Interculturalism as a means toward cultural inclusiveness and cross-cultural dialogue : The case of Panama ’ s Ngäbe Author

Using a case study approach, this article explores the role of the Jose Domingo de Obaldia maternity hospital in Western Panama, and its policies and practices for responding to the cultural differences between Panamanian hospital staff and pregnant Ngöble Buglé patients, and their different understanding of health and illness that has been shaped by principles of traditional medicine. Using a range of in-depth interviews with hospitality staff and management and intercultural interpreters, this study explores how cultural aspects and differences can be of a compound and complex nature, requiring strong intercultural understanding, awareness and cross-cultural dialogue. The case of the Ngöble Buglé illustrates how interculturalism can foster such cultural inclusiveness and cross-cultural dialogue, and how interculturalism can have implications for other Indigenous communities in Latin America, and for non-Indigenous communities facing increasingly cultural diverse environments and contexts.

Based on a case study approach, I explore the role of the Jose Domingo de Obaldia maternity hospital in Western Panama and its policies and practices for responding to the cultural differences between Panamanian hospital staff and pregnant patients who belong to the Indigenous Ngäbe tribe in Western Panama. The contribution of my study is twofold. First, it contributes to the research of Indigenous communities in Latin America, their cultural particularities, and the limited understanding and integration of these cultural particularities in Western or Westernised societies and organisations. The limited cultural understanding and inclusiveness remain some of the key reasons for why many of Latin America's 30-50 million Indigenous people continue to live in poverty and with very limited access to employment, education and health care (United Nations Population Fund [UNFPA], 2008).
The second contribution of my article is the proposition of interculturalism as a concept to foster cultural inclusiveness and cross-cultural dialogues. Management and organisation studies exploring cultural diversity and differences have either focused on cross-national differences between groups and individuals, and addressed local cultural diversity issues and their variations across countries (see Agocs & Burr, 1996;Egan & Bendick, 2003;Sippola & Smale, 2007), or they have studied cultural differences within multicultural groups (see Barinaga, 2007;Barkema & Shvyrkov, 2007;Earley & Gibson, 2002). While the two applications refer to conceptually different social phenomena (Harrison & Klein, 2007), they both reflect the differentiating nature of managing cultural diversity. Litvin (1997) criticises such a categorising perspective and calls its discourse 'divisive and disabling ' (p. 207). Lorbiecki and Jack (2000) caution that the current discourse of managing cultural diversity could 'mark just another colonizing moment of the Other' (p. S29), and engenders 'responses of antagonism and resentment on the part of the "managed diverse"' (p. S29). The multicultural perspective on which both applications are based has been described 'as a delimited, static space, within which different cultures cohabitate in a self-enclosed, silent ignorance' (Sarmento, 2014, p. 606), rarely considering notions of cultural inclusiveness and cross-cultural dialogues (Robertson, 2006).
While non-management/organisation studies have discussed interculturalism in detail at a macrosocietal level, only a few studies have explored intercultural aspects at a meso-social (organisational) or micro-social (interactional) level, and/or in qualitative ways. My case study of the Ngäbe extends the macro-social perspective of interculturalism to the meso/micro social level. Using a range of in-depth interviews with hospitality staff and an intercultural interpreter at the Jose Domingo de Obaldia maternity hospital in Western Panama, I explore how certain aspects related to the Ngäbe culture are of a compound and complex nature, and require trust, intercultural understanding, awareness and dialogue.
In the following section, I outline the notion of interculturalism in greater detail. Then I introduce the Ngäbe and outline the methodology. In the main part, I present the findings of my case study, followed by the discussion and conclusions. In the latter, I outline some of the implications of interculturalism for the future development of Indigenous communities in Panama and Latin America, and for non-Indigenous communities facing increasingly cultural diverse environments and contexts.

Interculturalism
According to the United Nations Educational, Scientific and Cultural Organization (UNESCO), the broader concept of interculturalism 'refers to the existence and equitable interaction of diverse cultures and the possibility of generating shared cultural expressions through dialogue and mutual respect' (United Nations Educational, Scientific and Cultural Organization [UNESCO], 2005). Interculturalism has been addressed by authors in a wide range of disciplines, including law (Bouchard, 2011), linguistics (see Sarmento, 2014), communications (see Frame, 2009, education (see Abdallah-Pretceille, 2007), public policy (see Cantle, 2012) and global management (see Bird, Mendenhall, Stevens, & Oddou, 2010). According to the disciplines in which interculturalism has been discussed, its meaning varies in perspective, level and depth. Consequently, more nuanced definitions and descriptions of interculturalism and its roots are manifold, with disparities in delineating what specifically comprises interculturalism, making it 'awfully difficult to pin down exactly what it means' (Perry, 2013, p. 221).
According to Sarmento (2014) the concept of interculturalism emerged in France during the 1970s 'due to the need for inclusion of immigrant children and consequent adaptation of educational methods in the face of an increasingly multicultural society' (p. 608). Within anthropological research, interculturalism developed in the 1960s as an alternative to the much-criticised concept of acculturation (Little, 2005). While the two examples illustrate the diverse roots and varying historical contexts from which interculturalism has emerged, they show at the same time how the discourse has largely taken place at a macro-social (societal) level. Bouchard (2011) discusses interculturalism regarding Canada's Anglophone and Francophone populations, and 'as a model for integration' (of Quebec) 'and the management of ethnocultural diversity' (p. 437). Much of Bouchard's (2011) discourse as to what constitutes interculturalism also focuses on aspects at a macro-social level, and takes an institutional and/or legal perspective. He highlights that interculturalism 'is not a disguised […] form of multiculturalism ' (p. 438). Interculturalism focuses on the integration of diverse coexisting traditions and cultures, and favours genuine interactions, exchanges and connections between cultures (Bouchard, 2011). According to Bouchard (2011), 'traditionally, multiculturalism does not cultivate these concerns to the same degree' (p. 448). The prefixes of the two concepts illustrate why 'the prefix inter assumes that two or more cultures interact, while the prefix multi does not assume hybridization, but instead the coexistence of various cultures, stratified and hierarchical' (Sarmento, 2014, p. 608).
In her discussion of interculturalism and its pragmatic consequences in academia and society, Sarmento (2014) states that 'as something greater than coexistence, interculturalism is allegedly more geared toward interaction and dialogue than multiculturalism' (p. 607). For Sarmento (2014), 'what the present formulation of interculturalism emphasizes is, beyond question, communication' [and] conviviality ' (pp. 609-610). Global management studies focusing on expatriates and managers operating in different cultures have adopted these characteristics and their interactive nature in their definitions of interculturalism and intercultural competencies (e.g. Holmgreen & Askehave, 2013;Lloyd & Härtel, 2010).
In contrast, multiculturalism, with its focus on coexistence aims at a 'cautious tolerance', stressing typologies and categorisations that hinder rather than nurture cultural inclusiveness and crosscultural dialogues (Sarmento, 2014, p. 611). According to the Council of Europe and the European Commission (2016), multiculturalism is 'reinforcing walls between culturally distinct groups that can lead to ethnic clustering and ghettoization'. In line with Sarmento's arguments, interculturalism for these two European institutions is about doing everything possible to 'increase interaction, mixing and hybridization between cultural communities' (Council of Europe and the European Commission, 2016). The two institutions define interculturalism as a means of building trust and reinforcing the fabric of the community.
In conclusion, studies of interculturalism agree widely on the concept's strong focus on cultural integration, cross-cultural interaction, communication and dialogue, cultural awareness and sensibilisation, trust building, and the importance of these characteristics for the development of sustainable relationships between culturally diverse groups. Interculturalism is about doing rather than being; it is about cultures in action rather than cultures as objects. Interculturalism emphasises the interactions between people and groups instead of pressing solely toward generating knowledge about their differences. This culture-in-action paradigm is the basis for the research approach of this study, outlined after the introduction of the Ngäbe and before the discussion of the findings and the concluding remarks.

The Ngäbe
The Ngäbe are often referred to as Guaymi people, and together with the Buglé tribe collectively make up the largest Indigenous population in Panama. Today there are around 155,000 Ngäbe people living in the mountainous Ngäbe-Buglé Comarca in the western provinces of Panama 1 (Veraguas, Chiriqui and Bocas del Toro; United Nations High Commissioner for Refugees, 2015). While originally the Ngäbe-Buglé territory included most of Western Panama, from the Pacific to the Caribbean Sea, Spanish invaders, cattle ranchers and farmers forced the Ngäbe into the tropical highlands of Western Panama bordering Costa Rica and the Caribbean Sea (Young, 1971).
While the Torrijos government in the early 1970s tried to organise the Ngäbe people into larger communities, many Ngäbe still live a nomadic lifestyle and/or in small, dispersed and secluded villages in the Ngäbe-Buglé Comarca, speaking only their native language, Ngäbere, a language belonging to the Chibchan language family. The Ngäbe-Buglé Comarca is a semi-autonomous region that was established by the Panamian government in 1997, and which is run by a mixture of official authorities such as governors and mayors, and traditional authorities such as chiefs (Center for World Indigenous Studies, 2015). The Ngäbe-Buglé Comarca is characterised by mountainous terrain, steep canyons and dense tropical forests that are difficult to access. These environmental characteristics, together with animal-like signs, are symbolised in geometric patterns that decorate the naguas, the colourful dresses of the Ngäbe women (Center for World Indigenous Studies, 2015). 2 Due to the difficulties to access the Ngäbe Buglé Comarca, roads and bridges, electricity and potable water are scarce (United Nations High Commissioner for Refugees, 2015). The lack of a sufficient infrastructure combined with nutrient poor soil and rocky farmland limit employment opportunities to small agricultural projects inside the Comarca and to seasonal work outside the Comarca, mainly in the coffee plantations of Chiriqui's highlands, making the Ngäbe the least developed group in Panama in terms of socio-economic standards (Centro de Estudio Economicos, 2014). The literacy rate among the Ngäbe population is around 20%, while the average number of years of schooling is three (United Nations Department of Economic and Social Affairs [UNDESA], 2007). The economic hardship has led to malnutrition and health problems that are particular widespread among Ngäbe children and pregnant women.
In the past, the isolation of many of the Ngäbe in the Comarca made it difficult for these children and pregnant women to access Panama's public healthcare centres. The lack of local medical facilities and doctors led to maternal mortality rates among pregnant Ngäbe women that were four times higher than the average rate among pregnant non-Indigenous Panamanian women (Gomez, 2015). In response to these high mortality rates and in line with the United Nations Millennium goals set in 1993, in 2000 the United Nations Population Fund (UNFPA) began to provide technical and financial support to bring together governmental bodies and local communities to address maternal mortality among pregnant Ngäbe women (UNDESA, 2007;UNFPA, 2008). From early on, key actions of UNFPA's maternal mortality reduction program included the involvement of the Ngäbe people as health agents and promoters, the development of local hostels near health centres, and the accessibility and quality of health centres and services. While some success was reported in the reduction of maternal mortality after the first phase in 2005 (see UNDESA, 2007), some challenges and obstacles remained to sustain this success in the future. According to UNDESA (2007) there was 'a limited number of facilitators with knowledge of the sexual and reproductive health practices or the cosmovision of indigenous people […] no intercultural service provision model that has been institutionalized or that is being taught in schools and medical/nursing training institutions […]Traditional birth attendants are not fully accepted owing to cultural and institutional factors' (p. 83).
In response to these challenges, UNFPA developed a strategy of an intercultural health model that aimed at increasing and strengthening the community involvement, and at creating an intercultural initiative at the Jose Domingo de Obaldia (JDO) tertiary hospital, the largest maternity and paediatric hospital in Western Panama (Gomez, 2015;UNFPA, 2008), and the case organisation of this study. The following section outlines the methodological approach to explore this intercultural initiative, and to provide insights and details of interculturalism applied at both a mesosocial and a micro-social level.

Methodology
Following Sarmento's call for intercultural research to be culture-in-action oriented, and given the exploratory nature of this research project, a case study approach was deemed the most appropriate research design. In particular, its flexibility favoured the case study approach over other research designs. Instead of testing hypotheses and theories, I aimed at exploring interculturalism and intercultural processes within their natural setting. The JDO hospital and its intercultural ward provided me with such a natural setting as it allowed me to study interactions and dynamics between cultures rather than cultures solely as objects or cultural multiplicity (Abdallah-Pretceille, 2007;Ibanez & Saenz, 2006). Considering its exploratory nature, this study could be seen as a 'snapshot' or pilot case rather than providing data that claims external validity and statistical generalisations.
The study relied on non-participant observations during a one-day visit at the JDO hospital and its different departments, and semistructured in-depth interviews as its data collection methods. Interviewees of the JDO hospital included the Head of the Intercultural Ward, the Director of the Department for Gynecology and Obstetrics, and the Director of the Research and Teaching Division of the JDO hospital. These individuals played key roles in the development and operationalisation of the intercultural ward. The Head of the Intercultural Ward was Ngäbe, while the two directors were Panamanian. This cultural mix and the diversity of the professional backgrounds of the interviewees allowed me to recognise and differentiate between the cultural and tnon-cultural dimensions of the interactions between staff and the Ngäbe patients.
Each of the interviews with the directors of the Department for Gynaecology and Obstetrics, and the Research and Teaching Division took 1.5 hours. The formal interview with the Head of the Intercultural Ward took 2 hours. During a tour throughout the ward and other hospital facilities, unstructured and informal discussions with the Head of the Intercultural Ward continued for approximately 3 hours. During the one-day visit, non-participant observations were conducted in the hospital's cultural ward, the maternity ward, and the public areas such as the reception. Conducting interviews with pregnant Ngäbe women was impossible for several reasons. Ngäbe women are by nature extremely shy-in particular toward non-Ngäbe persons. Most of the Ngäbe women were in advanced pregnancy, with many of them in physical discomfort and/or dressed with only light hospital covers. And finally, the Ngäbe women stayed in large rooms with up to 10 beds, which discouraged any privacy and confidentiality for an interview.
Due to the study's exploratory nature, a holistic position was taken toward the overall data preparation and analysis process, focusing on the richness of the collected data rather than 'turning it into numbers or … quantitative statements' (Easterby-Smith, Thorpe, & Lowe, 1996, p. 105). With regard to the interviews, data were organised (i.e. translated and transcribed) as soon as it was collected. Similarly, detailed field notes and summaries of observations and informal discussions with employees were taken. I analysed the data using a content analysis approach: I coded the data from the semistructured interviews and the observations manually. This approach provided me with a more comprehensive analysis as it allowed me to understand not only the coded terms but also their context in the interviews and observations. Using a cut-and-paste approach, I carved text segments out of their context in such a way that they retained meaning (Tesch, 1992), and then recontextualised them into appropriate categories and themes. The analysis was done in an iterative process in order to refine and understand the different categories emerging from the data (Glaser & Strauss 1967). The following section outlines and discusses the key findings regarding the hospital's intercultural service provision for pregnant Ngäbe women.

The role of the Intercultural Ward
In 2011, as part of the intercultural health model and as an extension to UNFPA's maternal mortality reduction program, UNFPA together with the JDO hospital created the Intercultural Ward in the JDO's Maternity Department, and recruited a Ngäbe woman as the Head of the Intercultural Ward. According to all the interviewees, initially the intercultural initiative was seen solely as an important step forward to address the language problems between medical staff and pregnant Ngäbe women, and the medical staff's lack of cultural sensitivity and its lack of awareness of the context and conditions in which the Ngäbe have been living-as the Director of the Research and Teaching Division recalled: I have been working for this hospital for 24 years. A long time ago I noticed that there were problems in the communication and the relations between the Indigenous and the professional staff. It was not only a problem of language but also a cultural problem … the biggest problem was to accept the other culture and its differences-but also to see the similarities … but in those days we did not have the tools to make a change. The medical education focused on the technical aspects and disregarded any cultural aspects. The medical experience was of no help when members of other communities came to the hospital.
Soon after the introduction of the Intercultural Ward, it became apparent that the ward could also be used to address the lack of information and awareness among Ngäbe women regarding family planning, contraception, pregnancy and giving birth.
The Intercultural Ward is located in the centre of the Maternity Ward, and includes office space and a large meeting and presentation room. Integrating the Intercultural Ward in the heart of the Maternity Ward has had a functional purpose as much as a symbolic meaning. The latter refers to reflecting the salience of cultural diversity within the country as a whole, and the cultural dialogue that was to be developed and established in the hospital between the different stakeholders and their different cultural backgrounds: Each person needs to be prepared to work with different cultures, being aware and cautious about what other people need and want. Particular attention should be given to each individual … There needs to be a dialogue. (Head of Intercultural Ward) In the Intercultural Ward, presentations are taking place for Ngäbe women about contraception and pregnancy. In the past, one of the key challenges with regard to maternal mortality was the lack of information about contraceptive methods. Ngäbe women started their sexual activities at the age of 14-16 years, and many of them had up to 10-12 babies. For the Ngäbe, pregnancy and a certain period following the birth of their babies is considered to be a special state, and women are treated differently-better, with less work and more attention from the husbands.
Presentations also include information about pregnancy and giving birth, as the Ngäbe people do not have enough information and knowledge about related health and illness issues-as the Director of the Research and Teaching Division explained: The [Ngäbe] women do not know why it is necessary to have control check-ups during their pregnancies. And they also do not understand why it is important to have check-ups after having given birth.
After the Ngäbe women have given birth to their babies, the medical staff also use this time at the Intercultural Ward to tell the mothers what they can do and what they cannot do when back at home in terms of taking care of the babies.
All presentations are conducted first by the medical staff and then translated by the Head of the Intercultural Ward and her assistant, another Ngäbe woman. Both speak Ngäbere to ensure that the Ngäbe women understand everything; as the Head of the Intercultural Ward explained: Many of the Ngäbe women either don't speak or understand Spanish, or understand only the very basics of Spanish. Also, the presentations are often very technical when it comes to aspects such as vaccinations, family planning, neonatal testing, lactation, and sexual deceases […] and some of the Ngäbe women don't understand anything and fall asleep.
The medical staff has noticed that when the Head of the Intercultural Ward translates, the Ngäbe patients pay attention-not only because of what she says but also because of the soft way she speaks and the terms she uses.

The role of the Ngäbe intercultural staff
The Head of the Intercultural Ward sees the technical translations of Spanish into Ngäbere only as the starting point for creating a dialogue between Ngäbe patients and the medical staff of the JDO hospital. For her, the development of a mutual and trusting intercultural dialogue is based on interactions that consider the Ngäbe patients holistically. According to the Head of the Intercultural Ward, 'you need to understand where these women are coming from, understand that many of them have never been outside their Comarca, that they are very shy and scared'. The two directors described the Head of the Intercultural Ward's behaviour as authentic, as having a genuine interest and concern in the patient's wellbeing, and an attitude of friendliness and openness that helps to overcome some of these Ngäbe patients' worries-as the Director of the Research and Teaching Division described: 'They [the Ngäbe patients] trust her and tell her openly things about their pregnancies … they feel comfortable around her … she is considered as one of them.' What helps in these interactions is the dress code of the Head of the Intercultural Ward. Just like the Ngäbe patients, she wears the traditional colourful Nagua dress. The colourfulness of her dress is an important factor in the development of trust and dialogue when considering how for the Ngäbe the colour white represents death. Thus, considering that traditionally the main colours of hospital facilities and the dress code of medical staff has been white, this did not help to attract and make Ngäbe patients feel comfortable in the hospital in the past.
Knowing the language, cultural traits and symbolic meanings of the Ngäbe is as important as knowing and understanding the local context and environment in which the Ngäbe people live and come from. As the Head of the Intercultural Ward explained: When the Ngäbe women need to do neonatal screening, they can now do it locally. The JDO has established some local facilities so that the women don't have to go too far. I know the region very well, and I can advise the women which local centre is nearest to their homes or the easiest to reach. In the old days this was not possible, not only because many of the current local facilities did not exist, but also because medical staff did not know the particularities of the region and localities.
Thus, the role of the Head of the Intercultural Ward and her assistant goes beyond language translations that facilitate exchanges of information between JDO's medical staff and Ngäbe patients. The role of the Intercultural Ward and its staff is also about translating cultural clues, characteristics and customs, and explaining environmental and local particularities of the Ngäbe people that foster greater cultural awareness and understanding among JDO's medical staff, and that turns into the creation of trust and dialogue between the two groups.

The medical staff-changing perspectives and creating trust
The interaction between medical staff and the staff of the Intercultural Ward has led to many changes in the facilities and processes in the maternity ward, and among the medical staff's perspective and approach toward the Ngäbe patients. Today, the nurses and doctors in the JDO hospital have integrated in their uniforms traditional Nagua designs, patterns and colours (e.g. arm wrists patterns) to address the the Ngäbe's fears of the colour white. In all the wards, the hospital now has symbols and signs with phrases in Spanish and in Ngäbere to communicate more relevant information, and to help the Ngäbe feel more welcome. Medical and non-medical staff receiving and registering patients have a better understanding of the difficulties and obstacles Ngäbe women have to endure to come to the hospital, and the staff is trained to welcome patients in a friendly and open way, as the Director of the Department for Gynaecology and Obstetrics explained: When a pregnant Ngäbe woman arrives at the hospital after walking nine hours through mountainous terrain and flooded rivers, and does not speak any Spanish, the least we can do is showing some empathy and making her feel welcome.
While in the past, the wellbeing of the babies was the main concern of the medical staff, today the hospital and its maternity ward takes a more holistic approach toward the 'puerpera'-the woman who has just given birth to her baby-as explained by the Director of the Department for Gynaecology and Obstetrics: Nowadays, the puerperas are informed about how to get back to their normal lives physically and mentally. Some time ago, the hospital has only taken care of the baby and all the things that are related to the baby … and nothing about the mothers … now the hospital is also taking care of the new mothers and how they need to take care of themselves.
This care of the patient as a person creates the much needed trust and communication between the medical staff and the Ngäbe women.
Aside from the Intercultural Ward staff learning to see the patient as a person, medical staff have also started to understand and to adapt to the particular Ngäbe Cosmo vision that influences their Ngäbe patients' view of the world in general, and how they deal with pregnancies and other health-and illness-related aspects in particular-as illustrated in the example given by the Director of the Research and Teaching Division: For example, in the Ngäbe Cosmo vision, the concept of time has a different meaning than in our context, and this has obviously implications for us when we want to treat the Ngäbe. Generally, when we treat people, we ask them how long they have been sick, how long they had certain symptoms, how long they had a certain problem. Everything is quantified and controlled by time. In the Ngäbe culture this approach does not exist. The Ngäbe live in the here and now. So, when I ask how long the baby has been sick, they don't know. For the mother the baby is sick now, the past does not exist. At some point, the Ngäbe just invented the time in their answers -four days, one week-they don't care … they just want to make us happy.
The different interpretation of time also has implications when it comes to medical histories and simple aspects such as identifying the age of the patient: Many Ngäbe don't know how old they are, as this is in the past. They count in being a child, a teenager, and being old. When we say 'How old are you?' we can give directly a number. When I ask the Ngäbe patients they just take out their ID cards and show them-because they have no idea how old they are in years. (Director of the Research and Teaching Division) As part of the intercultural process, medical staff begin to understand the Ngäbe's Cosmo vision and to look at pregnancies and other health-and illness-related aspects of the baby and the mother from the Ngäbe's perspective: 'It is not only what they explain but also how they explain it' (Director of the Research and Teaching Division).
Taking a holistic approach and understanding others' different cultural and environmental context and perspective is critical for the development of a dialogue, trust and closeness between the medical staff and the Ngäbe patients. In turn, the intercultural dialogue und understanding has played a salient role for the medical staff to realise the importance of the local midwives for the pregnant Ngäbe women. Due to the limited number of medical centres in the Comarca in the past, and the continuous isolation of Ngäbe villages and communities, pregnant Ngäbe women have always relied on and trusted local midwives; as the Director of the Department for Gynecology and Obstetrics explained: The pregnant women are very comfortable with the midwives. So, if they have to come to the hospital, they want the midwives to come with them. In the past we did not allow them into the hospital. Today, the midwives are allowed to come with the patients to the shelter and the hospital.
The shelter, or 'aberge', is a resting place for Ngäbe women in advanced pregnancy, who with their midwives come from far away to wait for the birth of their babies. The shelter is next door to the hospital and reminds the Ngäbe of their local aberges in the Comarca, which are substitutes for medical clinics or centres. This inclusive approach extends to all areas relevant to the pregnant Ngäbe patients, and plans are being developed to work more closely with traditional medicine, such as teas, herbs and plants, and the introduction of vertical births with an upright position.
Finally, as part of the intercultural health model and their medical training, resident doctors (generalists who are training to become specialists) are now participating in cultural awareness training at the hospital, with four months' internship in the Comarca. As the Director of the Research and Teaching Division explained, 'The best way to understand the other is to live in their culture-not just to see it from the outside'. Understanding the context of the Ngäbe helps medical staff to move away from the traditional diagnose-treatment-approach-as the following example of the Director of the Research and Teaching Division described: A few years ago, we all followed the medical routine of diagnosing the illness and then treat it. We rarely went to search for the causes. But when you understand the cause of an illness then you can better apply preventive methods. Here in the Ngäbe Bugle Comarca and in other Panamanian Indigenous regions the causes of illnesses are poverty, lack of transportation, lack of awareness and understanding amongst the Indigenous groups. That is why it is important to work with the community and to understand their context.
The investment in sensitising medical doctors to the cultural and environmental context of their patients contributes to the sustainability of the intercultural health model and the intercultural dialogue between the different groups in the JDO hospital. Today, the number of pregnant Ngäbe coming to the JDO hospital has increased, and non-Ngäbe (medical) staff are widely accepted by the Ngäbe patients. The rate of maternal mortality in the Ngäbe Buglé Comarca has decreased, and the majority of Ngäbe women in the Comarca now have only 6-7 children. While all interviewees are very positive about the future opportunities of the intercultural health model, the interviewees agree that there continue to be challenges in this intercultural process.

Future challenges and opportunities of the intercultural initiative
While the Panamanian government has no direct influence on the hospital in terms of the hospital's strategy and recruitment of key decision makers, the changes in staffing in the administration of the Ministry of Health after every governmental leadership change can affect the government's long-term support of JDO's intercultural initiative. 4 Considering the difficulty of quantifying the success of the JDO's intercultural initiative in economic terms, the hospital finds it challenging to put forward a business case for continuous support by the Ministry of Health. The support by the latter is critical for financially sustaining the Intercultural Ward and recruiting more intercultural staff.
The current leadership of the Ministry of Health is a great support of the JDO's intercultural health model. The Ministry wants to replicate this model in other hospitals that work with Indigenous communities, and apply the intercultural practices and processes that have been successfully implemented in the JDO hospital. Plans have been proposed to recruit Embara women 5 from the Darien Comarca for internships at the JDO hospital.
With many of the residential doctors leaving after their medical and cultural training at the JDO, the interviewees expect Panama's medical field to change in terms of mindset. The Director of the Research and Teaching Division predicts a snowball effect with many more medical staff able to understand and respect the role of culture awareness and sensibility in their dealings with Indigenous patients: The technical skills are as important as the cultural competencies … it is one of the things here that makes a good doctor … What we want is that in the next five to ten years there are plenty of doctors with a similar attitude and perspective of what makes a good doctor. These doctors are going to be cultural aware and more sensitive … they will have better communication skills … these doctors are changing the mind from a purely medical mind to a cultural awareness mind.
The medical staff's increased cultural sensitivity is not only beneficial for their work with Indigenous groups such as the Ngäbe. Although half of the patients in the maternity ward are non-Indigenous, very often they also come from contexts and socio-environments that are very different from the backgrounds of the medical staff and require a certain sensitivity and understanding by the medical staff.

Discussion and conclusions
This study has explored the concept of interculturalism at both a meso-and a micro-social level. The findings indicate that for managing different cultures beyond cultural coexistence, intercultural communication and intercultural dialogues are critical. As this study shows, including translators who not only speak the language of the cultures involved but who also know the cultures well and can translate cultural clues and traits is an important starting point in the development of an intercultural framework. The staff of the Intercultural Ward moved beyond simple, technical language translations to more complex interpretations and transmissions of cultural elements and characteristics that describe the Ngäbe's Cosmo vision and their views about pregnancy and health-and illness-related aspects.
The case of the Ngäbe also highlights how the intercultural dialogue between the medical staff and the Ngäbe relies on taking a holistic perspective of the Ngäbe, a perspective by which traditional cultural traits are merged or blended with environmental characteristics that describe the Ngäbe's context and background, as the Ngäbe's particular environmental context-the seclusion in the mountainous and isolating Comarca-seems to have had an impact on their Cosmo vision and vice versa. Understanding the historical and environmental context that shapes the culture of the Ngäbe, or 'the other', provides the basis for an enabling discourse that differs from multiculturalism in that the former is more of an opening, and less of a categorising and divisive nature (see Litvin, 1997;Sarmento, 2014).
Much of the implementation of an intercultural model and its success depends on the willingness and openness to wanting to sensitise oneself and to understand the other's cultural and environmental context. In the case of the Ngäbe, the medical staff saw the relevance and importance of gaining a greater understanding and appreciation of their Indigenous patients' cultural and environmental context, which created a trusting relationship between medical staff and the pregnant Ngäbe women. This trust was further enhanced by the acceptance and integration of Ngäbe cultural traits and symbols in the facilities and processes within the hospitalan inclusiveness that characterises the intercultural model, and that leads to its sustainability (Gröschl, 2003).
Aside from trust building as the basis for an intercultural initiative or model, this case study shows how equally important flexibility and adaptability are for the sustenance of intercultural activities and processes. Regardless of the government's financial support to continue JDO's intercultural initiative, the medical staff's flexibility and adaptability has been key to the continuity of JDO's intercultural health model; in particular, when taking into account that culture is neither static nor passive (see Sarmento, 2014).
Aside from extending the concept of interculturalism to meso and micro levels, the study's findings have implications of a practical nature for the integration of Indigenous communities in Latin American societies. Considering that throughout Latin America Indigenous women continue to have higher maternal mortality rates and more healthcare problems than women of non-Indigenous populations (UNFPA, 2010), the case of the JDO and its intercultural health model could be used as a framework to develop formalised networks of similar intercultural initiatives across Indigenous communities in other parts of Latin America. So far, similar programs are loosely scattered across the region and include, for example, the 'Sumak Kawsay' (Good living) interculturality and health care initiative in Ecuador, the intercultural public policies and healthcare plan in Bolivia, and the intercultural initiative for maternal health in Guatamela (UNFPA, 2008).
On a final note, I propose that the intercultural competencies identified in this case study at both a meso and a micro level could be considered by non-Indigenous societies and communities facing increasingly cultural diverse environments and contexts at a macro level. The most recent refugee movements in Europe is one of many examples that illustrate how communities struggle to address the cultural challenges and opportunities that come with such movements and other migration dynamics. While many political leaders and bodies have called for more integrative and inclusive actions and policies, no-go zones such as Bruxelles' Molenbeek and France's Seine Saint Denis illustrate the concerns by the Council of Europe and the European Commission (2016) mentioned earlier, that multiculturalism is 'reinforcing walls between culturally distinct groups that can lead to ethnic clustering and ghettoization'. Applying intercultural competencies or principles such as the willingness toward a comprehensive understanding of others and their context, the creation of mutual trust and communication, and the development of a context for constructive dialogues could support communities and their members in their efforts to create greater inclusiveness of culturally diverse groups.
sleeve and neck lines. The classic Ngäbe geometric pattern is called dientes, or 'teeth', and represents mountains, animal teeth, the flow of the river, and dragon scales (Gomez, 2015). 3 Reducing maternal mortality rates in childbirth by 75% by 2025 (World Health Organization, 2015). 4 In Panama, after every governmental leadership change, all administrative posts in most public offices will be staffed with the ruling party's affiliates. 5 The Embara are with the Kuna, the other two indigenous groups in Panama.