Culture and Health

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It is crucial for any health-care provider to have an appreciation for cross-cultural family values, language, norms, religion, and political ideology. An estimated 80% to 90% of all self-recognized episodes of illness are managed exclusively outside a formal health-care system. Traditional healers, mediums, self-help groups, and religious practitioners provide a substantial proportion of this health care.

Within the United States, there are many culturally distinct groups. Even within these groups, there are many variables such as educational achievement, socioeconomic class, generational status, and political relationship between the country of origin and the United States. All these factors contribute to establishing the dynamic reality of an ethnic group. Being in a low socioeconomic bracket appears to be a strong predictor that ethnicity will influence the behavior of such patients, regardless of whether they are newly arrived or native born. The following factors are other predictors of behavioral ethnicity:

Emigration from rural areas

Frequent return visits to the native area

• Lack of formal education

Immigration to the United States at an older age

# A major difference in dress or diet from the surrounding population

Newly arrived immigrants often experience prejudice; the toll on their psyche may be a heavy one. But cultural change is not limited merely to immigration. Moving around in the same country or changing professions may also result in culture shock. The new culture may be viewed as unempathetic, cruel, and critical. The newcomer may experience frustration, irritability, fatigue, loss of flexibility, and an inability to communicate feelings to others.

Distrust, paranoid tendencies, depression, anxiety, and physical and psychosomatic illnesses may develop. It is therefore necessary to include a patient's and family's immigrational and migra-tional history in the evaluation of the patient because the family is the carrier of ethnic traits and identity.

Cross-cultural marriages can offer the best and worst of both worlds. The reconciliation of different norms and traditions may provide an enriching experience, but a clash of different cultural traits may lead to strained relations among spouses and families.

The influence of ethnicity and culture on health and health-belief practices has long been recognized as a result of the presence of racially related diseases and syndromes, as well as societal predispositions to illness. It is very important to inquire about patients' perceptions of their symptoms and illness. To understand better the cultural influences on a patients' medical problem, Lipkin and colleagues (1995) suggested several questions for eliciting patients' explanations for their symptoms or health-belief practices:

''What do you call your problem?"

''What causes your problem?''

''Why do you think it started when it did?''

''How does it work—what is going on in your body?''

''What kind of treatment do you think would be best for this problem?''

'How has this problem affected your life?''

''What frightens or concerns you most about this problem and treatment?''

The answers to these questions provide insight into the hopes, aspirations, and fears of the patient.

Genetic Diseases

The simultaneous manifestation of two or more forms or alleles of a gene in a population is a genetic polymorphism. Certain genetic polymorphic states, such as blood groups, are strongly associated with disease. As early as 1953, an association of blood group A with gastric carcinoma was recognized. The causal relationship of hemoglobin S to sickle cell anemia is well known. Thalassemia comprises more than 50 genetic disorders characterized by ineffective erythropoiesis that leads to severe anemia, fever, hyperuricemia, and skeletal deformities. The association of these disorders with Mediterranean background has been established. The human leukocyte antigen gene complex and the many diseases associated with it continue to receive attention. Table 3-1 summarizes some specific diseases on the basis of geographic distribution and ethnic populations.

Traditional Medical Beliefs

People interpret traditional medical beliefs about the body's shape and size, inner structure, and functions in terms of their cultural background. To illustrate various cultural beliefs about body functions, consider that patients often ascribe their symptoms to blood that is ''too thin,'' ''too thick,'' ''too little,'' or ''too slow.'' Blood can be used as an index of an emotional state (blushing);a personality type (''cold-blooded'' or ''hot-blooded'');a kinship (''blood is thicker than water'');a diet (''thin blood'');or a social relationship (''bad blood between people''). ''Bad blood'' is also frequently used to refer to syphilis.

As another example of the cultural beliefs about blood, consider views about menstruation. A study in 1977 by Snow and Johnson evaluated the views of inner-city women in a public clinic in Michigan. Many of the 40 women interviewed felt that menstruation was a method of ridding the body of impurities that could cause illness or poison the body. Many of these women believed that when the uterus was ''open'' during menstrual flow, they were vulnerable to disease. They also believed that it was only at this time that a woman could become pregnant. At all other times in the menstrual cycle, the uterus was ''closed,'' and pregnancy was impossible. Another common fear among the women was that of impeded menstrual flow. They feared that stoppage might cause a backup of poison and hence a stroke, cancer, or sterility. This fear may be a reason why these women avoid the use of certain methods of contraception, such as intrauterine devices and diaphragms.

Table 3—1 Geographic and Ethnic Distributions of Specific Diseases

Specific Disease

Highest Incidence

Specific Disease

Highest Incidence

Cancer of the skin

Eastern Australia

Ischemic heart disease

North America South America

Cancer of the cheek

Southern India, New Guinea

Europe

Cancer of the nasopharynx

Southeast Asia, Kenya

Finland

Cancer of the esophagus

Northern France

Hypertension

Japan

(Brittany)

Taiwan

South Africa

Venous thrombosis

North America

Eastern Zimbabwe

South America

Western Kenya

North America

East of the Caspian Sea

Varicose veins

Cancer of the stomach

Japan

Korea

Diabetes

North America

Eastern Finland

South America

Mountain region of Colombia

Europe

Eastern Zaire

Southwest Uganda

Urinary bladder stones

Rural Thailand

Cancer of the colon

North America Western Europe

Multiple sclerosis

Northern United States Northern Europe

Cancer of the liver

Sub-Saharan Africa

Rosacea

Great Britain, especially Scotland

Burkitt's lymphoma

Africa (10° north and south of

equator)

Vogt-Koyanagi-Harada

Japan

syndrome

Italy

Appendicitis

North America

South America

Takayasu's disease

Japan

Europe

Lactase deficiency

Greece

Diverticular disease

North America Western Europe Australia New Zealand

African Americans

Thailand

Eskimos

Japan

Hemorrhoids

North America

South America

Choroideremia

Northern Finland

Europe

Abetalipoproteinemia

Ashkenazi Jews

Cholelithiasis

Southwestern

United States Sweden

Glycosphingolipidoses Gaucher's disease Niemann-Pick disease

Ashkenazi Jews

Stenosing duodenal ulcer

Southern India

Tay-Sachs disease

Eastern Zaire

Familial Mediterranean fever

Sephardic Jews Armenians

Another belief about menstruation was studied by Skultans (1970) in two groups of women from a small mining village in South Wales, U.K. One group of women felt that menstruation was a process by which the body ''cleansed'' itself;the longer the period or greater the blood loss, the better. These women regarded menstruation as normal and essential to a healthy life. In contrast, another group of women from the same mining town viewed menstruation as damaging to their overall health; they feared that the blood loss was threatening to their health and welcomed the thought of menopause.

Finally, Ngubane (1977) described the beliefs of South African Zulu women about menstruation. They felt that menstruating women had a ''contagious pollution'' that was deleterious to other living creatures and to the natural world. A man's virility would be reduced if he had sexual relations with a menstruating woman. Crops would be ruined and cattle would die if menstrual blood came in contact with them. In some of these African communities, menstruating women are isolated from the community because of their ''dangerous pollution.''

Although food is a source of nutrition, it plays many roles and is deeply embedded in almost all aspects of everyday life. Some foods eaten in one society are forbidden in others. Each culture has its own rules of food preparation and of how it is served and how it should be eaten.

Every culture defines foods that are edible and those that are not. In France, frogs' legs and snails are delicacies, whereas in the nearby United Kingdom, they are rarely eaten. Some foods are considered sacred and others are prohibited. Food abstentions occur during the Jewish fast of Yom Kippur and the Muslim fast of Ramadan. Orthodox Hindus are forbidden to kill or eat any animal, especially the cow. However, milk or milk products may be consumed because they do not require the death of the animal. Orthodox followers of Islam and Judaism are prohibited from eating pork products. Only the meat from mammals that chew their cud and that have cloven hoofs is edible, provided that the animal was slaughtered ritually: according to halal (Islam) or kosher (Jewish) law. Kosher law dictates that meat and milk products are never eaten together. In Sikhism, pork is allowed, but never beef. Rastafarians are generally vegetarians, and alcohol is strictly forbidden.

Some cultural groups in the Islamic world, the Indian subcontinent, Latin America, and China believe in the ''hot-cold theory'' of disease. This belief, which is intuitive and common throughout Latin America, states that the body is regulated by hot and cold ''humors.'' The belief stems from Hippocratic humoral theories brought to this hemisphere in the 16th and 17th centuries by the Spanish and Portuguese. Health is the balance of these hot and cold body fluids. Illness is defined by a humoral imbalance of these forces. All mental states, illnesses, and natural and supernatural forces are grouped into hot and cold categories. Foods, herbs, and medications are also classified as hot or cold and serve to restore the body to its natural balance. Although it may seem that the system is based on temperature, the thermal state in which the foods or medications are taken is not important. Certain types of herbal tea, served hot, are considered cold, whereas cold beer, because of its alcoholic content, is considered hot. In the hot-cold theory of disease, conditions that are hot, such as ulcer disease, constipation, pregnancy, diarrhea, and rashes, should be balanced and treated with cold foods, such as coconut, avocado, sugar cane, and lima beans. Menstruating or postpartum women who believe in the hot-cold theory may avoid certain ''cold'' vegetables and fruits because these fruits are liable to clot their ''hot'' menstrual blood, impeding its flow, making it flow backward into the body and thus causing nervousness or insanity. Cold illnesses, such as arthritis or joint pains, are treated with hot therapy, such as aspirin, iron tablets, penicillin, chili peppers, chocolate, evaporated milk, onions, garlic, or cinnamon.

Consider the following. A patient may be on diuretic therapy and require potassium supplementation. The clinician may advise the patient to eat foods high in potassium, such as oranges or bananas. If the patient acquires an upper respiratory infection, which is a cold disease, he or she may stop eating these fruits, which are classified as cold, because eating them will only worsen the imbalance. This belief should be recognized because it contributes significantly to whether a patient does or does not adhere to therapy. Problems can arise when a clinician prescribes a ''hot'' medication for a ''hot'' disease or a ''cold'' medication for a ''cold'' disease. The hot-cold theory is even more complex in that the assignment of the ''hot'' or ''cold'' qualities varies from culture to culture. It is often difficult for the health-care provider to remember the various hot-cold combinations. If a Hispanic/Latino patient has these beliefs, the clinician should ask Hispanic/Latino colleagues on the medical team or the patient and family directly about these combinations. Inquiring respectfully about the patient's culture can be effective in enhancing doctor-patient relationships. To achieve maximum therapeutic benefits for patients who believe in the hot-cold theory of disease, the health-care provider is advised to work within its framework, if possible, in prescribing medicines and diet. He or she should try to consult medical colleagues, nurses, and social workers who share the patient's background.

Belief in witchcraft as a cause of illness is widespread. In the Hispanic/Latino population, terms such as mal puesto, mal de ojo, mal artificial, brujería, hechicería, and enfermedad endañada are used to describe the ''illness of damage'': someone has done something to cause injury, illness, or death. Mal de ojo, or evil eye, is believed to result from excessive respect or love from another person, especially toward newborn children. A recurring theme in witchcraft belief is that animals are present in the body and are introduced by magical means. Almost always, the offending animal is a reptile, insect, or amphibian. These animals have been dried and pulverized, sprinkled onto food, and reconstituted in the body of the victim. Symptoms are often described as animals crawling over the body or wriggling throughout the intestines. The belief is that this is a magical expression of friends, relatives, or strangers wishing bad luck to come to an individual. A hex is an evil spell, a misfortune, or a case of bad luck that one person can impose on another. Magical oils, incenses, religious items, and candles may be used to repel the evil. In the Hispanic/ Latino community, a botanica, or religious artifact shop, sells many of these items. The shopkeeper serves as a consultant on health and related issues. Figures 3-1 and 3-2, taken in the Otto Chicas Rendon Botánica on 116th Street in New York City, depict examples of such shops. Often, the entrance to a botanica, as shown in Figure 3-1, shows predominant Roman Catholic imagery.

Figure 3—1 Entrance to Otto Chicas Rendon Botanica on 116th Street, New York City.

Figure 3—1 Entrance to Otto Chicas Rendon Botanica on 116th Street, New York City.

Candles, flowers, plants, and bowls of coconut and molasses frequently surround the Christian statues. The influence of Christianity, as well as of the African and Arabic cultures, is apparent in the idols shown in Figure 3-2. As of mid-2004, there were more than 750 botánicas listed in the business telephone books in the United States, of which there were more than 95 in Manhattan. There are probably many more that are not listed.

Very often, patients who believe they are victims of witchcraft do not seek medical attention from a clinician. Certain members of their community may be consulted to chant special prayers and incantations to cure the illness. At other times, they may require exorcism or some other dramatic therapy to drive the illness out of the body. Other common ''cures'' include turpentine, kerosene, mothballs, and carbon tetrachloride.

Culture and Response to Pain

The sociocultural variations in physical pain expression are important to recognize. Pain is a complex phenomenon for both the patient and the health-care provider, influenced as much

by personal values and cultural traditions as by physiologic injury and disease. Multiple factors influence the perception and expression of pain. Pain is an important form of biofeedback and is essential, as a warning signal, for survival. The experience of physical pain, however, has three components: (1) a person's sensation of pain, (2) a person's tolerance for pain, and (3) a person's expression of pain. Health-care providers must rely on the pain sufferer to describe the symptom of pain, the sum of these three components. The last of the three is culturally mediated.

Some studies have indicated that there may be cultural variations in the tolerance for pain as well. In some cultures, the complaints of pain are rewarded with increased attention and comforting behavior. Individuals of Hispanic/Latino background or from the Middle East or Mediterranean areas commonly voice their pain with great emotion. Some believe that they must openly express their pain; if they do not, they may aggravate their illness. In contrast, Southeast Asian, Asian-Indian, Japanese, and Native American patients believe that emotional control is extremely important. Their cultures encourage stoicism; these people rarely openly express or even indicate the presence of pain, unless it is extremely severe. In many instances, the ability to withstand great pain is a sign of manhood, reliability, and moral uprightness.

The anthropologist Zborowski (1952) studied pain in four groups of male patients in a veterans' hospital. Third-generation Americans generally expressed pain with little emotional behavior and became withdrawn from their friends. Italian and Jewish men were very expressive and preferred to be with others while in pain. Irish men endured pain as a private event and neither sought any medication for it nor wanted to socialize with others. These generalizations about cultural responses to pain must be used cautiously and not become the basis of stereotyping.

It is also important for the health-care provider to recognize that many patients from Southeast Asian and Native American cultures frequently express their illness through altered states of consciousness such as trances and hallucinations. The clinician who is unaware of this type of presentation may incorrectly diagnose it as some form of psychosis.

Ethnicity and Pharmacotherapy

It is increasingly recognized that there are ethnic differences in the response to pharmacologic agents. For example, in psychopharmacology, new research has begun to provide insight concerning the biologic mechanisms that underlie this differential response. Data have been accumulated about the ethnic differences in drug metabolism, as well as the plasma proteins that bind psychotropic agents. Several ethnic differences in drug metabolism appear to be related to different genetic forms in the drug-metabolizing cytochrome P-450 enzyme system. It has been demonstrated that a high percentage of Asians and African Americans have an enzyme form that metabolizes drugs at a much slower rate; in individuals with this form, potentially toxic blood levels of drugs may develop after administration of standard doses of certain psychotro-pic agents. Some Chinese herbs, such as ginseng and muscone, have been shown to have potent stimulating effects on cytochrome enzymes; other herbs substantially inhibit the activities of these enzymes. It is therefore important to determine the serum levels of drugs in a patient in whom an atypical response has developed. Other studies have shown that Asian and Hispanic/Latino patients with schizophrenia require lower doses of neuroleptic agents, such as chlorpromazine, than do white patients. Asian patients are also more likely to exhibit the extrapyramidal side effects of the neuroleptic agents than are white patients.

Cross-Cultural Differences in Morbidity and Mortality Rates

It is important to be aware of the considerable cultural diversity in patterns of morbidity and mortality rates in the United States. Some patterns may be purely genetic, as in Tay-Sachs disease among persons of Ashkenazi Jewish (Eastern European) descent or sickle cell anemia among African Americans. The pattern of health for African Americans is very different from that of their white counterparts. The average life expectancy for African Americans is 69.6 years of age, in comparison with 75.9 years of age for white persons. This may in part be related to a higher infant mortality rate among African Americans. The incidence of hypertension and its consequences is much higher in African Americans than in white persons. African-American men die from cerebrovascular accidents at almost twice the rate of white men. In addition, death from coronary artery disease in African-American women is more common than in white women. Diabetes is 35% more common among African Americans than among the white population. Many African Americans, like members of other ethnic groups, have had negative experiences with the Western medical system. The perception of a judgmental or impersonal attitude in a white health-care provider may contribute to a fear or distrust of the traditional health-care system. As a result of this lack of trust, many African-American patients seek alternative medical treatment.

People of Hispanic/Latino descent (Mexican Americans, Puerto Ricans, and Cuban Americans) are the fastest-growing minority in the United States. Many are at increased risk for alcoholism, cirrhosis, hypertension, specific cancers, and tuberculosis. The incidences of diabetes and cancers of the gallbladder, liver, pancreas, cervix, and stomach are higher among Hispanic/Latino people than in the general population. Cervical and stomach cancers occur more than twice as often in Hispanic/Latino people as among non-Hispanic/Latino whites. There is also an increased incidence of acute promyelocytic leukemia in the Hispanic/Latino population. Within this group, the Puerto Ricans have the poorest health. This may be related to the fact that many older patients do not trust conventional medicine or health-care providers or that migrant people are often forced to live in areas of crowding and poor sanitation.

The rate of tuberculosis among Chinese Americans is higher than in the general population. In fact, the incidence of tuberculosis is more than 40 times higher among Southeast Asians than among the non-Asian population. Both first- and second-generation Chinese Americans have a greater incidence of coronary artery disease than do Asian Chinese, presumably because of differences in diet and stress in the United States. The Japanese and Koreans have the highest incidence of gastric cancer, presumably related to diet and their high consumption of salt. The incidence of liver cancer is more than 12 times higher among the Chinese, Japanese, and Koreans than within the non-Asian population. Hepatitis B is also more common in Southeast Asians.

Native Americans have one of the highest morbidity and mortality rates; their death rate is 30% higher than that of the general population in the United States. This risk may be linked to the fact that Native Americans are one of the most disadvantaged ethnic groups in the United States. They have a high incidence of fetal alcohol syndrome and fetal alcohol effects. In addition, the incidence of congenital adrenal hyperplasia is greater in Native Americans than in the white population.

Traditional Healing Systems

Traditional, or folk, healers still play a large role in medicine in industrialized societies. Each culture has its own healers: spiritual healers, mediums, herbalists, shamans, fire doctors, medicine men, astrologists, occult healers, bone setters, lay midwives, and leg lengtheners are only a few. Meditation, prayer, massage, exercise, relaxation techniques, acupuncture, acupressure, hypnosis, imagery, therapeutic touch, martial arts, and herbs are important therapeutic modalities of many of these healers. Spiritual healing is widespread. Christian Science healing, started in 1879 in Boston, teaches that those who follow Jesus must follow him in healing, which is done through the mind.

The Hispanic/Latino groups call their traditional healers by different names, such as the Mexican-American curanderos (male) or curanderas (female) and parteras, Puerto Rican espiritistas, and Cuban santeros. The Haitian voodoo healers, Inuit and African shamans,* Hawaiian kahunas, and Navaho singers are also important folk healers for their ethnic groups. It is crucial for the health-care provider to respect patients who follow these practices and to encourage them to express their need for these providers without shame or fear. The health-care provider should discuss with the patients how to combine the help of these providers and medical therapy.

In addition to the natural healing traditions, there are many magical-religious traditions. As stated previously, religion plays a major role in one's perception of illness. The ''evil eye'' is one of the oldest and most widespread of all superstitions. The nature of the evil eye is defined differently by different groups, but it is generally accepted that an evil eye causes a sudden injury or illness that may be prevented or cured by rituals or symbols. The afflicted person may or may not know the source of the evil eye. There are several traditional practices used in the protection of health;they include wearing objects, such as charms, that protect the wearer.

*The shaman is a medicine man or priest. He cures illness, directs communal sacrifices, and escorts the souls of the dead to the other world. He accomplishes these tasks by his power to leave his body at will during a trancelike state. A person becomes a shaman by inheriting the shamanistic profession or by election by a supernatural agency. Most self-made shamans are regarded as weaker than those who inherit the profession. The shaman who is born to his role is said to have more bones or teeth than others.

Figure 3-3 is a photograph that was taken in a botanica; it shows eye bead charms that are worn on a string or chain around the neck, wrist, or waist to protect an individual. The blue eye bead is commonly worn by Greeks to ward off the evil eye. The mal occhio is worn by people of Italian descent;the mano milagroso by Mexicans;the mano negro by Puerto Rican babies;the hamsa, or Hand of God, by Jews;the ayn by the Arabic cultures;the Thunderbird by Hopi Indians;knotted hair or fragments of the Koran by people of South Asia;and red ribbons by Eastern European Jews. The Chinese wear jade to protect them from disease. When the green or red jade object discolors or turns brownish, it is replaced because it is assumed that the person has been exposed to an evil eye or other disease. Figure 3-4 shows several jade bracelets and charms. This photograph was taken in a Chinese jewelry shop in San Francisco's Chinatown.

Various traditional cultures use food substances to protect health. Many people eat raw garlic or onions or wear them around their necks to prevent disease. Members of Greek, Italian, and Native American ethnic groups may hang onion and garlic in their homes for protection. Chicken soup, a Jewish remedy, has long been thought to protect health and speed recovery. Nervo forza is a Guatemalan vitamin tonic commonly used in Central America. Traditional Chinese eat ''1000-year-old'' eggs to prevent illness. The most famous of all Chinese herbs is ginseng (Panax schinseng), which is derived from the root of a plant

Figure 3—5 Ginseng root.

resembling a human figure. A typical ginseng root appears in Figure 3-5. Ginseng has been revered for thousands of years as a general panacea. Known as an ''adaptogen,'' ginseng has many medicinal purposes;it naturally ''adapts'' the vital functions of the human system to compensate for adverse conditions such as stress, malnutrition, and the deterioration associated with aging. Ginseng is a slightly bitter root that is used to promote secretion of bodily fluids, and it is recommended by Chinese health practitioners to treat more than 25 medical problems. It is commonly used for anemia, indigestion, impotence, and depression, as well as for replenishing energy and improving sleep. By ''building the blood'' and stimulating vital organ energies, it is intended to balance the yin and yang (described later in this chapter) throughout the body. Ginseng must be prepared in earthenware and not in metal because metal destroys its healing properties. Ginseng is contraindicated in patients with excess heat. A bowl of ginseng roots and other ginseng preparations are shown in Figure 3-6.

Finally, many religious objects are worn to protect individuals from disease. The Virgin of Guadalupe is the patron saint of Mexico. It is believed that she protects people and their homes from the evil eye. Her image is pictured on medallions. In the Roman Catholic tradition, there are many saints who are concerned with specific illnesses. People may wear medals with the

name and the image of the saint on them to prevent the development of a problem. Figure 3-7 shows holy cards with the pictures of saints. These pictures are used to cure and protect individuals from disease. Gris-gris are symbols of voodoo;they may take a variety of forms and be used either to protect or harm a person.

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