoy of 30 other vessels. Columbus's personal gold and other belongings were put on the fragile Aguya, considered the fleet's least seaworthy vessel. The onset of a hurricane drove some ships ashore, with some sinking in the harbor of Santo Domingo; Bobadilla's ship is thought to have reached the eastern end of Hispaniola before sinking. About 20 other vessels sank in the Atlantic, with a total of some 500 people drowning. Three damaged ships made it back to Santo Domingo; one of these had Juan de la Cosa and Rodrigo de Bastidas on board. Only the Aguya made it to Spain, causing some of Columbus's enemies to accuse him of conjuring the storm.

After the hurricane, Columbus regrouped with his men, and after a brief stop at Jamaica and off the coast of Cuba to replenish, he sailed to modern Central America, arriving at Guanaja (Isla de los Pinos) in the Bay Islands off the coast of Honduras on 30 July 1502. Here Bartolomeo found native merchants—possibly (but not conclusively) Mayans—and a large canoe, which was described as "long as a galley" and was filled with cargo. The natives introduced Columbus and his entourage to cacao. Columbus spoke with an elder, and thought he described having seen people with swords and horses (possibly the Spaniards), and that they were "only ten days' journey to the river Ganges". On 14 August, Columbus landed on the mainland of the Americas at Puerto Castilla, near Trujillo, Honduras. He spent two months exploring the coasts of Honduras, Nicaragua, and Costa Rica looking for the passage, before arriving in Almirante Bay, Panama, on 16 October.

In mid-November, Columbus was told by some of the natives that a province called Ciguare "lie just nine days' journey by land to the west", or some 200 miles from his location in Veragua. Here was supposed to be found "gold without limit", "people who wear coral on their heads" who "know of pepper", "do business in fairs and markets", and who were "accustomed to warfare". Columbus would later write to the sovereigns that, according to the natives, "the sea encompasses Ciguare and ... it is a journey of ten days to the Ganges River." This could suggest that Columbus knew he had found a unknown continent distinct from Asia.

On 5 December 1502, Columbus and his crew found themselves in a storm unlike any they had ever experienced. In his journal Columbus writes,

For nine days I was as one lost, without hope of life. Eyes never beheld the sea so angry, so high, so covered with foam. The wind not only prevented our progress, but offered no opportunity to run behind any headland for shelter; hence we were forced to keep out in this bloody ocean, seething like a pot on a hot fire. Never did the sky look more terrible; for one whole day and night it blazed like a furnace, and the lightning broke with such violence that each time I wondered if it had carried off my spars and sails; the flashes came with such fury and frightfulness that we all thought that the ship would be blasted. All this time the water never ceased to fall from the sky; I do not say it rained, for it was like another deluge. The men were so worn out that they longed for death to end their dreadful suffering.

In Panamá, he learned from the Ngobe of gold and a strait to another ocean. After some exploration, he established a garrison at the mouth of Belén River in January 1503. By 6 April, the garrison he had established captured the local tribe leader El Quibían, who had demanded they not go down the Belén River. El Quibían escaped, and returned with an army to attack and repel the Spanish, damaging some of the ships so that one vessel had to be abandoned. Columbus left for Hispaniola on 16 April; on 10 May, he sighted the Cayman Islands, naming them Las Tortugas after the numerous sea turtles there. His ships next sustained more damage in a storm off the coast of Cuba. Unable to travel any farther, the ships were beached in St. Ann's Bay, Jamaica, on 25 June.

Illustration of Columbus awing and frightening the natives by predicting a lunar eclipse (1879)

For a year Columbus and his men remained stranded on Jamaica. A Spaniard, Diego Mendez, and some natives paddled a canoe to get help from Hispaniola. The island's governor, Nicolás de Ovando y Cáceres, detested Columbus and obstructed all efforts to rescue him and his men. In the meantime, Columbus had to mesmerize the natives in order to prevent being attacked by them and gain their goodwill. He did so by correctly predicting a lunar eclipse for 29 February 1504, using the Ephemeris of the German astronomer Regiomontanus.

In May 1504 a battle took place between men loyal to Columbus and those loyal to the Porras brothers, in which there was a sword fight between Bartholomew Columbus and Francisco de Porras. Bartholomew won against Francisco but he spared his life. In this way, the mutiny ended. Help finally arrived from the governor Ovando, on 29 June, when a caravel sent by Diego Méndez finally appeared on the island. At this time there were 110 members of the expedition alive out of the 147 who sailed from Spain with Columbus. Due to the strong winds, it took the caravel 45 days to reach La Hispaniola. This was a trip that Diego Méndez had previously made in four days in a canoe.

About 38 of the 110 men who survived decided not to board again and stayed in Hispaniola instead of returning to Spain. On 11 September 1504, Christopher Columbus and his son Fernando embarked in a caravel to travel from Hispaniola to Spain, paying their corresponding tickets. They arrived in Sanlúcar de Barrameda on 7 November and from there they traveled to Seville.

Legacy

Painting of Columbus by Karl von Piloty (19th century)

The news of Columbus's first voyage set off many other westward explorations by European states, which aimed to profit from trade and colonization. This would instigate a related biological exchange, and trans-Atlantic trade. These events, the effects and consequences of which persist to the present, are sometimes cited as the beginning of the modern era.

Upon first landing in the West, Columbus pondered enslaving the natives, and upon his return broadcast the perceived willingness of the natives to convert to Christianity. Columbus's second voyage saw the first major skirmish between Europeans and Native Americans for five centuries, when the Vikings had come to the Americas. One of the women was captured in the battle by a friend of Columbus, who let him keep her as a slave; this man subsequently beat and raped her. In 1503, the Spanish monarchs established the Indian reductions, settlements intended to relocate and exploit the natives.

With the Age of Discovery starting in the 15th century, Europeans explored the world by ocean, searching for particular trade goods, humans to enslave, and trading locations and ports. The most desired trading goods were gold, silver and spices. For the Catholic monarchies of Spain and Portugal, a division of influence of the land discovered by Columbus became necessary to avoid conflict. This was resolved by papal intervention in 1494 when the Treaty of Tordesillas purported to divide the world between the two powers. The Portuguese were to receive everything outside of Europe east of a line that ran 270 leagues west of the Cape Verde Islands. The Spanish received everything west of this line, territory that was still almost completely unknown, and proved to be primarily the vast majority of the continents of the Americas and the Islands of the Pacific Ocean. In 1500, the Portuguese navigator Pedro Álvares Cabral arrived at a point on the eastern coast of South America on the Portuguese side of the dividing line. This would lead to the Portuguese colonization of what is now Brazil.

In 1499, Italian explorer Amerigo Vespucci participated in a voyage to the western world with Columbus's associates Alonso de Ojeda and Juan de la Cosa. Columbus referred to the West Indies as the Indias Occidentales ('West Indies') in his 1502 Book of Privileges, calling them "unknown to all the world". He gathered information later that year from the natives of Central America which seem to further indicate that he realized he had found a new land. Vespucci, who had initially followed Columbus in the belief that he had reached Asia, suggested in a 1503 letter to Lorenzo di Pierfrancesco that he had known for two years that these lands composed a new continent. A letter to Piero Soderini, published c. 1505 and purportedly by Vespucci, claims that he first voyaged to the American mainland in 1497, a year before Columbus. In 1507, a year after Columbus's death, the New World was named "America" on a map by German cartographer Martin Waldseemüller. Waldseemüller retracted this naming in 1513, seemingly after Sebastian Cabot, Las Casas, and many historians convincingly argued that the Soderini letter had been a falsification. On his new map, Waldseemüller labelled the continent discovered by Columbus Terra Incognita ('unknown land').

On 25 September 1513, the Spanish conquistador Vasco Núñez de Balboa, exploring overland, became the first European to encounter the Pacific Ocean from the shores of the Americas, calling it the "South Sea". Later, on 29 October 1520, Magellan's circumnavigation expedition discovered the first maritime passage from the Atlantic to the Pacific, at the southern end of what is now Chile (Strait of Magellan), and his fleet ended up sailing around the whole Earth. Almost a century later, another, wider passage to the Pacific would be discovered farther to the south, bordering Cape Horn.

In the Americas the Spanish found a number of empires that were as large and populous as those in Europe. Small bodies of Spanish conquistadors, with large armies of indigenous groups, managed to conquer these states. The most notable amongst them were the Aztec Empire in modern Mexico (conquered in 1521) and the Inca Empire in modern Peru (conquered in 1532). During this time, pandemics of European diseases such as smallpox devastated the indigenous populations. Once Spanish sovereignty was established, the Spanish focused on the extraction and export of gold and silver.

Cultural competence in healthcare

A physician gathers medical information from a patient with the help of a local interpreter.

Cultural competence in healthcare refers to the ability for healthcare professionals to demonstrate cultural competence toward patients with diverse values, beliefs, and feelings. This process includes consideration of the individual social, cultural, and psychological needs of patients for effective cross-cultural communication with their health care providers. The goal of cultural competence in health care is to reduce health disparities and to provide optimal care to patients regardless of their race, gender, ethnic background, native languages spoken, and religious or cultural beliefs. Cultural competency training is important in health care fields where human interaction is common, including medicine, nursing, allied health, mental health, social work, pharmacy, oral health, and public health fields.

The term cultural competence was first used by Terry L. Cross and colleagues in 1989, but it was not until almost a decade later that health care professionals began to be formally educated and trained in cultural competence. In 2002, cultural competence in health care emerged as a field and has been increasingly embedded into medical education curricula and taught in health settings around the world since then.

Definitions

Cultural competence is a practice of values and attitudes that aims to optimize the healthcare experience of patients with cross cultural backgrounds. Essential elements that enable organizations to become culturally competent include valuing diversity, having the capacity for cultural self-assessment, being conscious of the dynamics inherent when cultures interact, having institutionalized cultural knowledge, and having developed adaptations to service delivery reflecting an understanding of cultural diversity. By definition, diversity includes differences in race, ethnicity, age, gender, size, religion, sexual orientation, and physical and mental ability. Accordingly, organizations should include these considerations in all aspects of policy making, administration, practice, and service delivery.

Cultural competence involves more than having sensitivity or awareness of cultures. It necessitates an active process of learning and developing skills to engage effectively in cross-cultural situations and re-evaluating these skills over time. Cultural competence is often used interchangeably with the term cultural competency. Multicultural competency is a more encompassing term that includes the ability to function effectively in cross-cultural interactions with a wide range of different cultural groups. Acquiring cultural competence is a continuous process.

Other terms relating to cultural competence include cultural responsiveness, cultural humility, cultural intelligence, and cultural safety. Cultural responsiveness involves recognizing the unique cultural identity of each client and exploring the differences as well as being open to valuing clients’ knowledge and expertise. Cultural humility is the process by which providers participate in the process of self-reflection and self-critique devoted to being life-long learners or practitioners to further address power differences between professionals and clients and a commitment to respect the clients’ values. Cultural intelligence relies on cultural metacognition (knowledge of your own attitudes and values) and encompasses the ability to interact effectively with culturally different clients. Cultural safety relates to the assumptions of power held by health providers of particular groups of people that have been historically marginalized. Providers must recognize their own beliefs, attitudes, and culture to foster a safe, trusting, and respectful experience for their clients to encourage trust and empowerment.

Awareness

The awareness aspect of cultural competence relates to the consciousness of one's personal reactions to people who look or exhibit different practices from cultural norms. According to the American Sociological Association, culture itself is understood as the languages, customs, beliefs, rules, arts, knowledge, collective identities, and memories shared by members of a social group that form the foundations of motives or actions. In measuring cultural competence in health care, one must recognize their own implicit biases toward patients or employees. Lack of awareness causes cultural discrimination during patient care. An analysis by researchers at UC San Francisco, UC Berkeley, and Stanford University found that almost one in five patients with chronic conditions over the age of 54 reported feeling discrimination within health care in a national survey that took place between 2008 and 2014.

Attitude

Paul Pedersen, a pioneer in multicultural competence, theorized a framework of culturally competence practices that consisted of three factors: awareness, knowledge, and skills. The Diversity Training University International (DTUI) included an attitude component that is delineated from the other factors increasing the analysis of general biases and beliefs as a scheme in one's daily life. This differs from an exercise that forces students to examine their own values and beliefs of cultural differences.

Knowledge

The problem of cultural incompetency lies in the lack of familiarity of the cultural and social experiences of the patient. Social psychologist Patricia Devine and her colleges conducted research that found that low-scorers on a cultural familiarity test tended to exemplify more discriminatory actions or speech in cross-cultural interactions. When awareness, attitudes, and knowledge are given prominence in these encounters, ethnocentrism, racism, and inequitable relations are no longer present.

Knowledge of culture also includes awareness of the structural, social, and environmental barriers that give meaning to certain actions in patients' lives. In the Cross-cultural Counseling Inventory, practitioners are examined by their understanding of "the current socio-political system and its impact on the client". In 2017, there was an estimated 20.5 million Black, Hispanic, and Native Americans living below the poverty line. Without taking aspects like socioeconomic status, immigrant status, and environment into consideration, physicians often resort to stereotyping or biases in their behavior.

Skills

The skills aspect of cultural competence involves implementing the practices of cultural knowledge, sensitivity, and awareness into daily experiences with patients. One aspect of developing skills is learning respectful and effective communication strategies whether within an organization or between individuals. Learning communication practices includes examining communication through body language and other non-verbal cue as some gestures may have extreme variations and meanings from one culture to another. Developing skills is an active process that requires reexamining one's own internal belief system.

Cultural competence in various settings

Healthcare system

A healthcare system, sometimes referred to as health system, is the organization of people, institutions, and resources that deliver healthcare services to meet the health needs of target populations. A culturally competent health system not only recognizes and accepts the importance of cultural diversity at every level but also assesses the cross-cultural relations, stays vigilant towards any changes and developments resulting from cultural diversity, broadens cultural knowledge, and adapts services to meet the needs that are culturally-unique.

As more and more immigrants are coming to America, healthcare professionals with good cultural competence can use the knowledge and sensitivity that they obtain in order to provide holistic care for clients from other countries, who speak foreign languages. The challenges for American healthcare systems to meet the health needs of the increasing number of diverse patients are becoming very obvious. The challenges include but are not limited to the following:

Leadership and workforce

In response to a rapid growth of the population of minority groups in the United States, healthcare organizations have responded by providing new services and undergoing health reforms in terms of diversity in leadership and workforce. Despite improvements and progress seen in some areas, minorities are still underrepresented within both healthcare leadership and workforce.

Clinical practice

To provide culturally sensitive patient-centered care, physicians should treat each patient as an individual, recognizing and respecting his or her beliefs, values and care seeking behaviors. However, many physicians lack the awareness of or training in cultural competence. With the constantly changing demographics, their patients are increasingly getting diverse as well. It is utterly important to educate physicians to be culturally competent so that they can effectively treat patients of different cultural and ethnic backgrounds.

Ignorance of these cultural differences could manifest in discomfort for the patient, subpar healthcare, incorrect diagnosis, and even racism, all which lower patients’ access to quality healthcare. Studies stress culturally sensitive training and education programs in healthcare settings that will impart to physicians how culture can affect healthcare treatment. Additionally, when interacting with patients of different cultures, specifically East Asian culture, it is important to “bridge the health care system with more traditional Eastern medical care… entail[ing] education for health professionals as part of a broader curriculum on providing culturally competent care.”  Within western healthcare, there are also large amounts of inaccuracies and misperceptions of health risks for different minority groups, which could be addressed through further linguistically and culturally appropriate health education.

Implicit bias aimed towards certain races or ethnicities is frequent in the healthcare field, specifically in the United States, commonly with Black Americans, Hispanic Americans, and American Indians. Subconscious discrimination occurs regardless of the advancement of disease prevention in the United States, as shown by the significantly high mortality rates of the groups mentioned earlier in the paragraph. This discrimination is shaped by attitudes of healthcare professionals, who often differ in effort and type of treatment based on the race and physical appearance of a patient. Carrying over to the diagnosis and treatment of minority patients, the disparities in quality of healthcare increase the likelihood of developing diseases such as asthma, HIV/AIDs and other life-threatening diseases. For example, a study that focused on the treatment and diagnosis differences between black women and white women in regards to breast cancer indicated this discrimination against minorities and its effects. Furthermore, the study indicated that "white women are more likely to be diagnosed with breast cancer, [and] Black women are more likely to die from it."

The differences in responses from healthcare professionals to black patients versus white patients is drastic, indicated by subconscious negative perceptions of various races. In a study that evaluated physicians' immediate assumptions made about different races "two-thirds of the clinicians subconsciously formed a bias against Blacks (43% moderate to strong) and Latinos (51% moderate to strong)". Without intentionally concocting stereotypes about patients, these clinicians are indirectly negatively affecting the patients they mistreat. To remedy this, the study expresses support for clinicians to form a stronger connection with each patient and to focus on the patient at hand, rather than considering their race or background. This will help to prevent negative attitudes and tones when speaking with patients, creating a positive atmosphere that allows for equal environments and treatments for all patients, regardless of race or physical appearance.

These subconscious negative perceptions of different races could also potentially lead to mistrust of western healthcare by minority populations. Mistrust of the government or Western medicine is a big reason that many immigrant/minority populations do not seek out healthcare, leading them to believe that equitable, affordable, quality healthcare is not a resource that is available to them. A program called Minnesota Immunization Networking Initiative (MINI) was started “in 2006 to reduce vaccination barriers of underserved populations” like African-Americans, Hispanic-Americans, etc. MINI succeeded in increasing vaccination and trust within these communities. Their success came from engaging the community, establishing strong partnerships with service providers, and actively involving and communicating with community partners, and holding clinics in trusted community facilities. Other research studies have also recommended that providers build trust with clients by making efforts to establish relationships with patients and “keeping in mind unique cultural profiles."

In response to the increasingly diverse population, several states (WA, CA, CT, NJ, NM) have passed legislation requiring or strongly recommending cultural competency training for physicians. In 2005, New Jersey legislature enacted a law requiring all physicians to complete at least 6 hours of training in cultural competency as a condition for renewal of their New Jersey medical license, whether or not they actively practice in New Jersey. Physicians' responses to this CME requirement varied, both positively and negatively. But the overall feedback was positive towards the outcomes of participation in and satisfaction with the programs. The United States also passed federal legislation on Culturally and Linguistically Appropriate Standards (CLAS), which is legislation aimed at reducing healthcare inequities like those in refugee health in the United States through culturally competent care.

In order to provide culturally competent care for their diverse patients, physicians should at the first step understand that patients' cultures can influence profoundly how they define health and illness, how they seek health care, and what constitutes appropriate treatment. They should also realize that their clinical care process could also be influenced by their own personal and professional experiences as well as biomedical culture. Dr. Like pointed out in one of his articles that "in transforming systems, transcultural nurses, physicians, and other health care professionals need to remember that cultural humility and cultural competence must go hand in hand."

Community Health Clinics

Because of insurance, costs, and a variety of other reasons, the types of services needed to meet the needs of minority communities are not usually offered at private hospitals. Federally qualified health centers (FQHCs) are legally mandated to provide primary care for medically underserved communities, and thus are ideal settings to implement and provide culturally and linguistically inclusive services to immigrant communities.

Community Health Centers, at their most basic level, provide low to no cost primary medical care to low-income, minority, and underserved communities. They are usually located in underserved communities and neighborhoods, with the idea to increase access, reduce travel and wait times, and to combat gentrification. They were meant to be of the people, by the people.

In an Integrated Care Model that allows clients to get an all-in-one-experience, the CHC model was unique in that it offered a wide range of auxiliary services  in addition to primary care, such as dental, behavioral, social services, etc. CHC's also “pride themselves equally on providing community-accountable and culturally competent care aimed at reducing health disparities associated with poverty, race, language, and culture”, as seen by their offered translation, interpretation, transportation, and social services. According to research, CHC's have successfully increased health service utilization in low-income areas, as well as lowered hospital admissions and readmissions (a positive metric) compared with other major providers of primary care in these areas.

Occupational Therapy

Occupational therapists are a valued member of healthcare among the allied health professions and can offer a unique contribution to the improvement of cultural competence. In healthcare, occupational therapists work with a variety of individuals across the lifespan with a variety of diagnosis or impairments in a client-centered approach to use meaningful activities or interventions to improve their quality of life and promote independence. Due to the client-centered approach, occupational therapists have the opportunity to develop trusting relationships with clients and use an individual's client factors related to beliefs and values while being culturally sensitive to their needs and desires for their own outcomes in treatment. Occupational therapists develop an individualized effective intervention plan based on understanding the client's values and beliefs of health and illness. The therapist-patient relationship is very important in occupational therapy to promote the client's engagement in purposeful activities and meaningful occupations from the client's cultural view. Therefore, learning about culture, applying cultural knowledge and reflecting on culture is crucial to reach the ultimate goals of the treatment plan successfully with equity and justice.

A useful resource that is available to assist with improving cultural competence is listed on the American Occupational Therapy Association (AOTA) website and provides more extensive definitions of various cultural terms and cultural competence toolkits which provide resources and information regarding specific groups of individuals that can be helpful in improving cultural competence in practice as an occupational therapist.

Research

Cultural competence in research is the ability of researchers and research staff to provide high quality research that takes into account the culture and diversity of a population when developing research ideas, design, and methodology. Cultural competence can be crucial for ensuring that the sampling is representative of the population and therefore application to a diverse number of people. It is important that a study's subject enrollment reflect as closely as possible the target population of those affected by the health problem being studied.

In 1994, the National Institutes of Health established policy (Public Law 103-43) for the inclusion of women, children, and members of minority groups and their subpopulations in biomedical and behavioral clinical studies. Overcoming challenges to cultural competence in research also means that institutional review board membership should include representatives of large communities and cultural groups as representatives.

Medical education

The critical importance of training medical students to be future culturally competent physicians has been recognized by accrediting bodies such as the Accreditation Council on Graduate Medical Education (ACGME) and the Liaison Committee on Medical Education (LCME) and other medical organizations such as American Medical Association (AMA) and the Institute of Medicine (IOM).

Culture is definitely beyond ethnicity and race. Healthcare professionals need to learn about the tolerance of other's beliefs. Professional care is about meeting patients' needs even if they do not align with the caretaker's personal beliefs. Discovering one's own beliefs and their origin (from upbringing or modeling of parents, for example) helps understand what is believed and moderates actions at times when others are cared for with different beliefs. As a result, it is essential for healthcare professionals to practice cultural competence and recognize the differences as well as cultural sensitivities to provide holistic care for the patients.

According to the LCME standard for cultural competence, "the faculty and students must demonstrate an understanding of the manner in which people of diverse culture and belief systems perceive health and illness and respond to various symptoms, diseases, and treatments." In response to the mandates, medical schools in the U.S. have incorporated teaching cultural competency in their curricula. A search on cultural competency in the curriculum of a medical school revealed that it was covered in 33 events in 13 courses in spring 2014. A similar search was performed on health disparities yielding 16 events in 10 courses covering the topic.

The cultural competence curriculum is intended to improve the interaction between patients and physicians and to assure that students will possess the knowledge, skills, and attitudes that enable them to provide high quality and culturally competent care to patients and their families as well as the general medical community.

A "visual intervention" was completed to educate healthcare professionals on the dangers of subconscious discrimination toward minority groups in order to lessen the common discrimination certain races or ethnicities face in a healthcare setting. This study allowed for physicians to focus more on the problems of their patients, and truly listening to their issues. By creating a supportive space that fosters a strong channel of communication, the study targeted the lack of connection between healthcare professionals and patients due to either language barriers or the patient's mistrust in the professional.

Patient education

Patient-Physician communication involves two sides. While physicians and other healthcare providers are being encouraged or required to be culturally competent in delivery of quality healthcare, it would be reasonable to encourage patients as well to be culturally sensitive and be aware that not all health care providers are equally competent in cultures. When it comes to illness, cultural beliefs and values affect greatly a patient's behavior in seeking healthcare. They should try their best to communicate their concerns relating to their beliefs, values and other cultural factors that might affect care and treatment to their physicians and other healthcare providers. If effective communication is unlikely achieved, then they should be provided with language assistance and interpretation services. Recognizing that patients receive the best care when they work in partnership with doctors, the General Medical Council issued guidance for patients "What to expect from your doctor: a guide for patients" in April 2013.

Health promotion advertising campaigns. Communication campaigns are attempts to inform or influence behaviors in large audiences to produce noncommercial benefits to individuals and society. Health communications designed for the general audience may not reach many due to cultural and language barriers. Cultural competence is analyzing, detecting and correcting these barriers. A one size fits all approach is not optimal for cultural competence. Instead, specific community organizations would know best about their own specific concerns. Care should be taken to not make the intended audience feel targeted. Public health advertising that features models who belong to their own group may cause a "Why us?" reaction. Public health advertising featuring minorities does not generate this backlash effect when the advertising appears in community-based publications mostly read by the featured group. Examples: In March 2022, Houston Health Department (HHD)  announced minority-owned, Houston-based media and creative business firm 9thWonder Agency as its partner to help reduce vaccine hesitancy.

Nursing

The core functions of a nurse rely on conversation and communication, which is directly impacted by the ability to speak or understand the language and culture of the patient. However, there are limited interventions for nurses to effectively manage language discordance. One study aimed to understand the components of nursing that are impacted by language discordance and the interventions that have been successfully used to overcome these barriers. The authors analyzed 299 studies and 24 met the selection criteria. The selection criteria included whether the studies addressed the topic of language discordance and the languages the studies were published in. The studies were mainly qualitative and were not large, numerical experiments. The majority, 20 out of 24, of the studies only focused on using interpreter services, whether they are professional or ad-hoc. While the risks of ad-hoc interpreters are clearly posed in the studies, the nurses regularly resort to ad-hoc interpreters when professional interpreters are not available. The authors recommend that each health care service plan and implement processes and systems to give nurses the tools, training, or resources they need to effectively carry out their job, specifically when communicating with patients who do not speak the same first language as them. Nevertheless, this study provides another angle to support the argument that interpreters and resources to mitigate the risks of language barriers are urgent for not just the diverse patient, but also for the clinicians who want to provide the best possible care.

Challenges to cultural competence

Language barriers

Linguistic competence involves communicating effectively with diverse populations, including individuals with limited English proficiency (LEP), low literacy skills or are not literate, disabilities, and individuals with any degree of hearing loss. According to the U.S. Census in 2011, 25.3 million people are considered limited English proficient, accounting for 9% of the U.S. population. Hospitals frequently admit LEP patients for treatment. With cultural and linguistic barriers, it is not surprising that it is hard to achieve effective communication between the health care providers and the LEP patients. Results from a 2019 systematic review of the literature found that overcoming the English-language barrier for LEP patients is a factor connected with improving patient health outcomes. Even so, in 2021, 25 million people who spoke Spanish received a third less health care than those that spoke English or other Americans.

The National Culturally and Linguistically Appropriate Services (CLAS) Standards in Health and Health Care developed by the Office of Minority Health (OMH) are intended to advance health equity, improve quality and help eliminate health care disparities. The three themes of the fifteen CLAS standards areGovernance, Leadership, and workforce; Communication and Language Assistance; and Engagement, Continuous Improvement, and Accountability. The standards clearly emphasized that the top levels of an organizational leadership hold the responsibility for CLAS implementation, and that language assistance should be provided when needed, and quality improvement, community engagement, and evaluation are importance.

Research emphasizes the need for culturally and linguistically sensitive services in providing healthcare to immigrant/minority populations, and studies show that interpreters and translation services could decrease linguistic barriers for minorities in clinical health settings. Communities who don't speak the dominant language would have a hard time accessing and understanding healthcare, especially when it comes to insurance. Immigrant communities might face even higher barriers to access because of cultural differences and not knowing how things work. In these cases, interpreters and language services are especially important.

Variability in interpreter use

Though the standard of interpreter use in medical discourses has been perceived to be the solution for cross-linguistic encounters within the hospital flow, a close analysis of the social role of the translator uncovers varying effects on the quality of care and accuracy of medical advice. A previous study of 83 U.S. public and private hospitals reported an average of 11 percent of the patient population requiring interpreter services. At one particular hospital, only seven full-time Spanish-English interpreters were hired to attend to the linguistic needs of 33,000 patients in need of Spanish interpretation. The high demand but low value for this position generates interpreters who may be ill-fit for the responsibility, consistently running late and not having the adequate training to perfectly translate the patient's needs or the doctors orders. Ad hoc translators were found to display a higher level of error frequency in their patient interactions with 77% of the translations being found to some level of inaccuracy. This is relatively higher compared to professional medical translators. Ad hoc translators are nurses, family members, or other available bilingual staff that are utilized on the spot for translation purposes. However, in the same study, professional translators were still found to exhibit error in 53% in their evaluated interactions. In a review of 28 in-site research studies conducted, use of professional interpreters was associated with overall improved clinical care in four categories: communication, utilization, clinical outcomes, and satisfaction. Of the twenty-eight, only six were found to have an overall patient rating of "satisfactory" or higher in the context of their clinic care with the use of a professional translator.

One of the big problems with language services is that it is maintained by the hospitals and clinics, and is the first to be cut in financial strain. Health insurance also does not reimburse the use of interpreters. It is shown from these studies that professional translation and interpreter services, coupled with language education, are not enough to overcome these cultural and linguistic hurdles. Clough et al. suggests that “culturally competent guidance provided by navigators from a patient's own ethnic community [patient navigators] might play a major role in overcoming barriers to healthcare.” 

Community Navigators (also known as community health workers, patient navigators, health advocates, and a variety of other names) are healthcare workers who are trained to provide culturally appropriate support to populations with historically limited access to healthcare. Community Navigators work as the bridge between patients and providers, and help patients overcome language barriers, financial barriers, unfamiliarity with the healthcare system, cultural and religious differences, and more. In studies, Community Navigators have been found to improve primary outcomes relating to chronic disease management. For example, in studies, Community Navigators at Federally Qualified Health Clinics helped improve the cancer diagnosis and screening process and timeline among underserved, vulnerable populations. Many clinical practices, especially Federally Qualified Health Clinics, employ Community Navigators.

Cultural barriers

Diversity

One factor that impinges on delivery culturally competent care is the degree in which the leadership and workforce of the physician population reflect the rates of minority groups in the United States. Research has shown that for minority patients, racial similarity between patient and physician correlates with a greater sense of patient satisfaction. On a study conducted on a cohort of 147,815 primary care physicians, the Black, Hispanic, and Native American groups together constituted 13.4 percent of the population as compared. However, since 2018, these groups comprised a total of 33 percent of the population of the United States. Despite the small pool of Black and Hispanic physicians, studies show that 25 percent of Black patients participating in a study and 23 percent of the Hispanic patients had primary care physicians that coincided with their racial identity. Given their connections and experiences, minority health professionals are more likely to develop care models that more effectively meet the needs of the communities they serve. The lack of diversity and sociocultural awareness risks the chance of stereotyping patients or having lack of attentiveness to the individual needs of their patients.

A study of Asian American children showed that ethnic match between mental health provider and client increased the likelihood that the client would utilize the services, the number of sessions attended, and the functioning score at discharge, as well as decreased the likelihood the client would drop out of treatment. According to studies, a diverse and socially inclusive workforce is incredibly important. Thomson writes that direct provider-patient communication increases the chances of the patient's customs and beliefs being understood and taken into account during treatment, leading to better care.

Europe

International migration is a global and complex phenomenon. Many European countries, including Belgium, are experiencing increasing population diversity arising from international immigration. Labor migrants, past colonial links, and, for some countries, their strategic position in the European Union are factors contributing to this diversity. Leadership and Cultural Competence of Healthcare Professionals 2015

Routine medical care in Germany, Austria, and Switzerland is being increasingly impacted by the cultural and linguistic diversity of an ever more complex world. Both at home and as part of international student exchanges, medical students are confronted with different ways of thinking and acting in relation to health and disease. Despite an increasing number of courses on cultural competence and global health at German-speaking medical schools, systematic approaches are lacking on how to integrate this topic into medical curricula. Cultural Competence and Global Health: Perspectives for Medical Education – Position paper of the GMA Committee on Cultural Competence and Global Health 2018

Saturday, August 24, 2024

Culture-bound syndrome

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Culture-bound_syndrome
In medicine and medical anthropology, a culture-bound syndrome, culture-specific syndrome, or folk illness is a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or culture. There are no objective biochemical or structural alterations of body organs or functions, and the disease is not recognized in other cultures. The term culture-bound syndrome was included in the fourth version of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1994) which also includes a list of the most common culture-bound conditions (DSM-IV: Appendix I). Its counterpart in the framework of ICD-10 (Chapter V) is the culture-specific disorders defined in Annex 2 of the Diagnostic criteria for research.

More broadly, an endemic that can be attributed to certain behavior patterns within a specific culture by suggestion may be referred to as a potential behavioral epidemic. As in the cases of drug use, or alcohol and smoking abuses, transmission can be determined by communal reinforcement and person-to-person interactions. On etiological grounds, it can be difficult to distinguish the causal contribution of culture upon disease from other environmental factors such as toxicity.

Identification

A culture-specific syndrome is characterized by:

  • categorization as a disease in the culture (i.e., not a voluntary behaviour or false claim)
  • widespread familiarity in the culture
  • complete lack of familiarity or misunderstanding of the condition to people in other cultures
  • no objectively demonstrable biochemical or tissue abnormalities (signs)
  • recognition and treatment by the folk medicine of the culture

Some culture-specific syndromes involve somatic symptoms (pain or disturbed function of a body part), while others are purely behavioral. Some culture-bound syndromes appear with similar features in several cultures, but with locally specific traits, such as penis panics.

A culture-specific syndrome is not the same as a geographically localized disease with specific, identifiable, causal tissue abnormalities, such as kuru or sleeping sickness, or genetic conditions limited to certain populations. It is possible that a condition originally assumed to be a culture-bound behavioral syndrome is found to have a biological cause; from a medical perspective it would then be redefined into another nosological category.

Medical perspectives

The American Psychiatric Association states the following:

The term culture-bound syndrome denotes recurrent, locality-specific patterns of aberrant behavior and troubling experience that may or may not be linked to a particular DSM-IV diagnostic category. Many of these patterns are indigenously considered to be "illnesses," or at least afflictions, and most have local names. Although presentations conforming to the major DSM-IV categories can be found throughout the world, the particular symptoms, course, and social response are very often influenced by local cultural factors. In contrast, culture-bound syndromes are generally limited to specific societies or culture areas and are localized, folk, diagnostic categories that frame coherent meanings for certain repetitive, patterned, and troubling sets of experiences and observations.

The term culture-bound syndrome is controversial since it reflects the different opinions of anthropologists and psychiatrists. Anthropologists have a tendency to emphasize the relativistic and culture-specific dimensions of the syndromes, while physicians tend to emphasize the universal and neuropsychological dimensions. Guarnaccia & Rogler (1999) have argued in favor of investigating culture-bound syndromes on their own terms, and believe that the syndromes have enough cultural integrity to be treated as independent objects of research.

Guarnaccia and Rogler demonstrate the issues that occur when diagnosing cultural bound disorders using the DSM-IV. One of the key problems that arise is the "subsumption of culture bound syndromes into psychiatric categories", which ultimately creates a medical hegemony and places the western perspective above that of other cultural and epistemological explanations of disease. The urgency for further investigation or reconsideration of the DSM-IV's authoritative power is emphasized, as the DSM becomes an international document for research and medical systems abroad. Guarnaccia and Rogler provide two research questions that must be considered, "firstly, how much do we know about the culture-bound syndromes for us to be able to fit them into standard classification; and secondly, whether such a standard and exhaustive classification in fact exists".

It is suggested that the problematic nature of the DSM becomes evident when viewed as definitively conclusive. Questions are raised to whether culture-bound syndromes can be treated as discrete entities, or whether their symptoms are generalized and perceived as an amalgamation of previously diagnosed illnesses. If this is the case, then the DSM may be what Bruno Latour would define as "particular universalism". In that the Western medical system views itself to have a privileged insight into the true intelligence of nature, in contrast to the model provided by other cultural perspectives.

Some studies suggest that culture-bound syndromes represent an acceptable way within a specific culture (and cultural context) among certain vulnerable individuals (i.e. an ataque de nervios at a funeral in Puerto Rico) to express distress in the wake of a traumatic experience. A similar manifestation of distress when displaced into a North American medical culture may lead to a very different, even adverse outcome for a given individual and the individual's family. The history and etymology of some syndromes such as brain-fog syndrome, have also been reattributed to 19th century Victorian Britain rather than West Africa.

In 2013, the DSM 5 dropped the term culture-bound syndrome, preferring the new name "cultural concepts of distress".

Cultural collision between medical perspectives

Within the traditional Hmong culture, epilepsy (qaug dab peg) directly translates to "the spirit catches you and you fall down" which is said to be an evil spirit called a dab that captures one's soul and makes one ill. In this culture, individuals with seizures are seen to be blessed with a gift: an access point into the spiritual realm which no one else has been given. In westernised society, epilepsy is recognized as a serious long-term brain condition that can have a major impairment on an individual's life. The way the illness is dealt with in Hmong culture is vastly different due to the high status epilepsy has in the culture, compared to individuals who have the condition in westernised societies. Individuals with epilepsy within the Hmong culture are a source of pride for their family.

Another culture-bound illness is neurasthenia, which is a vaguely described medical ailment in Chinese culture that presents as lassitude, weariness, headaches, and irritability and is mostly linked to emotional disturbance. A report done in 1942 showed that 87% of patients diagnosed by Chinese psychiatrists as having neurasthenia could be reclassified as having major depression according to the DSM-3 criteria. Another study conducted in Hong Kong showed that most patients selectively presented their symptoms according to what they perceived as appropriate and tended to only focus on somatic suffering, rather than the emotional problems they were facing.

Globalisation

Globalisation is a process whereby information, cultures, jobs, goods, and services are spread across national borders. This has had a powerful impact on the 21st century in many ways including through enriching cultural awareness across the globe. Greater level of cultural integration is occurring due to rapid industrialisation and globalisation, with cultures absorbing more influences from each other. As cultural awareness begins to increase between countries, there is a consideration into whether cultural bound syndromes will slowly lose their geographically bound nature and become commonly known syndromes that will then become internationally recognised.

Anthropologist and psychiatrist Roland Littlewood makes the observation that these diseases are likely to vanish in an increasingly homogenous global culture in the face of globalisation and industrialisation. Depression, for example, was once only accepted in western societies; it is now recognised as a mental disorder in all parts of the world. In contrast to Eastern civilizations such as Taiwan, depression is still much more common in Western cultures like the United States. This could indicate that globalisation may have an impact on allowing disorders to be spread across borders, but these disorders may remain predominant in certain cultures.

DSM-IV-TR list

The fourth edition of Diagnostic and Statistical Manual of Mental Disorders classifies the below syndromes as culture-bound syndromes:

Name Geographical localization/populations
Running amok Brunei, Singapore, Malaysia, Indonesia, Philippines, Timor-Leste
Ataque de nervios Latinos in the United States and Latin America
Bilis, cólera
Bouffée délirante France and French-speaking countries
Brain fag syndrome West African students
Dhat syndrome India
Falling-out, blacking out Southern United States and Caribbean
Ghost sickness Native American (Navajo, Muscogee/Creek)
Hwabyeong Korean
Koro Chinese, Malaysian and Indonesian populations in Southeast Asia; Assam; occasionally in the West
Latah Malaysia and Indonesia, as well as the Philippines (as mali-mali, particularly among Tagalogs)
Locura Latinos in the United States and Latin America
Mal de pelea Puerto Rico
Evil eye Mediterranean; Hispanic populations and Ethiopia
Piblokto Arctic and subarctic Inuit populations
Zou huo ru mo (Qigong psychotic reaction) Han Chinese
Rootwork Southern United States, Caribbean nations
Sangue dormido Cape Verde
Shenjing shuairuo Han Chinese
Shenkui, shen-k'uei Han Chinese
Shinbyeong Koreans
Spell African American, White populations in the Southern United States and Ethiopia
Susto Latinos in the United States; Mexico, Central America and South America
Taijin kyofusho Japanese
Zār Ethiopia, Somalia, Egypt, Sudan, Iran, and other North African and Middle Eastern societies

DSM-5 list

The fifth edition of Diagnostic and Statistical Manual of Mental Disorders classifies the below syndromes as cultural concepts of distress, a closely related concept:

Name Geographical localization/populations
Ataque de nervios Latin America
Dhat syndrome India
Khyâl cap Cambodian
Ghost sickness Native American
Kufungisisa Zimbabwe
Maladi moun Haiti
Shenjing shuairuo Han Chinese
Susto Latinos in the United States; Mexico, Central and South America
Taijin kyofusho Japanese

ICD-10 list

The 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD) classifies the below syndromes as culture-specific disorders:

Name Geographical localization/populations
Amok Southeast Asian Austronesians
Dhat syndrome (dhātu), shen-k'uei, jiryan India; Taiwan
Koro, suk yeong, jinjin bemar Southeast Asia, India, China
Latah Malaysia and Indonesia
Ataque de nervios Mexico, Central and South America
Pa-leng (frigophobia) Taiwan; Southeast Asia
Pibloktoq (Arctic hysteria) Inuit living within the Arctic Circle
Susto, espanto Mexico, Central and South America
Taijin kyofusho, shinkeishitsu (anthropophobia) Japan
Ufufuyane, saka Kenya; southern Africa (among Bantu, Zulu, and affiliated groups)
Uqamairineq [ru] Inuit living within the Arctic Circle
Fear of Windigo Indigenous people of north-east America

Other examples

Though "the ethnocentric bias of Euro-American psychiatrists has led to the idea that culture-bound syndromes are confined to non-Western cultures", within the contiguous United States, the consumption of kaolin, a type of clay, has been proposed as a culture-bound syndrome observed in African Americans in the rural South, particularly in areas in which the mining of kaolin is common.

In South Africa, among the Xhosa people, the syndrome of amafufunyana is commonly used to describe those believed to be possessed by demons or other malevolent spirits. Traditional healers in the culture usually perform exorcisms in order to drive off these spirits. Upon investigating the phenomenon, researchers found that many of the people claimed to be affected by the syndrome exhibited the traits and characteristics of schizophrenia.

Some researchers have suggested that both premenstrual syndrome (PMS) and the more severe premenstrual dysphoric disorder (PMDD), which have currently unknown physical mechanisms, are Western culture-bound syndromes. However, this is controversial.

Tarantism is an expression of mass psychogenic illness documented in Southern Italy since the 11th century.

Morgellons is a rare self-diagnosed skin condition that has been described as "a socially transmitted disease over the Internet".

Vegetative-vascular dystonia can be considered an example of somatic condition formally recognised by local medical communities in former Soviet Union countries, but not in Western classification systems. Its umbrella term nature as neurological condition also results in diagnosing neurotic patients as neurological ones, in effect substituting possible psychiatric stigma with culture-bound syndrome disguised as a neurological condition.

Refugee children in Sweden have been known to fall into coma-like states on learning their families will be deported. The condition, known in Swedish as uppgivenhetssyndrom, or resignation syndrome, is believed to only exist among the refugee population in Sweden, where it has been prevalent since the early part of the 21st century. In a 130-page report on the condition commissioned by the government and published in 2006, a team of psychologists, political scientists, and sociologists hypothesized that it was a culture-bound syndrome.

A startle disorder similar to latah, called imu [ja] (sometimes spelled imu:), is found among Ainu people, both Sakhalin Ainu and Hokkaido Ainu.

A condition similar to piblokto, called menerik [ru] (sometimes meryachenie), is found among Yakuts, Yukaghirs, and Evenks living in Siberia.

The trance-like violent behavior of the Viking age berserkers – behavior that disappeared with the arrival of Christianity – has been described as a culture-bound syndrome.

Introduction to entropy

From Wikipedia, the free encyclopedia https://en.wikipedia.org/wiki/Introduct...