Lessons in cultural competence from Mango House

In addition to medical services, Mango House includes tenant spaces for the refugees and asylees to use, including dozens of shops, seven restaurants, and about 15 spaces for meetings, events and religious gatherings. 

Parmar is of Indian descent. He said his family was on the privileged side of immigration. 

“In my observation, immigrants follow a bit of a bimodal distribution. You have those who are better off and those who are worse off. That's by design,” he explained. “Our country gives certain types of visas to workers from certain backgrounds and attracts those talents from other countries. And the other countries get what's called a ‘brain drain,’ and that's probably my family's story.”

Parmar shared that on the flip side of that are the refugees, asylees and undocumented people — populations he was determined to use his privilege and medical expertise to help. But he didn’t want to limit his services to medicine - partially, he said, due to an aversion to boredom. 

Burmese restaurant Urban Burma prepares for customers. 

“You're  going to family medicine because you like doing a little bit of everything. You don't want to just do one body system or one gender or one age group,” he said.  

With the help of others in the community, including a talented pharmacist from Ethiopia and a driven dental hygienist, Parmar was able to expand his medical services. And thanks to his purchase of a building that was once a JCPenney, he had plenty of space for other opportunities.

Copy of an issue of  "Aurora Advocate" highlighting the history of the Mango House building.

Demonstrating cultural competence

At Mango House, Parmar has a unique glimpse into the lives of refugees from many different countries, and in addition to medical practices, business ownership, conflict resolution and gardening, he has become an expert in cultural competence. 

Cultural competence holds various definitions depending on the environment, but overall the term refers to a set of values that allows someone to operate in cross-cultural settings through education, understanding and respect. 

It is a phrase commonly used in conversations around diversity, equity and inclusion. But what does it look like in practice?

Ensuring autonomy 

Some might assume that due to the ethos of Mango House, it must be a nonprofit. But Parmar runs a for-profit medical office and was very intentional in doing so. 

“That simply allows me to think and move much quicker,” he said.  “Nonprofits have boards, you have to ask a lot of people and those checks and balances are put in there for a reason. But the opposite of that, is innovation.”

Parmar said that this autonomy helps various elements of Mango House function more smoothly. Business owners are motivated by their own decisions and mistakes, and patients receive care catered to them. “We try to focus on the patients and the ways we know that work best, because often the foundations don't know that,” he shared. 

Addressing the universal culture of poverty

According to Parmar, an important element to cultural competence is the realization that “culture” is not limited to heritage. 

“A lot of people don't realize what I do is deal with the culture of poverty, which is not a refugee-specific thing,” he said.  “We have plenty of it with people who are born in the United States and have been here their whole lives, and there's plenty of it around the world.”

Understanding the culture of poverty comes with a thorough grasp on the way poverty affects people’s day-to-day lives. 

“Some do not have a reliable cell phone, or a reliable car. Or maybe they come from backgrounds where they're not taught some of the same manners in the same ways because they didn't have as much hope when they were growing up.”

In order to address the throughline of poverty, Parmar first examined his business model. 

Gaining a thorough understanding of these barriers allowed Parmar to make the clinic more accessible. At Mango House, this starts with a walk-in only model. 

“If you don't have to call for an appointment, you don't need a phone, you don't have to worry about what time the number 15 bus is going to get here on Colfax.” he explained. 

Parmar highlighted that the "walk-in only" model is usually limited to hospitals and urgent care facilities. But by providing the model in a primary care facility, it increases the use of preventative care, saving patients (and taxpayers) money. 

Another financial barrier Mango House addresses is affordability. Parmar accepts Medicaid, which is something not all doctors adhere to. He said the lack of Medicaid practitioners is partially due to the fact Medicaid and Medicare pay doctors about a third less than many insurance companies. 

However, he said, sometimes the difference in pay is offset by the reliability of Medicaid compared to other forms of insurance, as navigating insurance can be complicated for both patients and doctors. 

Mango House does not require residency documents, another barrier to care many face. 

“You never know whether you're going to get paid that amount. With Medicaid, you actually do get paid. So it's a misconception that a lot of doctors have.”

Parmar also highlighted that there is a stigma that comes with Medicaid that some doctors prefer to avoid. 

“They come in with language barriers, cultural barriers or other. We call them social determinants of health,” he shared. “They might have housing needs or food needs - unpredictable reasons why they cannot follow your instructions as a doctor that makes them a more challenging patient, rather than in a richer neighborhood where you just say, ‘take this medicine, see you in two weeks.’”

Even if a doctor does accept Medicaid, Parmar said, it can result in longer wait times for treatment.

The power of representation

Medical office employees help walk-in patients get checked in.

Having staff hailing from the various cultures the office serves also allows for medical issues to be specified to a patient’s background. 

“We know the communities very well. We we know their groceries, their pastors, their daycare leaders. We just know what makes them tick,” said Parmar. “I know the Somalis eat pasta. I know the Congolese eat fufu. The Ethiopian eat injera, the Burmese and Nepali eat rice. I know what's causing their diabetes.”

A side effect of this in-depth knowledge of his patients’ communities, Parmar said, is joy. 

“You really get to know them, where you sponsor their cricket team, where you shop at their grocery stores, where you attend their funerals," he mused.  “This all becomes part of family, and that becomes your joy.”