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Cultural Competency for the Health Professional

Patti R. Rose, MPH, EdD

University of Miami
Miami, Florida
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Library of Congress Cataloging-in-Publication Data
Rose, Patti Renee.
Cultural competency for the health professional / Patti R. Rose.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4496-1451-5
I. Title.
[DNLM: 1. Cultural Competency—United States. 2. Allied Health Personnel—United States. 3. Professional-Patient Relations—
United States. W 21]

610.69’6--dc23
2012001358
6048
Printed in the United States of America
16 15 14 13 12 10 9 8 7 6 5 4 3 2 1
Dedication

With deep and abiding gratitude, I dedicate this work to my wonderful husband, Jeffrey, and our two beautiful and
intelligent children, now young adults, Courtney and Brandon. I am extremely proud of these three fantastic people and
love them intensely. I have been blessed with the joyful experience of being married to my husband for over 25 years
and we have been honored with the gift of raising two wonderful children together. This dedication is offered to Jeff,
Courtney, and Brandon, humbly and with appreciation that life has given us cherished moments and memories together
that will last a lifetime.
Also, although they have departed this earth, I dedicate this book to the memory of my beloved brother Rande, who,
beyond being my sibling, was a wonderful friend, and my mother, Effie, who was the strongest and most intuitive
woman I have ever encountered. They both inspired me and helped me to define myself in this complex world. They
solidified my understanding that people are in your life for a season/reason/lifetime. I enjoyed both the season and
reason for sharing a portion of my life experience with them and I am grateful that I had the experience of knowing
them.
Contents

Preface
Acknowledgments
About the Author
Contributors
Reviewers

Chapter 1 Introduction
Chapter Organization

Chapter 2 Overview and Specific Details of Various Racial, Cultural, and Ethnic Groups
Introduction
Racial Groups
African American/Black
Native American/Alaska Native
Asian American and Pacific Islander
White
Ethnic Group
Hispanic/Latino
Conclusion
Chapter Summary
Chapter Problems
References
Suggested Readings

Chapter 3 Relevance of Cultural Competency to Various Health Professions

Introduction
Political Correctness as a Necessary Consideration for Cultural Competency
Considering Cultural Competency in All Healthcare Settings
Difference Between Interpretation and Translation
Visual Affirmation in the Healthcare Setting
Diversifying the Health Service Professional Workforce
Trust
Conclusion
Chapter Summary
Chapter Problems
References
Suggested Readings

Chapter 4 Health Professions and Understanding Cultural Concerns

Introduction
Cultural Views Regarding Modern Medical Practices
Recruiting Diverse Healthcare Professionals
Cultural Competence Continuum
Cultural Destructiveness
Cultural Incapacity
Cultural Blindness
Cultural Precompetence
Cultural Competence
Cultural Proficiency
Cultural Competence Framework
Parameters that Differentiate Cultures
 Purnell Model for Cultural Competence
LEARN Model
Assumption Exercise
Conclusion
Chapter Summary
Chapter Problems
References
Suggested Readings

Chapter 5 US Educational System and the Intersection of Cultural Competency and Health Literacy
Introduction
Educational Interventions in the United States
Teach for America
No Child Left Behind and Race to the Top
Health Literacy
Responsibility of Health Professionals
Conclusion
Chapter Summary
Chapter Problems
References
Suggested Readings

Chapter 6 Cultural Competency and the Need to Eliminate Health Disparities

Contributing Author: Anthony Munroe, MPH, MBA, EdD
Introduction
Health Disparities Defined
An Historical Overview of Health Disparities
Health Disparities and Minority Groups
Immigration and Cultural Competency
Cultural Competency as a Contributing Factor Toward Health Disparities
The Role of Culturally Competent Health Professionals in Closing the Gap
Conclusion
Chapter Summary
Chapter Problems
References

Chapter 7 Cultural Competency and Assessment

Introduction
Attitudes
Assessment
Test–Retest Reliability
Alternative form Reliability
Internal Consistency Reliability
Validity
Cultural Competence Assessment Tool
Importance of Valid and Reliable Assessment Tools
Conclusion
Chapter Summary
Chapter Problems
References
Suggested Readings

Chapter 8 Cultural Competence Training

Introduction
Significance of Cultural Competence Training
Approaches to Training
Elements to Ensure Successful Training Programs
Cross-Cultural Education and Other Training Essentials
Importance of Providing Key Terms Relevant to Cultural Competence
Key Components of Cultural Competence Training
Evaluation of Cultural Competence Training
Conclusion
 Chapter Summary
Chapter Problems
References
Suggested Readings

Chapter 9 Case Studies

Introduction
Dental Hygienists
Case Study
Comments
Physical Therapists
Case Study
Comments
Occupational Therapists
Case Study
Comments
Speech-Language Therapists
Case Study
Comments
Pharmacists
Case Study
Comments
Radiology Technicians
Case Study
Comments
Emergency Medical Technicians
Case Study
Comments
Medical Records Technicians
Case Study
Comments
Physician Assistants
Case Study
Comments
Medical Assistants
Case Study
Comments
Nurses
Case Study
Comments
Dentists
Case Study
Comments
Chapter Summary
References
Suggested Readings

Chapter 10 Healthcare Reform and Economic Concerns Regarding Cultural Competency

Introduction
Interview
Conclusion
References
Suggested Reading

Chapter 11 Psychosocial Impact of Culturally Incompetent Health Care

Contributing Author: Omari W. Keeles, MPH, MA, EdM
What Exactly is Culture?
Prejudice, Discrimination, and Racism
Prejudice
Discrimination
Racism
Aversive Racism
 Racial Microaggresions
Microassault
Microinsult
Microinvalidation
Psychosocial Outcomes of Culturally Incompetent Care
Clash of Racial Realities
Invisibility of Unintentional Expressions of Bias
Perceived Minimal Harm of Racial Microaggression
Catch-22 of Responding to Microaggressions
Conclusion
Chapter Summary
Chapter Problems
References
Suggested Readings

Chapter 12 Health Professionals and the Paradigm Shift

Introduction
Need for a Paradigm Shift
Expansion of Minority Markets
Investing in Cultural Competence
Business Aspect of Health Care
Decreasing Malpractice Claims
Enhanced Customer Service and Quality of Care
Conclusion
Chapter Summary
Chapter Problems
References
Suggested Readings

Chapter 13 Culturally and Linguistically Appropriate Services Standards: An Overview

Introduction
Culturally and Linguistically Appropriate Standards
Need for CLAS Standards and Action Plans for Administrators
Qualitative Research
Conclusion
Chapter Summary
Chapter Problems
References
Suggested Readings

Chapter 14 Ultimate Challenge: Educational and Institutional Considerations for the Health Professions
Introduction
American Medical Association
Joint Commission on Accreditation of Healthcare Organizations
Institute of Medicine
Agency for Healthcare Research and Quality
Sullivan Commission
Necessary Educational Requirements
Challenging Health Professionals
Conclusion
Chapter Summary
Chapter Problems
References
Suggested Readings

Appendix I Cultural Competence Assessment Survey

Executive Team and Management

Appendix II Cultural Competence Assessment Survey

Staff

Appendix III Cultural Competence Assessment Survey

 Health Professionals

Appendix IV Glossary of Important Terms

Appendix V Websites and Resources

Cultural Competence and Other Relevant Websites
Journal Articles and Books

Appendix VI Cultural Competence Plan

Appendix VII Cultural Competence Accreditation Information for Selected (Examples) Health Professions
Individual and Cultural Differences
Professional Practice Expectation: Communication
Professional Practice Expectation: Cultural Competence
Interaction and Personal Qualities

Appendix VIII Sample Focus Group Questions for Qualitative Cultural Competence Research
Questions

Appendix IX Acronyms
Index
Preface

The 2010 Census data has emerged, and it is clear the United States is more diverse than ever before. Consequently, the
term “minority,” which is used to describe various racial groups and the Hispanic ethnic group, in terms of their
previous national percentages relative to the mainstream population, is becoming obsolete. The current replacement
term for minority is “emerging majority.” This new information is relevant to health professionals and will help them
serve these emerging majority groups in a more culturally competent manner. According to Kosoko-Lasaki, Cook, and
O’Brien (2009, p. xiii), “Cultural competency has been addressed by legislative, accreditation and regulatory mandates
since 1946 (Hill-Burton) Act (p. xiii).” To some this is a known fact, but I often encounter individuals who disagree
with the necessity for cultural competency. For example, I recently gave a presentation for approximately 300 health
professionals at a university. The lecture was entitled “Cultural Competency in the Clinical Setting.” The main points
in my lecture, also covered in this text, were to explain the difference between cultural competency and diversity,
provide insight into nuances of various cultural groups, and review the cultural competence continuum.
After the lecture I was met with a long line of students, eager to ask questions and speak with me one-on-one. One
student approached me and indicated he had a great deal of concern about the focus of my talk; he stressed that it
promoted “tribalism.” He believed all people immigrating to the United States or from a minority group living in the
United States should assimilate to the mainstream culture. He also believed that there should not be accommodations
made to meet “their” needs but they should conform to “our” way of life. Interestingly, I was not surprised by his
comments. There are always individuals in attendance who have strongly held beliefs in this regard. From a linguistic
competency perspective, some of these same individuals believe that in order to be treated by health professionals,
patients must speak English. This view does not take into consideration the need to value and appreciate the diversity
of all people, and the importance of health professionals to continually learn about other cultures to ensure the
provision of optimal health services.
According to Snipp (2010), “The process of identifying some people as ‘like us’ and others as ‘not like us’ is one
that predates written history and quite possibly was present in the earliest forms of human societies” (p. 106). Snipp
(2010) further states “counting people by race is a tradition deeply embedded within the governing framework of the
United States” (p. 111). Understanding that there are culturally diverse groups in the United States who may or may not
want to assimilate into mainstream culture but nevertheless need health care providers who value and appreciate their
diversity, would seem to be an area of agreement in the healthcare field, but is not necessarily the case. Sometimes the
lack of cultural understanding leads to areas of concern, including malpractice suits and other forms of disagreement,
which are discussed thoroughly in this text.
The health professions are very diverse, with more than 200 recognized professional fields comprising a substantial
portion of the US healthcare workforce (all fields except for physicians and nurses are considered within the term
“health professionals” in this text). Because of the enormity of this field, the services are far reaching, resulting in
various encounters with culturally diverse individuals. Furthermore, as demographics continue to change rapidly in the
United States, occupations in the health professions continue to grow. To meet the needs of health care in the United
States, based on the new healthcare reform bill signed into law in 2010, there will inevitably be a need to increase the
number of those individuals who can help foster the system through the offering of their expertise. These individuals
include but are not limited to physician assistants, medical assistants, physical and occupational therapists, laboratory
technicians, radiology technologists, dental hygienists, dieticians, surgical assistants, phlebotomists,
audiologists/speech-language pathologists and respiratory therapists. Given that all these health professionals are
formally educated, clinically trained and credentialed within the context of the certification process, and registered
and/or licensed, it is clear that cultural competency should be included in the process. This inclusion in their education
will only enhance the health professional’s ability to interact with culturally diverse patients and hopefully provide
more positive outcomes. The following is according to Koenig (2008, p. 161):

The United States’ persistent health disparities are widely recognized. In 2003 the Institute of Medicine (IOM 2003)
published a major report examining the state of minority health in the United States. The report documented differences
in rates of common diseases like cancer or heart disease, as well as significant variations in mortality rates and overall
life expectancy. Black-white differences are especially troubling; U.S. whites consistently outlive blacks. And these
differences persist even among those with equal access to health insurance, such as those older than 65 who are covered
by Medicare. The experts convened by the IOM cited a large body of empirical research that underscores the existence
of this and other health disparities among U.S. groups.
 An important aspect of this book is the discussion of health disparities and its relevance to health professions.
Another aspect is to provide insight into how cultural competency, as a skill set acquired by health professionals, will
help to alleviate these serious issues health disparities cause. Clearly, a number of contributing factors are relevant to
health disparities, also pointed out by Koenig (2008, p. 161) in her indication that “… lack of health services, and
unequal treatment when care is sought, account for a significant portion of racial and ethnic health disparities….” This
text offers a detailed perspective on how cultural competency plays a crucial role in finding a resolution.

REFERENCES
Koenig, B., Lee, S. and Richardson, S., Eds. (2008) Revisiting race in a genomic age. Piscataway, N.J.: Rutgers
University Press.
Kosoko-Lasaki, S., Cook, C., & O’Brien R. (2009). Cultural proficiency in addressing health disparities. Sudbury,
MA: Jones and Bartlett.
Snipp, M. C. (2010). Defining race and ethnicity. In H. Marcus & P. Moya (Eds.), Doing race: 21 Essays for the 21st
century (pp. 106 and 111). New York: W.W. Norton and Company.
Acknowledgments

I would like to acknowledge my gratitude for a number of individuals who made this work possible. First, I begin with
my husband, Jeffrey, for his patience and painstaking reading of each chapter with his purple pen and for his
perspective as a teacher, letting me know, gently, where changes should be made. His advice and loving support of my
endeavors is immeasurable and deeply appreciated. Additionally, with gratitude and joy I acknowledge my two young
adult children, Courtney and Brandon. To me they are precious gems who inspire me with their zest for life and energy
as they eagerly make their way through young adulthood. Offering them insight and advice motivates me and keeps me
enthusiastic about all I strive to accomplish.
My daughter, Courtney Rose, who received a Master’s Degree in Education from Harvard University, is now a fifth
grade teacher and serving as a Teach for America Corp Member. Watching her serve in the challenging educational
system in the inner city is intense, but seeing her accomplish this courageous task is inspiring.
I also thank my son, Brandon Rose, who graduated from Yale University with a Bachelor’s Degree in History and
who is completing his third year of Law School at the University of Florida. Observing him complete a summer
associate position and receive and accept an offer as an associate with a prestigious law firm in Miami, which he will
begin upon graduation from law school, is a delight, knowing he is steadfastly achieving his goal to become an
attorney, successfully.
I thank my children because they inspire me and brighten my life experience, always. Their presence helps me to
accomplish my dreams and goals, one of which is to write books that hopefully will make a difference in the lives of
those who read them. The difference I attempt to make with my work is to bring to the forefront a clear understanding
that we must value and appreciate differences in each other as diversity and culture are wonderful aspects of life.
I also thank my colleagues, Dr. Anthony Munroe and Omari Keeles for their submission of one chapter each as
contributing authors. Their efforts are very important aspects of this work. Additionally, gratitude is offered to Dr.
Donna Shalala, current President of the University of Miami and former Secretary of the US Department of Health and
Human Services, for taking time out of her hectic schedule for an interview with me, which is the basis for Chapter 10.
Her candid, knowledgeable, and straightforward insight is deeply appreciated.
I also thank Dr. Edmund Abaka, Director of the Africana Studies Program at the University of Miami. As with my
first Cultural Competency text, he continued to offer support, ensuring that my teaching schedule was flexible enough
to enable me to write, although I had a heavy teaching load each semester. His encouraging words and understanding
lend to an environment of academic scholarship that was rewarding and uplifting as progress was made in the
completion of this book. I also want to thank Dr. Robert Fullilove, Public Health Professor at the Mailman School of
Public Health at Columbia University, for providing me with the opportunity to interview him. Although, ultimately, a
decision was made not to include the interview in this book, I thank him for taking time for a comprehensive, detailed
conversation with thoughtful and interesting insight regarding cultural competence as it relates to health care.
Additionally, I acknowledge, with gratitude, Shadeh Ferris-Francis for meticulously transcribing the interview with
Dr. Donna Shalala and serving as an invaluable assistant; Lorry Henderson for her research efforts regarding
accreditation as it relates to cultural competence and the health professions; and Regine Darius for her assistance with
the glossary of terms. I am grateful and proud of these student assistants for their commitment and tenacity in
completing the task assigned to them regarding this book.
Finally, and with the highest regard, I thank God, without whom nothing I achieve would be possible. There is a
power in this universe that is greater than my imagination can conceive, that intuitively guides my life, and with
gratitude I embrace and recognize this unseen and loving force for good.
About the Author

Dr. Patti Rose acquired her Master’s Degree in Health Services Administration from the Yale University School of
Public Health followed by her Doctorate in Health Education from Columbia University, Teachers College. She is the
author of Cultural Competency for Health Administration and Public Health, published by Jones and Bartlett
Publishers in 2011. She is currently a lecturer for the University of Miami Department of Anthropology where she
teaches courses for Africana and American and Women and Gender Studies Programs entitled “Black Women in
Medicine and Healing,” “Race and Healthcare in America,” “African Women in the Diaspora,” “Black America and
the Educational System: Ideology vs. Reality,” “Culture, Race and Diversity” and “Contemporary Issues in America.”
Formerly, she served as CEO of Rose Consulting, Inc., followed by CEO of Plainfield Health Center in Plainfield, NJ.
Before that she served as Vice President of Behavioral Health Services at The Jessie Trice Center for Community
Health, formerly known as Economic Opportunity Family Health Center (EOFHC), Inc., one of the largest community
health centers in the nation, located in Miami, Florida, and as Consultant for that organization and other health entities.
She has also held the title of Lecturer for the Yale University School of Public Health and Adjunct Professor for the
University of Miami Education Department and Executive MBA Program and for the Barry University Health Services
Administration Program, Associate Professor at Nova Southeastern University in Fort Lauderdale, Florida, and
Assistant Professor at Florida International University in Miami, Florida (graduate-level public health programs).
Her professional affiliations have included the American College of Health Care Executives, the American Public
Health Association, the Black Executive Forum, and the National Association of Health Services Executives. She was
inducted into the Public Health Service Honor Roll at the Yale University School of Public Health for her long-term
commitment to public health service and was appointed by the US Department of Commerce, National Institute of
Standards and Technology to serve in the capacity of Examiner on the 2004 Board of Examiners of the Malcolm
Baldrige National Quality Award. Dr. Rose has been married for 26 years and is the mother of two.
Contributors

Omari W. Keeles, MPH, MA, EdM

University of Michigan
Research Technician Senior
Ann Arbor, MI

Anthony Munroe, MPH, MBA, EdD

Malcolm X College
President
Chicago, IL
Reviewers

Carol Deakin, PhD, CCC/SLP

Associate Professor
Alabama A&M University
Normal, AL

LaKeisha L. Harris, PhD, CRC

Assistant Professor
University of Maryland Eastern Shore
Princess Anne, MD

DeAnna Henderson, PhD, LPC, CRC

Assistant Professor
Alabama State University
Montgomery, AL

Paul Leung, PhD

Professor
University of North Texas
Denton, TX

Tsega A. Mehreteab, PT, MS, DPT

Clinical Professor
Department of Physical Therapy
New York University
New York, NY

Mona Robinson, PhD, PCC-S, CRC

Associate Professor, Program Coordinator
Ohio University
Athens, OH

Sheila Thomas Watts, PT, DPT, GCS, MS, MBA

Professor, Clinical Instructor
Sacred Heart University
Fairfield, CT
 Chapter 1
Introduction

This book is intended for health professional students and practicing professionals and provides an overview of cultural
competency and its relevance to healthcare providers. Health professions addressed include pharmacists, physician
assistants, physical therapists, occupational therapists, speech-language pathologists, respiratory care technologists,
physical therapist assistants, occupational therapist assistants, pharmacy technicians, and radiology technologists. This
is in no way an exhaustive list because numerous career titles are relevant to the health professions.
Cultural competency is important and relevant to health professions primarily because patients need to feel
comfortable in receiving services at all levels of care. Patients who believe there is a lack of cultural understanding may
not express their medical concerns or fears and may decline to seek care or follow through on necessary suggestions
and treatment regimens offered by their healthcare providers. Furthermore, lack of cultural understanding can lead to
noncompliance on many levels, including missed appointments, seeking care from culturally accepted providers in
their community who may not be formally trained in the health professions, and not divulging pertinent information
such as certain nonpharmaceutical treatments they may be using, which may have a synergistic effect when combined
with treatments given by their healthcare providers.
These scenarios may lead to malpractice cases because the health professional may be found liable for providing
inadequate services due to lack of sufficient information because of trust issues with the patient. The medical history
assessment process, for example, must take into consideration patients’ cultural factors so that accurate information can
be gathered to ensure optimal provision of care to the patient based on said histories.
In the United States millions of people are without health care due to lack of health insurance and, consequently, are
medically underserved. Many of these individuals are poor and/or people of color. The new healthcare reform law will
not be implemented in its entirety until 2014. The legislation was designed to ensure that more Americans have access
to health care by changing how coverage is provided; factors such as job changes and others previously led to the
cancellation of coverage by insurance providers. In addition, people cannot be precluded from getting health care due
to preexisting conditions. As healthcare reform gradually unfolds more people will soon have access to health
insurance, and because those individuals who were disenfranchised were largely from minority groups with lower
socioeconomic status, it is inevitable that cultural competency will be a necessary factor in terms of moving forward in
serving all patients optimally.
Healthcare reform has also increased the need for additional healthcare professionals to meet the forthcoming rising
demand for healthcare services. For example, physician assistants and nurse practitioners may begin to fill the gap due
to the shortage of primary care providers. Schools that train health professionals must be poised to meet critical needs
and ensure their students are diverse and culturally competent. The health professional students in training to meet
these needs must be strong in their individual fields but also fully competent in terms of linguistic and cultural
competency in all settings, including hospitals, community health centers, physicians’ offices, and beyond. Cultural
competency skill sets must be provided throughout their coursework to enable them to work in a cross-cultural
capacity.
The new healthcare reform legislation is still a mystery to a certain degree because rules and guidance pertinent to
implementation of the law are still in progress. These changes will take place at both the federal and state level.
Cultural competency must be a key aspect of this process if a smooth transition is to occur. Healthcare professionals are
critical to this process and can help the efficiency of this transition if they are optimally trained to do so in all aspects of
their area of expertise. Consequently, cultural competency must be part of their curriculum as they are cultivated to
serve all, particularly as the growing demand for health care increases for individuals from all walks of life.
Although it is imperative to discuss the need for cultural competency as an important aspect of the work of health
professionals, it is equally important to point out some of the controversy surrounding issues pertaining to particular
groups that seek health care in the United States, namely undocumented immigrants. This text will not serve to debate
this issue, as there are varying opinions on this subject, but it is a hot button issue that is very relevant to cultural
competency and the health professions and so is explored to some degree in this work. On April 23, 2010 Arizona
Governor Jan Brewer sparked tremendous controversy when she signed an immigration bill for her state based on her
perception that the federal government was not protecting the Arizona border. Subsequently, on July 6, 2010 the
Obama Administration sued the State of Arizona and Governor Brewer regarding the new legislation, indicating the
Arizona law was unconstitutional and to preclude its implementation on July 29, 2010. No matter what takes place
between these entities, in terms of health care (and beyond) immigration reform, of some sort, must take place in
America as the provision of health care for undocumented immigrants remains a complex scenario without any clear-
cut solutions.
In the interim, as immigration reform is debated, understanding various cultures that must be legally provided for in
the United States, regardless of whether healthcare professionals agree with their immigration status, must be
considered. Immigrants, documented and undocumented, are covered under the Emergency Medical Treatment and
Active Labor Act, passed in 1986, which requires the provision of services to anyone in need of health care. This law
pertains to all hospitals receiving federal funding from the US Department of Health and Human Services, Centers for
Medicare & Medicaid Services under the Medicare Program, hence practically all hospitals. Immigration reform is
largely a political matter. Regardless of how the situation is resolved, health professionals remain responsible for the
provision of efficacious health care to their patients with cultural competency as a significant skill set.
In general, this text offers detailed descriptions of cultural and linguistic competency and other relevant terms and
establishes the relevance of cultural competency to the health professions. Cost concerns, rapid demographic change,
and cultural competency as a competitive change are also covered. Chapter 2 focuses on specific details associated with
the designated racial and ethnic groups in the United States as established by the US Office of Management and Budget
(OMB). Because various health professions offer services in many different settings, an exploration of the provision of
cultural competency is considered in Chapter 3. Insight is also provided regarding cultural nuances, interpretation
versus translation, multilingual signage, visual affirmation, and diversity of health professions.
Chapter 4 considers the curriculums of the health professions and why it is important to include cultural competency.
The cultural competence continuum will also be explained in detail and relevant models theories and concepts will be
considered within the context of cultural competency. Chapter 5 continues in this vein, focusing on the US educational
system and the intersection of cultural competence and health literacy. Educational interventions such as No Child Left
Behind, Race To The Top, and Teach for America are also discussed along with the issue of the digital divide.
Perspectives regarding standardized testing are explored as the goal of this chapter is to highlight how education or the
lack thereof impacts health and how cultural competency and health literacy intersect.
Chapter 6 focuses on the provision of a definition of health disparities along with an historical overview. An
explanation is also provided regarding health disparities among minority groups. The issue of immigration is also
discussed in terms of its relevance to cultural competency. The role of culturally competent health professionals in
terms of health disparities is also explored. Action steps taken by the federal government and other key entities are
highlighted. In Chapter 7 the cultural competency assessment process is reviewed with insight provided as to why this
process is imperative. Terms such as “reliability” and “validity” are explored, specific to survey instruments. Beyond
self-assessment, customer service assessment and its relevance to cultural competency is also considered.
Subsequently, Chapter 8 provides an overview of cultural competency and improved patient outcomes with a focus on
training programs, including implementation, evaluation, and cost-effectiveness.
A different approach is undertaken in Chapter 9 in that cultural competency case studies for specific health
professions are considered. As there are numerous health professions, examples are chosen that can be considered in a
broader context with relevance to other fields. Chapter 10 highlights key aspects of the new healthcare reform law and
its relevancy to the health professions and cultural competency. Funding of cultural competency initiatives are also
considered. This information is provided within the context of an interview with Dr. Donna Shalala, currently the
President of the University of Miami and the former Secretary of the US Department of Health and Human Services.
Chapter 11 explores the psychosocial impact of culturally incompetent care, focusing on the difference between
prejudice and racism. Explanations are provided regarding how culturally incompetent care can cause psychological
dilemmas for patients as well as explanations of microaggressions. Chapter 12 emphasizes the need for a paradigm
shift for health professionals and cultural competency. Furthermore, there is a discussion of the expansion of minority
markets, investing in cultural competence and the business aspect of health care, as well as decreasing malpractice
claims, enhanced customer service, and quality care. Culturally and Linguistically Appropriate Services standards as
well as qualitative research are discussed in Chapter 13. Finally, Chapter 14 focuses on the ultimate challenge in terms
of educational and institutional considerations for health professionals.

CHAPTER ORGANIZATION
Beginning with Chapter 2, each chapter contains learning objectives, a list of key terms, an introduction, a conclusion,
a summary chapter problems, references, and suggested readings. Chapter 9 has a different format in that only case
studies are provided. Chapter 10 consists of a brief introduction followed by an interview. Appendices are provided to
call attention to cultural competency attitudinal assessment surveys; a list of useful websites, journal articles, and
books; a list of acronyms; and sample focus group questions for further research and exploration, among others. An
index is provided for the convenience of the reader.
 Chapter 2
Overview and Specific Details of Various Racial, Cultural, and
Ethnic Groups

LEARNING OBJECTIVES
After reading this chapter you should be able to
• Understand the role the Office of Management and Budget in terms of racial and ethnic groups in the United States.
• List the major racial groups in the United States.
• Explain the fact that Hispanic is an ethnic, not a racial designation in the United States.
• Discuss specific details regarding African Americans/Blacks, Asians/Pacific Islanders, Native Americans and
Alaska Natives, Whites, and the Hispanic population.

KEY TERMS
African American
Asian American/Pacific Islander
Hispanic
Latino
Native American/Alaskan Native
Office of Management and Budget
White

INTRODUCTION
According to the US Department of Health and Human Services Office of Minority Health (2008), the Office of
Management and Budget (OMB) Standards for Race and Ethnicity were established as follows:

Development of these data standards stemmed in large measure from new responsibilities to enforce civil rights laws.
Data was needed to monitor equal access in housing, education, employment, and other areas, for populations that
historically had experienced discrimination and differential treatment because of their race or ethnicity. The categories
represent a social-political construct designed for collecting data on the race and ethnicity of broad population groups in
this country, and are not anthropologically or scientifically based.

Hence, in terms of the rationale for the use of certain categories in determining race and ethnicity in the United States,
the OMB is the entity at the forefront of this matter. It is important for health professionals to understand these
categories and learn as much about the cultural specifics of these groups as possible. There may be some disagreement
with the categories, but, nevertheless, they are in place. Understanding the categories enables the provision of optimal
care to patients based on an understanding of who they are and what they value, and provides them with care based on
appreciation and understanding of their culture.
In this chapter we explore these categories by considering details regarding the four racial groups identified by OMB
(Table 2-1): African American/Black, Asian/Pacific Islander, Native American or Alaska Native, and White.
Additionally, the OMB-designated ethnic group, Hispanic, is also explored.

Table 2-1 Office of Management and Budget’s Racial and Ethnic Categories/Standards
Category Description
Race
Native A person having origins in any of the original peoples of North America and who maintains
 American or cultural identification through tribal affiliations or community recognition.
Alaskan Native
Asian/Pacific A person having origins in any of the original peoples of the Far East, Southeast Asia, the
Islander Indian subcontinent, or the Pacific Islands. This area includes, for example, China, India,
Japan, Korea, the Philippine Islands, and Samoa.
African A person having origins in any of the black racial groups of Africa.
American/Black A person having origins in any of the original peoples of Europe, North Africa, or the
White Middle East.
Ethnicity
Hispanic A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish
culture or origin, regardless of race.
Source: Data from Standards for the classification of federal data on race and ethnicity. Office of Management and Budget (OMB),
August 1995.

RACIAL GROUPS
African American/Black
The history of African American/Black people in the United States is one that begins, for the most part, with the
unfortunate aspect that entailed chattel slavery. Many Africans (primarily from the West Coast) were brought to the
new world to serve as slaves on plantations owned by Europeans who had established colonies. African American
people, also referred to as Black people, per the OMB classification, currently comprise the largest racial minority
group in the United States and the second largest minority group. The latter categorization, second largest minority
group, is confounded by the fact that the Hispanic population, now designated the largest minority group, is not a racial
but an ethnic group. Black people are also part of this category as a person may be White Hispanic or Black Hispanic,
as an example. Therefore, if all Black Hispanic people were placed under the category of African American/Black,
perhaps the African American group would in fact be the largest minority group.
Nevertheless, given the significant numbers of African American/Black people in the United States, health
professionals need information regarding this group to provide optimal healthcare services. The greatest concentration
of Africa American/Black people can be found in Louisiana, Mississippi, Alabama, Georgia, South Carolina, and
Maryland (Office of Minority Health and Health Disparities, 2009). However, because there are large numbers of
African Americans/Blacks throughout the United States, although less concentrated in some areas than others, the
likelihood of health professionals serving this group is high, particularly in the aforementioned states, in great numbers,
and in cities beyond those listed above, albeit in smaller numbers. Therefore, it is imperative that health professionals
have knowledge and insight regarding the specific cultural aspects of this group.
According to the OMB, African American/Black people are any persons having origins in any of the Black racial
groups of Africa. Hence, this category assumes that African Americans/Blacks are direct descendants of Africans.
Although this may seem like an obvious fact, it is not necessarily clear to Black people in America or to groups of other
races whom they may encounter. For example, when teaching an undergraduate-level course entitled “Culture, Race
and Diversity,” I ask students, per an exercise, “How many students in this class, by show of hands, have ancestral
origins in any of the Black racial groups of Africa?” Often, many of the Black students will not raise their hands. When
queried about this, their responses indicate they believe their ancestral origins are in one of the Caribbean islands or
North or South America. They indicate they do not have origins, in terms of ancestors, in Africa and they are in fact in
no way of African descent. It leads to very interesting dialogue and sometimes they are enlightened, as college
students, to learn that their ancestral origins are African, even though these students may have been born in the
Caribbean or the United States. Generally, it is a matter of them not knowing the history of the most likely events that
led to their ancestors ultimately being born in the Americas or the Caribbean, namely slavery. This is compelling in
trying to learn how to serve Black people in America optimally, in terms of health care, as it is important to determine
their worldview.
For the health professional, this knowledge is important because it may be offensive to refer to patients as African
American when they consider themselves to be, for instance, Jamaican or Haitian. Some prefer to identify with their
family-related nationality rather than the place where they reside or were born. Hence, Jamaican, Haitian, Trinidadian,
and so on may be preferred identifying categories rather than African American/Black. Some individuals may find the
term “Black” to be politically incorrect because “African American” is the current term used to categorize Black
people. On the other hand, some may prefer the term “Black” because they believe it is a more unifying term that better
connects them to other people of African descent without division around the term “African American.”
In this text the terms “African American” and “Black” are used interchangeably to include all people who are of
African descent (not including White people or other racial groups born on the continent of Africa). In short, it is rather
complex, which is why it is important for health professionals to understand these multiple concerns so they may
establish a positive rapport with their patients. The best approach is to simply ask the person how she or he identifies
her- or himself in terms of race. Most people are able to provide a clear and cogent response that can then be organized
in terms of OMB standards if necessary. Again, it is important to note there may be disagreement with OMB
categorization and hence opposition to such, which is often the case.

Native American/Alaska Native

This group has quite an interesting history in that it is the only racial group in which its members are indigenous to the
United States. In fact, when Christopher Columbus arrived in America he thought he was in India and consequently
named the people who were already there “Indians.” This is clearly incorrect. Nevertheless, history records that he
“discovered” America even though the Native American people were already there. Hence, although the OMB refers to
this race of people as Native American and Alaska Natives, in this text they are referred to as Native Americans
(Alaska Natives), as they were native to American soil before Columbus arrived.
There are two points to consider here. First, because native peoples were already on the land when Columbus
arrived, America was not “discovered” by him. Second, referring to Native Americans as Indians, given the mistake
that was made by Columbus, becomes a derogatory act, and many Native Americans consider it as such. This issue
came to the forefront in the United States when the Ivy League Institution, Brown University, decided to change the
name of the holiday Columbus Day to Fall Weekend because of their concerns that Columbus took slaves back to
Spain and led the way for conquistadors to kill Native Americans (Dougherty & Reddy 2009). From a culturally
competent vantage point, health professionals will benefit from understanding why referring to Native Americans as
Indians may be deemed offensive and politically incorrect by some Native Americans and hence culturally
incompetent.
In 1790 the federal government held its first census but did not include a category for Native Americans, because
they were thought to exist outside of the nation (Cornell University Law School Legal Information Institute, 2010).
Although the United States exploited Native Americans and imposed its laws on their sovereign territories, Native
Americans continued to be ostracized and were defined as “domestic dependent nations” by the Marshall court in the
1831 Cherokee Nation v. Georgia ruling. In considering the Cherokee Nation, as an example, this ruling meant the US
Supreme Court had no primary jurisdiction within the Cherokee lands, which were considered not to be a part of the
United States. What has to be taken into consideration, however, is the fact that although Native American nations are
considered to be sovereign, the federal government still has jurisdiction over them, to a certain degree. This is
illustrated by the fact that genocidal acts have taken place against many Native American nations in the United States.
As the United States continued to expand, it was deemed necessary to eradicate those who were occupying desired
territory.
Consequently, Native Americans have suffered greatly, from a socioeconomic vantage point, due to the conquering
of their lands, in often brutal approaches. Many, as a result, experience serious health problems. As stated by Kosoko-
Lasaki, Cook, and O’Brien (2009) in terms of “past segregationist practices, inferior housing and physical
environments … disenfranchisement, extermination of tradition, language and land rights; broken treaties; sterilization
of Native women … and other experiences of oppression” (p. 230), trust is often a necessary factor in terms of the
provision of health care. Although the Indian Health Service is in place, under the auspices of the US Government,
Native Americans continue to suffer from a health perspective. Their cultures, values, beliefs, and health-seeking
behaviors may be different from mainstream Americans; consequently, to serve them optimally every effort must be
made by health professionals to become culturally adept at meeting their healthcare needs. Table 2-2 provides the
leading causes of death among Native Americans.
Additionally, Alaska Natives are a very diverse group and make up about 16% of the population of Alaska; they
consist of Native Americans (Athabascans, Tlingits, Haidas, Eyaks, and Tsimshians) and Eskimos (Inupiaqs and St.
Lawrence Island Yupiks and Yup’iks and Cup’iks) spread out over about 200 rural communities (Alaska Natives,
2010).

Table 2-2 Leading Causes of Death Among Native Americans in 1980 and 2004
Source: National Center for Health Statistics. (2006). Health, United States, 2006. With chartbook on trends of the health of Americans.
Hyattsville, MD: Author.

Asian American and Pacific Islander

According to the OMB people from Asia are placed in this category, defined as having origins in any of the original
peoples of the Far East, Southeast Asia, the Indian subcontinent, or the Pacific Islands. This category includes, for
example, China, India, Japan, Korea, the Philippine Islands, and Samoa. Because Asia is vast, language is not a
unifying factor for the Asian group. Consequently, both language and cultural differences distinguish one Asian group
from another very specifically. Furthermore, according to Duncan and Goddard (2005), Asian people are considered
the model minority group because of their tendency to assimilate into American society. They generally assimilate in
terms of education, a strict work ethic, and language (Reynolds, 2006).
Additionally, because of the significant number of languages spoken by Asian people, linguistic competency
becomes an issue for healthcare professionals in the process of providing the Asian population, generally speaking,
with optimal care. Reeves and Bennett (2003, p. 2) stated the following:
Ninety-five percent of all Asians and Pacific Islander people lived in metropolitan areas, a much greater proportion than
of non-Hispanic Whites (78 percent). Of the two populations, Asians and Pacific Islanders were twice as likely to live
in central cities located in metropolitan areas (41 percent compared with 21 percent). However, among those living in
metropolitan areas but not in central cities, Asians and Pacific Islander people were only 3 percentage points below
non-Hispanic Whites (54 percent and 57 percent, respectively).

The following is from the Pacific Islander Cultural Center (2010):

Pacific Islanders are originally from Polynesia, Melanesia, and Micronesia—Fiji, Guam, Hawai`i, Commonwealth of
Northern Mariana Islands, Republic of Palau, American and Western Samoa, and Tonga. Interestingly, their histories
vary.

Although these may be the locations they inhabit, understanding their ancestral origins is an important factor.
Although Fijians, for example, are placed under the category of Pacific Islanders, Fijian history indicates that the
people of Fiji are actually from East Africa, namely Tanganyika (Tanzania) (Rashidi, 2000). Therefore, although
people who inhabit the various islands of the Pacific are named as such, critical to understanding them culturally is
grasping a sense of their origins and how this influences their culture. Again taking Fijians as an example, if they are in
fact from Tanzania, they should be considered, per the OMB categorization, as African American/Black rather than
Asian American/Pacific Islander.

White
The inception of White people in America began with exploration and then colonization of the 13 colonies of the New
World. Although the British initially populated the colonies, independence was ultimately claimed and was soon
followed by an influx of 450,000 immigrants representing a dozen European nationalities: Dutch, Swedes, Scotch-Irish,
French, Spaniards, and so on (Hing, 2004). The history of White people in America is one that is largely based on
immigration. Whites are the dominant group, in terms of numbers and power in the United States, and hence the
current majority. Per the OMB, White people are identified as persons having origins in any of the original peoples of
Europe, North Africa, or the Middle East. The North African aspect of this definition is rather puzzling given that
North Africa comprises Algeria, Egypt, Libya, Morocco, Sudan, Tunisia, and Western Sahara and by its very name,
North Africa, is located on the continent of Africa. The only plausible explanation for labeling people of this region as
White is the fact that Europeans (namely, Greeks and Romans), Asians, and Arabs migrated into these areas that were
indigenously populated by Black people of Africa and became the dominant groups, leading to a variation of race that
is substantial when comparing North Africa with Sub-Saharan Africa. According to (Manneh, 2010, p. 1),
The government has treated Arabs as white since 1915, when George S. Dow, a Syrian immigrant living in Jim Crow
South Carolina, went to court after being deemed racially ineligible for citizenship based on a 1790 law limiting
citizenship to “free white persons.” In his decision granting Dow citizenship, U.S. Circuit Court Judge Chas A. Woods
ruled that the 1790 law was meant to “deny naturalization to negroes” and not peoples from the “western Asiatic side of
the Caspian Sea and the Ganges.” “It seems reasonable to think that Congress must have believed there were white
persons natives of countries outside of Europe,” he wrote. “As the consensus of opinion at the time of the enactment of
the statute now in force was that they were so closely related to their neighbors on the European side of the
Mediterranean that they should be classed as white, they must be held to fall within the term white persons.”

In actuality, the categorization of Arabs as Whites, as established by OMB, has been largely detrimental to this group
in the United States. As indicated by Manneh (2010, p. 1), the following occurred:
White people look at us as black people and black people look at us as white people,” Hanania said. “Most Arab grocers
open stores in black neighborhoods because they’re treated better, it’s easier for Arabs to assimilate in African-
American communities … the black community is more sympathetic to the discrimination Arabs face.”

The notion of who is White and who is not goes as far back as Ancient Egypt. Although Egypt is located in North
Africa and is largely composed of Arabs today, before the arrival of Arabs the inhabitants of Egypt were Greeks,
Romans, and Persians. Initially, however, during the Old, Middle, and New Kingdoms, which were the timeframes of
the Pharaohs, Egyptians were largely Africans interspersed with various groups (the Hyskos from Asia, who were
neither European nor Arabs, etc.) during intermediate periods (Jochannan, 1989). Arabs technically did not arrive in
Egypt until 640 A.D. Hence, the OMB’s definition and classification of Arab people as White lacks accuracy given
they are not the original peoples of North Africa. This only confuses those who are using this definition as a guide in
terms of clarifying this racial group and understanding them culturally. Therefore, perhaps a more reliable
determination as to who falls into the category of White is self-identification. Bahk and Jandi (2004, pp. 58–59) stated
the following:
According to a U.S. Labor Department survey of approximately 60,000 households as to how they prefer to be
identified as people not belonging to Asian American, American Indian, Black, Hispanic, or multiracial, the most
favorite term chosen by 61.7% of the population was white.

Perhaps the rationale for the categorization of one’s self as White is due to the privilege that accompanies such a
choice as the dominant group in the United States. Specifically, White people in the United States hold long-term
advantages in terms of wealth and power with better health outcomes as compared with minority groups.

ETHNIC GROUP
Hispanic/Latino
The key factor related to the term “Hispanic” is that it is an ethnic rather than racial designation. See Table 2-1 for
OMB’s categorization of Hispanic people. Nevertheless, Saragoza, Juarez, Valenzuela, and Gonzalez (1992, p. 45)
point out the following, which is critical to understanding this term within the context of people designated as Hispanic:

The diversity of the groups commonly covered by the term Hispanic is complicated by a number of factors including
the particular aspects of the history of relations between the U.S. and Mexico, Puerto Rico, Cuba and the seven distinct
countries that make up Central America. Immigration from these areas has been directly affected by domestic and
foreign policies from the U.S. This is not to mention the individual histories and cultures of Latin America including the
Portuguese speaking nation of Brazil, as well as the French and British influenced islands of the Caribbean.
Furthermore, the wide range of patterns of race, ethnicity, and cultural expression in Latin America extended from the
Rio Bravo (Rio Grande) to the Patagonia, defy easy generalization. More specifically, a host of terms have emerged
over time to describe a variety of groups currently covered by the Hispanic classification.

Saragoza et al. (1992, p. 45) continue as follows:

In short, no indelible physical characteristics, language or cultural norms are shared by all of the people south of the
 US-Mexico border that would invariably unify them under one ethnic or racial term. Hence, the term Hispanic presents
several difficulties of definitions.

Additionally, race and color are problematic to the term “Hispanic” and merely serve as unclear categories of
definition and identification (Saragoza et al., 1992). To that end, healthcare professionals providing services to
Hispanic people should consider a number of factors, including nationality, which is an identity defined by a person’s
place of legal birth or by a person’s associational citizenship status governed by where an individual resides and works,
which may defy national boundaries and sovereignty (Borak, Fiellin, & Chemerynski, 2004). Table 2-3 provides detail
regarding sociodemographic characteristics of Hispanics.
The term “Latino” is also significant in that it is often used interchangeably with “Hispanic.” Generally, “Hispanic”
refers to people from the predominantly White Iberian Peninsula (including Spain and Portugal), whereas Latinos are
generally from the Americas south of the United States and the Caribbean who are descendants from the brown
indigenous Native Americans who were conquered by the Spaniards in the distant past. Table 2-4 shows the
percentages of racial and ethnic groups in Latin America.

CONCLUSION
The OMB has established four racial and one ethnic category that are the basis for determining the race or ethnicity of
individuals in the United States. Individuals may choose more than one racial category as well as the ethnic category.
For example, a person may indicate that he or she is White Hispanic or Black Hispanic with White and Black as racial
categories and Hispanic as the ethnicity. Although these categories were developed to simplify the process of racial and
ethnic categorization, in actuality such a process causes confusion for many and requires clarification. Individuals may
not agree with the OMB categories or may not understand with which classification to identify. Nevertheless, their
cultural differences based on their nationalities, racial, and ethnic identification and beyond may impact their health-
seeking behaviors and other factors associated with their health (e.g., dietary patterns). Therefore, it is important for
health professionals to understand the OMB categories and associated concerns and to learn as much as possible about
the wide array of cultures that exist in the United States.

Table 2-3 Sociodemographic Characteristics of Hispanics

Characteristic Value
Hispanic or Latino (2006) 47.5 million
In the 50 States 43.7 million
Commonwealth of Puerto Rico 3.8 million
Population not Hispanic or Latino 255.4 million
Total US population (50 states) (2006) 299.1 million
Hispanic subpopulations (2006)
Mexican Americans 66.0%
Puerto Ricans 9.4%
Central Americans 7.8%
South Americans 5.2%
Cuban Americans 4.0%
Other Hispanics 7.6%
Hispanics Non-Hispanic
Whites
Median age, year, Hispanics (2007) 27.4 40.5
≥65 years (2005) 6% 15%
Education, completed high school or more (2004) 58.4% 90%
Income: families with annual earnings <$35,000 50.9% 26%
Sources: US Bureau of Census, 2005 Puerto Rico Survey (B03002-3-est): 2006b; US Bureau of the Census. The Hispanic Population in
the United States: March 2004. Current Population Reports, Data Tables including Educational Attainment in the United States,
Detailed Tables (PPL-169) (does not include Commonwealth of Puerto Rico). Internet release, last revised March 2004; US Bureau of
the Census. Annual estimates of the population by sex, race, and Hispanic or Latino origin for the United States: July 1, 2006 (NC-EST
2005-03); May 17, 2007b; US Bureau of the Census. 65+ in the United States: 2005. Current population reports; 2005c; and US Bureau
of the Census. Current population survey, annual social and economic supplement. Ethnicity and Ancestry Statistics Branch, Population
Division (does not include the Commonwealth of Puerto Rico); 2004b.
Table 2-4 Percentage of Racial and Ethnic Groups in Latin America

aChinese.
bBlacks, Japanese, Chinese, and other.
cMestizo and European; indigenous peoples (Mayans), including K'iche (9.1%), Mam (7.9%), Q’eqchi (6.3%), other Mayans (8.6%),
others (0.3%).
Source: Central Intelligence Agency. The World Factbook. https://www.cia.gov/library/publications/the-world-
factbook/docs/profileguide.html. Accessed September 17, 2009.

CHAPTER SUMMARY
A wide array of cultures exists within the context of racial categories established by the OMB. Although there is some
disagreement with the OMB categorization regarding race and ethnicity, they serve to guide the United States. Hence,
the four racial categories and the ethnic category identified here must be studied by health professionals so that services
provided are optimal and insightful regarding cultural specifics of the various groups. Factors such as race, nationality,
and ethnicity must be explored for each group, enabling better understanding and appreciation of the unique cultural
specifics that each group may hold in high regard.

CHAPTER PROBLEMS
1. Explain the unique circumstances under which the ancestors of most Black/African American people arrived in
the Americas. Why is it important for health service professionals to understand this history?
2. Only one group of the five racial categories established by the OMB is indigenous to US soil. What is the name
of that group and their associated concerns to which health professionals should be sensitive? Provide insight in
terms of the health status of this group.
3. Is Hispanic a racial or ethnic category? Explain. How might this impact the status of the African/Black group,
for example, in terms of whether it is the largest or second largest minority group?
4. White people came to the Americas largely based on immigration. Is this a true or false statement?
5. List the racial categories based on the OMB classification in the United States. Explain the geographic origins
of the people designated for each of the categories. Why is it important for health professionals to understand
cultural differences among and between groups?

REFERENCES
Alaska Natives. (2010). Retrieved October 8, 2010 from http://www.anchorage.net/821.cfm.
Bahk, C., & Jandi, F. (2004). Being White in America: Development of a scale. Howard Journal of Communications,
15(1), 57–68.
Borak, J., Fiellin, M., & Chemerynski, S. (2004). Who is Hispanic? Implications for epidemiologic research in the
United States. Epidemiology, 15(2), 240–244.
Cornell University Law School Legal Information Institute. Cherokee Nation v. Georgia. Retrieved July 18, 2011 from
http://www.law.cornell.edu/supct/html/historics/USSC_CR_0030_0001_ZS.html.
Dougherty, C., & Reddy, S. (2009). Is Columbus Day sailing off the calendar: Parades get dumped, the holiday
renamed: Brown’s “Fall Weekend?” Retrieved on September 16, 2010 from
http://online.wsj.com/article/SB125512754947576887.html.
Duncan, R., & Goddard, J. (2005). Contemporary America (2nd ed.). New York:Palgrave, Macmillan.
Hing, B. (2004). Defining America through immigration policy. Philadelphia: Temple University Press.
Jochannan, Y. (1989). Black man of the Nile and his family. Baltimore: Black Classic Press.
Kosoko-Lasaki, S., Cook, C., & O’Brien, R. (2009). Cultural proficiency in addressing health disparities. Sudbury,
 MA: Jones and Bartlett Publishers.
Manneh, S. (2010). Census to count Arabs as White, despite write-in campaign. New American Media Report.
Retrieved October 8 2011 from http://news.newamericamedia.org/news/view_article.html?
article_id=87932e5f600086f93be8b029e4a6ff40.
Office of Minority Health and Health Disparities. (2009). Black or African American populations. Retrieved July 9,
2010 from http://www.cdc.gov/omhd/Populations/BAA/BAA.htm.
Pacific Islander Cultural Center. (2010). Retrieved on October 8, 2011 from http://www.pica-
org.org/picawho/picawho.html
Rashidi, R. (2000). Introduction to the African presence in Fiji. Retrieved October 8, 2011 from
http://www.raceandhistory.com/historicalviews/africanfiji.html.
Reeves, T., & Bennett, C. (2003). The Asian and Pacific Islander population in the United States. Washington, DC: US
Census Bureau.
Reynolds, D. (2006). Improving care and interactions with racially and ethnically diverse populations in health care
organizations. Journal of Healthcare Management, 49(4), 243.
Saragoza, A., Juarez, C., Valenzuela, A and Gonzalez, O. (1992) History and Public Policy: Title VII and the Use of
the Hispanic Classification. La Raza Law Journal, 4(45).
US Department of Health and Human Services Office of Minority Health. (2008). Retrieved July 8, 2010 from
http://minorityhealth.hhs.gov/templates/browse.aspx?lvl=2&lvlID=172.

SUGGESTED READINGS
Baxter, C. (2001). Managing diversity and inequality in healthcare. Oxford, UK: Bialliere Tindall.
Byrd, M., & Clayton, L. (2000). An American health dilemma: A medical history of African Americans and the
problems of race: Beginnings to 1900. New York: Routledge.
Jones, D. (2006). The persistence of American Indian health disparities. American Journal of Public Health, 96(12),
2122–2134.
Naylor, L. (Ed.). (1997). Cultural diversity in the United States. Westport, CT: Bergin and Garvey.
Purnell, L., & Paulunka, B. (1998). Transcultural healthcare: A culturally competent approach. Philadelphia: F.A.
Davis.
Richard, A. (Ed.). (2007). Eliminating healthcare disparities in America. New York:Humana Press.
Another random document with
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The Project Gutenberg eBook of Essays
 This ebook is for the use of anyone anywhere in the United
States and most other parts of the world at no cost and with
almost no restrictions whatsoever. You may copy it, give it away
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Title: Essays

Author: Winthrop Mackworth Praed

Author of introduction, etc.: Henry Morley

Editor: Sir George Young

Release date: October 9, 2023 [eBook #71838]

Language: English

Original publication: London: George Routledge and Sons, 1887

Credits: Chuck Greif and the Online Distributed Proofreading

Team at http://www.pgdp.net (This file was produced
from images available at The Internet Archive)

*** START OF THE PROJECT GUTENBERG EBOOK ESSAYS ***

 CONTENTS
MORLEY’S UNIVERSAL LIBRARY.
INTRODUCTION.
PREFACE.
RHYME AND REASON.
ON THE PRACTICAL BATHOS.
NICKNAMES.
YES AND NO.
THOUGHTS ON THE WORDS “TURN
OUT.”
SOLITUDE IN A CROWD.
POLITENESS AND POLITESSE.
A WINDSOR BALL.
LOVERS’ VOWS.
ON THE PRACTICAL ASYNDETON.
ON HAIR-DRESSING.
ON A CERTAIN AGE.
NOT AT HOME.
MUSÆ O’CONNORIANÆ.
THE KNIGHT AND THE KNAVE.
MAD—QUITE MAD!
THE BOGLE OF ANNESLIE; OR, THE
THREE-CORNERED HAT.
ON THE PROPOSED ESTABLISHMENT
OF A PUBLIC LIBRARY AT ETON.
THE MISTAKE; OR, SIXES AND
SEVENS.
SENSE AND SENSIBILITY.
MR. LOZELL’S ESSAY ON
WEATHERCOCKS.
GOLIGHTLY’S ESSAY ON BLUES.
OLD BOOTS.
ON THE DIVINITIES OF THE
ANCIENTS.
REMINISCENCES OF MY YOUTH.
ON TRUE FRIENDSHIP.
THE COUNTRY CURATE.
THE WEDDING:
PRIVATE CORRESPONDENCE OF
PEREGRINE COURTENAY.
ABDICATION OF THE KING OF CLUBS.
THE UNION CLUB.
MY FIRST FOLLY.
POINTS.
LEONORA.
DAMASIPPUS.
MY FIRST FLAME.
THE INCONVENIENCE OF HAVING AN
ELDER BROTHER.
TOUJOURS PERDRIX.
THE BEST ΒΑΤ IN THE SCHOOL.
 Ballantyne Press
BALLANTYNE, HANSON AND CO.
EDINBURGH AND LONDON

ESSAYS
BY

WINTHROP MACKWORTH PRAED

COLLECTED AND ARRANGED BY

SIR GEORGE YOUNG, Bart., Μ.A.

WITH AN INTRODUCTION BY HENRY MORLEY

LL.D., PROFESSOR OF ENGLISH LITERATURE AT

UNIVERSITY COLLEGE, LONDON

LONDON
GEORGE ROUTLEDGE AND SONS
BROADWAY, LUDGATE HILL
GLASGOW AND NEW YORK

1887
 MORLEY’S UNIVERSAL LIBRARY.

1.Sheridan’s Plays.
2.Plays from Molière. By English Dramatists.
3.Marlow’s Faustus and Goethe’s Faust.
4.Chronicle of the Cid.
5.Rabelais’ Gargantua and the Heroic Deeds of Pantagruel.
6.Machiavelli’s Prince.
7.Bacon’s Essays.
8.Defoe’s Journal of the Plague Year.
9.Locke on Civil Government and Filmer’s “Patriarcha.”
10.Butler’s Analogy of Religion.
11.Dryden’s Virgil.
12.Scott’s Demonology and Witchcraft.
13.Herrick’s Hesperides.
14.Coleridge’s Table-Talk.
15.Boccaccio’s Decameron.
16.Sterne’s Tristram Shandy.
17.Chapman’s Homer’s Iliad.
18.Mediæval Tales.
19.Voltaire’s Candide, and Johnson’s Rasselas.
20.Jonson’s Plays and Poems.
21.Hobbes’s Leviathan.
22.Samuel Butler’s Hudibras.
23.Ideal Commonwealths.
24.Cavendish’s Life of Wolsey.
25 & 26. Don Quixote.
27.Burlesque Plays and Poems.
28.Dante’s Divine Comedy. Longfellow’s Translation.
29.Goldsmith’s Vicar of Wakefield, Plays, and Poems.
30.Fables and Proverbs from the Sanskrit. (Hitopadesa.)
31.Lamb’s Essays of Elia.
32.The History of Thomas Εllwood.
33.Emerson’s Essays, &c.
34.Southey’s Life of Nelson.
35.De Quincey’s Confessions of an Opium Eater, &c.
36.Stories of Ireland. By Miss Edgeworth.
37.Frere’s Aristophanes: Acharnians, Knights, Birds.
38.Burke’s Speeches and Letters.
39.Thomas à Kempis.
40.Popular Songs of Ireland.
41.Potter’s Æschylus.
42.Goethe’s Faust: Part II. Anster’s Translation.
43.Famous Pamphlets.
44.Francklin’s Sophocles.
45.M. G. Lewis’s Tales of Terror and Wonder.
46.Vestiges of the Natural History of Creation.
47.Drayton’s Barons’ Wars, Nymphidia, &c.
48.Cobbett’s Advice to Young Men.
49.The Banquet of Dante.
50.Walker’s Original.
51.Schiller’s Poems and Ballads.
52.Peele’s Plays and Poems.
53.Harrington’s Oceana.
54.Euripides: Alcestis and other Plays.
55.Praed’s Essays.
“Marvels of clear type and general neatness.”—Daily Telegraph.
 INTRODUCTION.
The readers of our Library are greatly indebted to Sir George Young for his
kindness in presenting them with this first collected edition of the prose
writings of his uncle, Winthrop Mackworth Praed. He little knows the
charm of the bright regions of Literature who cannot yield himself to full
enjoyment of their infinite variety. As we pass from book to book, it is a
long leap from Euripides to the brilliant young Etonian who brought all the
grace of happy youth into such work as we have here. Happy the old who
can grow young again with this book in their hands. If we all came into the
world mature, and there were no childhood and youth about us, what a dull
world it would be! Any book is a prize that brings the fresh and cheerful
voice of youth into the region of true Literature. Of Praed’s work in this
way none can speak better than Sir George Young in his Preface.
Of his life, these are a few dry facts. He was born in 1802, lost his
mother early, and went to Eton at the age of twelve. He was still at Eton
when, at the age of eighteen, in 1820, he and his friend Walter Blount edited
the Etonian, which began its course in October 1820 and ended in July
1821. In the following October Praed went to Trinity College, Cambridge,
where he obtained a Fellowship. He obtained medals for Greek odes and
epigrams, a medal for English verse, and he was still full of the old grace of
playfulness. He was called to the Bar in 1829. An elder sister died in 1830,
and his love for her is shown in tender touches of his later verse. The vers
de société which he wrote, and which no man wrote better than Praed,
retain their charm because their playfulness is on the surface of a manly
earnest nature, from the depth of which a tone now and then rises that
comes straight into our hearts. Praed was in Parliament from November
1830 until after the passing of the Reform Bill, and again in 1834, when he
was Secretary to the Board of Control under Sir Robert Peel. His father died
in 1835; in the same year Praed married; and in July 1839 he died, aged
thirty-seven.
Η. Μ.
October 1887.
 PREFACE.
The prose pieces of Winthrop Mackworth Praed have never before been
presented in a collected form. They are worthy of preservation, in a degree
hardly less than his verse; though by the latter he has hitherto been best
known, and will probably be longest remembered. At the time when the
high quality of his literary work obtained for the Etonian the honour,
unprecedented in the case of a school magazine, of a complimentary notice
in the Quarterly Review, it was to the merit of his prose, as much as to that
of his poetry, that attention was called by the reviewer. It is not, however, as
the phenomenally precocious work of a schoolboy that these papers have
been thought worthy of reproduction in the Universal Library. The
circumstance that they were, most of them, written at Eton, is only to be
accounted of as adding to their interest, by giving the reader a point of view
from which to sympathize with the writer’s humour. It would, however, be a
mistake to consider the senior Etonian of 1820 as corresponding to any
reasonable description of what is generally denoted by the word
“schoolboy.” At the age of eighteen or nineteen, when his grandfathers had
already taken their first degrees, subjected to a discipline as light as that of a
modern University, more free to study in the way the spirit moved him, or
not to study at all, than the undergraduate of a “good” college now, the
pupil of Goodall, Keate, or Plumptre was of a maturer sort than is now to be
found among the denizens of Sixth Forms. He came between two ages in
the history of our Public Schools, in neither of which could such literary
work as here follows have been produced by a “schoolboy.” There preceded
him the age in which a youth went early to the University, and early into
life. There has followed the day in which “boys” at school, when no longer
boys, but men in years, are held fast by discipline to boyish studies, or at
any rate to boyish amusements. The circumstance that a few individuals, of
great and early matured literary gifts, were assembled together under these
conditions at a single school, on two several occasions, in two successive
generations, at an interval of about thirty years, operated to enrich English
Literature with two graceful and unique volumes. Of the Microcosm, the
best pieces are due to Canning and Frere; in the Etonian, the share of Praed
surpasses and eclipses that of his contemporaries. From his University
friends, indeed, he derived powerful help; there are a few lines of poetry, by
William Sidney Walker, better than any of his own; and there are a few
pages of prose, by Henry Nelson Coleridge, which are also better; but for
sustained excellence, and for an energy and variety in production, truly
extraordinary under the circumstances, Praed, and Praed only, is the hero of
the Etonian; the over-praised and ambitiously constructed efforts of his
friend Moultrie not excepted.
After Praed left Eton, his bent led him to verse, rather than to prose, as
his appropriate vehicle of expression; and it was only occasionally that he
sent a prose contribution, either to Knight’s Quarterly Magazine, or to the
London Magazine, or to the ephemeral pages of the Brazen Head. Two
speeches of his in Parliament were “reprinted by request;” but they seem to
have owed this distinction rather to the special interest, at the time, of their
subject-matter, than to any exceptional finish in their literary form. They
were speeches in Committee on the Reform Bills of 1831 and 1832, the one
on moving as an amendment what was afterwards known as the “three-
cornered constituency” arrangement; the other on moving, similarly, that
freeholds within the limits of boroughs should confer votes for the borough
and not for the county. His partly versified squib, “The Union Club,” in
which he parodied the style and matter of the principal speakers among
Cambridge undergraduates in 1822, has been included in this collection, for
the sake especially of the comical imitations of Lord Macaulay and Lord
Lytton. It was written, as Macaulay himself informed me, “for Cookesley to
recite at supper-parties.” The late Rev. William Gifford Cookesley, long an
assistant master at Eton, who acted as Lord Beaconsfield’s cicerone when
he came down to the spot to make studies for “Coningsby,” is gratefully
remembered by many of his scholars for his genuine, if somewhat irregular,
love of literature, and for his hearty sympathy with boyish good-fellowship.
He was a contemporary of Praed’s both at Eton and Cambridge, and long
preserved, in maturer years, his admirable faculty of mimicry.
Among the characteristics of these pieces will be found an almost
unfailing good taste; a polished style, exhibiting a sparkle, as of finely
constructed verse; a strong love of sheer fun, not ungracefully indulged; a
dash of affectation, inoffensive, and such as is natural in a new-comer, upon
whom the eyes of his circle have, by no fault of his, been drawn; a healthy,
breezy spirit, redolent of the playing-fields; and a hearty appreciation of the
pleasures arising from a first fresh plunge into the waters of literature.
Powers of observation are shown of no mean order, and powers, also, of
putting in a strong light, whether attractive or ridiculous, the more obvious
features of everyday characters. These powers afterwards ripened into a
truly admirable skill of political and social verse-writing; and they showed
signs of deepening into a more forcible satiric power, tempered with
humour, as his too short career drew towards its end.
Praed is moreover especially to be commended in that he is never dull.
Although free from “sensationalism,” he is not forgetful that the first
business of a writer is—to be read. There are gentle lessons of good
manners, of unselfishness, and of chivalry, to be read in his pages; they are
not loudly trumpeted, but there they are; there is also a sincere respect for
great minds and for good work in literature, enlivened, not neutralized, by
unfailing high spirits. One could dispense, certainly, with some of his
antithesis; perhaps with all his punning; but life is not so short, or so lively
in itself, as to leave us no time to be amused, and no ground for gratitude to
the writers who amuse us.
The only omissions from this collection are, besides the speeches above
mentioned, the prefaces contributed, in the taste of the day, to the several
numbers of the Etonian, under the title “The King of Clubs,” and to
Knight’s Quarterly Magazine, under the title “Castle Vernon.” These are
lively in their way, but unequal, and full of allusions which would require
notes to make them intelligible. Occasionally, too, they are padded out with
contributory matter by other hands. One rather ambitious failure, to be
found in the Etonian, “On Silent Sorrow,” has also been omitted, and will
not be missed.
It should be added, that the leading articles of the Morning Post
newspaper, from August 1832 to some time in the autumn of 1834, were for
the most part of Praed’s writing. Many of them are exceedingly well
written; but their contents are, of necessity, too ephemeral for reproduction
in these pages.
GEORGE YOUNG.
October 1887.

Praed’s Essays.
 RHYME AND REASON.

“Non eadem est ætas, non mens.”—Horace.

He whose life has not been one continued monotony; he who has been
susceptible of different passions, opposite in their origins and effects, needs
not to be told that the same objects, the same scenes, the same incidents,
strike us in a variety of lights, according to the temper and inclination with
which we survey them. To borrow an illustration from external scenes,—if
we are situated in the centre of a shady valley, our view is confined and our
prospect bounded; but if we ascend the topmost heights of the mountain by
which that valley is overshadowed, the eye wanders luxuriantly over a
perpetual succession of beautiful objects, until the mental faculties appear
to catch new freedom from the extension of the sight; we breathe a purer
air, and are inspired with purer emotions.
Thus it is with men who differ from each other in their tastes, their
studies, or their professions. They look on the same external objects with a
different internal perception, and the view which they take of surrounding
scenes is beautified or distorted, according to their predominant pursuit or
their prevailing inclination.
We were led into this train of ideas by a visit which we lately paid to an
old friend, who, from a strong taste for agricultural pursuits, has abandoned
the splendour and absurdity of a town life, and devoted to the cultivation of
a large farming establishment, in a picturesque part of England, all the
advantages of a strong judgment and a good education. His brother, on the
contrary, who was a resident at the farm during our visit, has less of sound
understanding than of ardent genius, and is more remarkable for the warmth
of his heart than the soundness of his head. In short, to describe them in a
word, Jonathan sees with the eye of a merchant, and Charles with that of an
enthusiast; Jonathan is a man of business, and Charles is a poet. The
contrast between their tempers is frequently the theme of conversation at
the social meetings of the neighbourhood; and it is always found that the
old and the grave shake their heads at the almost boyish enthusiasm of
Charles, while the young and the imprudent indulge in severe sarcasms at
the mercenary and uninspired moderation of his brother. All parties,
however, concur in admiring the uninterrupted cordiality which subsists
between them, and in laughing good-humouredly at the various whims and
foibles of these opposite characters, who are known throughout the country
by the titles of Rhyme and Reason.
We arrived at the farm as Jonathan was sitting down to his substantial
breakfast. We were delighted to see our old friend, now in the decline of
life, answering so exactly the description of Cowper—

An honest man close-buttoned to the chin,

Broadcloth without, and a warm heart within.

We felt an inward satisfaction in contemplating his frieze coat, whose début

we remember to have witnessed five years ago, and in speculating upon the
snows which five additional winters had left upon his head since our last
interview. It was some time before we recovered sufficiently from our
reverie to inquire after the well-being of our younger companion, who had
not yet made his appearance at the board. “Oh!” said Jonathan, “Charles is
in his heyday years; we must indulge him for the present; we can’t expect
such regularity from five-and-twenty as from six-and-fifty.” He had hardly
done speaking when a loud halloo sounded as an avant-courier of Charles’s
approach, and in less than a minute he presented himself before us. “Ten
thousand pardons!” he cried. “One’s enough,” said his brother. “I’ve seen
the finest sunrise,” said Charles. “You’re wet through,” said Jonathan. “I’m
all over rapture,” said Rhyme. “You’re all over dirt,” said Reason.
With some difficulty Charles was persuaded to retire for the re-
adjustment of his dress, while the old man continued his meal with a
composure which proved he was not unused to the morning excursions of
his volatile yoke-fellow. By the time he had got through his beefsteak, and
three columns of the Courier, Charles re-entered, and despatched the
business of eating with a rapidity in which many a modern half-starved
rhymer would be glad to emulate him. A walk was immediately proposed;
but the one had scarcely reached an umbrella, and the other prepared his
manuscript book, when a slight shower of rain prevented our design.
“Provoking,” said Rhyme. “Good for the crop,” said Reason.
The shower, however, soon ceased, and a fine clear sun encouraged us to
resume our intentions, without fear of a second disappointment. As we
walked over the estate, we were struck with the improvements made by our
friend, both as regarded the comfort and the value of the property; while
now and then we could not suppress a smile on observing the rustic arbour
which Charles had designed, or the verses which he had inscribed on our
favourite old oak.
It was determined that we should ascend a neighbouring hill, which was
dear to us from its having been the principal scene of our boyhood’s
amusements. “We must make haste,” said Charles, “or we shall miss the
view.” “We must make haste,” said Jonathan, “or we shall catch cold on our
return.” Their actions seemed always to amalgamate, though their motives
were always different. We observed a tenant of our friend ploughing a small
field, and stopped a short time to regard the contented appearance of the
man, and the cheerful whistle with which he called to his cattle. “Beatus ille
qui procul negotiis,” said the poet. “A poor team, though,” said his brother.
Our attention was next excited by a level meadow, whose green hue, set
off by the mixture of the white fleeces of a beautiful flock of sheep, was, to
the observer of Nature, a more enviable sight than the most studied
landscape of Gainsborough’s pencil. “Lovely colours!” ejaculated Charles.
“Fine mutton,” observed Jonathan. “Delightful scene for a rustic hop!”
cried the enthusiast. “I am thinking of planting hops,” said the farmer.
We reached the summit of the hill, and remained for some moments in
silent admiration of one of the most variegated prospects that ever the
country presented to the contemplation of its most ardent admirer. The
mellow verdure of the meadows, intermingled here and there with the
sombre appearance of ploughed land, the cattle reclining in the shade, the
cottage of the rustic peeping from behind the screen of a luxuriant hedge,
formed a tout-ensemble which every eye must admire, but which few pens
can describe. “A delightful landscape!” said Charles. “A rich soil,” said
Jonathan. “What scope for description!” cried the first. “What scope for
improvement!” returned the second.
As we returned we passed the cottage of the peasant whom we had seen
at his plough in the morning. The family were busily engaged in their
several domestic occupations. One little chubby-faced rogue was
conducting Dobbin to his stable, another was helping his sister to coop up
the poultry, and a third was incarcerating the swine, who made a vigorous
resistance against their youthful antagonist. “Tender!” cried Rhyme—he
was listening to the nightingale. “Very tender!” replied Reason—he was
looking at the pigs.
As we drew near home, we met an old gentleman walking with his
daughter, between whom and Charles a reciprocal attachment was said to
exist. The lateness of the evening prevented much conversation, but the few
words which were spoken again brought into contrast the opposite tempers
of my friends. “A fine evening, Madam,” said the man of sense, and bowed.
“I shall see you to-morrow, Mary!” said the lover, and pressed her hand. We
looked back upon her as she left us. After a pause: “She is an angel!” sighed
Charles. “She is an heiress,” observed Jonathan. “She has ten thousand
perfections,” cried Rhyme. “She has ten thousand pounds,” said Reason.
We left them the next morning, and spent some days in speculations on
the causes which enabled such union of affections to exist with such
diversities of taste. For ourselves, we must confess that, while Reason has
secured our esteem, Rhyme has run away with our hearts; we have
sometimes thought with Jonathan, but we have always felt with Charles.
 ON THE PRACTICAL BATHOS.

“To sink the deeper—rose the higher.”—Pope.

Although many learned scholars have laboured with much diligence in the
illustration of the Bathos in poetry, we do not remember to have seen any
essay calculated to point out the beauties and advantages of this figure
when applied to actual life. Surely there is no one who will not allow that
the want of such an essay is a desideratum which ought, as soon as possible,
to be supplied. Conscious as we are that our feeble powers are not properly
qualified to fill up this vacuum in scholastic literature; yet, since the learned
commentators of the present day have their hands full either of Greek or
politics, we, an unlearned, but we trust a harmless, body of quacks, will
endeavour to supply the place of those who kill by rule, and will
accordingly offer, for the advantage of our fellow-citizens, a few brief
remarks on the Practical Bathos.
We will first lay it down as a principle that the ἀπροσδόκητον, as well in
life as in poetry, is a figure, the beauties of which are innumerable and
incontrovertible. For the benefit of my fair readers (for Phœbus and Bentley
forbid that an Etonian should here need a Lexicon) I will state that the
figure ἀπροσδόκητον is “that which produceth things unexpected.” Take a
few examples. In poetry there is a notable instance of this figure in the
“Œdipus Tyrannus” of Sophocles, where the messenger who discloses to
Œdipus his mistake in supposing Polybus to be his father, believing that the
intelligence he brings is of the most agreeable nature, plants a dagger in the
heart of his hearer by every word he utters. But Sophocles, although he
must be acknowledged a great master of the dramatic art, is infinitely
surpassed in the use of this figure by our good friend Mr. Farley of Covent
Garden. When we sit in mute astonishment to survey the various pictures
which he conjures up, as it were by the wand of a sorcerer, in a moment—
when columns and coal-holes, palaces and pig-sties, summer and winter,
succeed each other with such perpetually diversified images; we are
continually exclaiming, “Mr. Farley, what next?” Every minute presents us
with a new and more perfect specimen of this figure. Far be it from us to