In the past five years, there has been a surge in the attention shown to community and community-based health programs among Native Americans, particularly for chronic health problems such as diabetes. New Mexico’s Native American Diabetes Project, a diabetes education and gardening project in the American Northwest, and the Daya Tibi health center in Poplar, Montana are just a few of the programs to report outcome success using a community-based model. What do these projects have in common, and to what does community-based refer? Is community participation, as Bell and Franceys declare, just a euphemism for unpaid labor? Community participation in health programming—from the efforts of community health workers (CHWs), to participatory research, to the impact of politics on community health programs—has been a popular approach in anthropology and public health since the late 1970s and is now a hackneyed expression in health programming. As part of a comprehensive edited volume on the subject, Barbara Israel et al. declare community participation to be not a method but an orientation based upon nine principles such as the facilitation of collaborative, equitable partnerships in all phases of the work; promotion of colearning and capacity building among partners; and the involvement of systems development through a cyclical and iterative process. This discussion offers a view of community participation from Indian country. One major impetus behind this resurgence of “community”-developed programs for Native Americans is the momentum of self-determination. The era of tribal self-determination, stemming from the 1975 Self-Determination Act among other pieces of legislation, is nascent in its capacity to produce novel, culturally relevant, and community-minded programs in health. Tribal councils and other governing bodies have increasingly demanded participatory methods of research, health care, and education from both Native and non-Native professionals. It is little wonder, then, that these terms fill the titles of public health, medical anthropology, and even diabetes care literature on tribes. Tribes have motivated this transformation.

As notions of cultural competency have risen to prominence in health care, some of our most powerful models and strategies come from successful tribal health care. In this chapter, we deconstruct notions of cultural competency, rebuilding this important aspect of medical practice under Bourdieu's model of reflexivity (1986). We outline a critical discourse of cultural competency based on a processual (and distinctively anthropological) model. In promoting several specific strategies for culturally competent care, we point to the assumptions regarding the boundedness and neutrality of culture within biomedical practice as well as the authority and power structures through which competency is determined. We offer two case studies: one, an examination of a community-based ambulatory care practice; the second, a consideration of both practitioners' and institutions' use of cultural capital in addressing the community they serve. We promote a reflexive form of culturally competent care that goes beyond "cookbook" uses of cultural capital to move toward an engaged and structurally flexible approach, one that allows the blending of biomedical paradigms with patient culture and history.