Specific Cross Cultural Perspectives

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In this section, some cross-cultural perspectives, including some common beliefs regarding health and illness, are examined. This section also discusses some strategies that can be applied to improving care of patients. The intention is to sensitize the reader to the vast differences among the major ethnic groups in the United States. It is beyond the scope of this book to include all ethnic groups; the reader is referred to the Bibliography at the end of this chapter.

A note about socioeconomic status: Any patient in a low socioeconomic bracket is concerned with maintaining dignity and autonomy, and this should never be compromised in the eyes of the clinician. In addition, a respectful attitude is necessary in attaining a patient's confidence and trust. Patients who are poor may fear that they may not be treated respectfully. Addressing the patient by the appropriate title, such as Dr., Miss, Ms., Mr., or Mrs., is important.

African Americans

African Americans constitute a heterogeneous ethnic group, and therefore it is impossible to make generalizations because there is no prototypical African-American patient. They live in all areas of the United States and are represented in every socioeconomic group, with a disproportionate number living in poverty. As a result, in many inner-city populations, lack of access to quality health care has particular deleterious consequences for many of them. One alarming result is that many preventable diseases often progress to life-threatening stages. Some diseases, such as diabetes mellitus and hypertension, are highly prevalent among African Americans. Consequently, when examining an African-American patient, regardless of socioeconomic status, the clinician should screen for these diseases and educate both the patient and the patient's family. Because of media stereotyping, African Americans may react negatively to a general screening for human immunodeficiency virus (HIV) or substance abuse. Clinicians need to approach this with sensitivity and reserve this testing for the segment of the African-American community that is at risk.

In Africa, illness has traditionally been attributed to several causes, primarily to demons and evil spirits. Beliefs regarding the role of spirits in causing disease may persist.

It is particularly important to investigate dietary patterns in the African-American patient. Certain ethnic foods, such as rice, plantain, yams, and okra, have deep cultural roots and should not be eliminated from the diet, if possible. Other ethnic foods, such as collards and turnips that are often heavily seasoned with salt and cured meat, may pose a health problem. Without the salt, these foods are wholesome parts of a diet. The eating of Argo starch has a historical basis because slaves ate clay and dirt, having been taught that these were rich in iron and other minerals. Some African Americans even today consume Argo starch as a substitute for clay and a source of minerals.

As culture defines health and illness, it also defines acceptable health-care and treatment practices. All cultures offer home remedies as part of self-care. For some African Americans, the following is a partial list of home remedies:

Poultices to fight infection Herbal teas

Hot lemon tea with honey for colds

Hot toddies for colds and congestion

Raw onions placed on the feet in cases of fever

The white membrane from a raw egg placed over a boil to bring it to a head Hot camphorated oil and mustard plaster on the chest for chest congestion Garlic placed on an ill person or in the person's room to remove evil spirits

Hispanic/Latino People

The fastest-growing minority group in the United States comprises the Spanish-speaking peoples from various parts of the western hemisphere: Puerto Rico, Cuba, the Dominican Republic, Mexico and other Central American countries, and South America. The Latinos residing in the United States are one of the youngest of the ethnic groups. In Census 2000, 35.7% of people in the Hispanic/Latino group were younger than 18 years of age. Demographers have predicted, on the basis of the Latinos' young age, their high fertility rate, and their migratory patterns, that by 2010 they would become the largest ethnic group in the United States, accounting for 42% of the population. Although bonded by a common language and grouped together by their Spanish surnames, the Latino group has great heterogeneity and diversity in its many different traditions. Although Spanish has no dialects, many words may carry different meanings for various Latino groups, depending on their community of origin. The prevention of illness is a common practice frequently accomplished with praying, keeping relics in the home, and wearing religious amulets or medals. Figure 3-8 shows some religious amulets;Figure 3-9 shows a variety of rosaries and good-luck beads hanging in the foreground and magical oils and elixirs in the background. These photographs were taken in a botanica in New York City.

Latinos, like other traditional groups, are known for having a close-knit family unit, la familia. Latino families have strong ties and have maintained many of the qualities of the extended family system. They may have a great fear of being hospitalized and thus being separated from their families. Those who speak only Spanish are concerned that they will not be able to communicate with the medical personnel when help is needed. They have a sense of obligation toward each other and are expected to be responsible for all members of the family. It is not uncommon for a 90-year-old patient who speaks no English to be accompanied to the hospital by his or her children, grandchildren, great-grandchildren, and even great-

Physical Ill Health Cross Culture

Figure 3—9 Beads, rosaries, and magic oils. Figure 3—10 Dried exotic herbs and teas in a botánica.

Figure 3—9 Beads, rosaries, and magic oils. Figure 3—10 Dried exotic herbs and teas in a botánica.

great-grandchildren. Decision-making is likewise a family matter. Never pressure the patient into making a decision; allow the patient time to discuss an issue with his or her family.

It is common for first- and second-generation Hispanic/Latino U.S. residents, as for many other immigrant groups, to regard health-care institutions with a certain amount of distrust. When caring for a Hispanic/Latino patient, the clinician must consider the family as well. Some Hispanic/Latino people (more often the elderly, recent immigrants, and the less educated) still believe in curanderos or curanderas, espiritistas, or santeros, who are the holistic, family folk practitioners and spiritual counselors. These spiritualists believe that illness is caused by an intentional act of God, supernatural forces, or the ill will of others, and they emphasize healing through religious or medical ceremonies, potions, and amulets. They use a variety of yerbas (herbs, especially teas), charms, massages, and magical rituals. Limpias, or cleansing, is performed by passing an unbroken egg or selected herbs tied together over the body of the ill person. These healers do not advertise but are well known throughout their individual communities and play an important role in Hispanic/Latino health care. A yerberia or botanica is a community resource for purchasing traditional remedies and charms. Figure 3-10 shows containers with dried exotic herbs and teas. Again, the Christian and Arabic influences are evident.

Patients are often fearful of discussing these health-care practices with clinicians. For this reason, when they feel trusting enough to do so, it is important that the health-care provider receive this information in a respectful manner. Try to work with the belief. Because many herbal remedies are pharmacologically active, it may be necessary to ask the patient not to consume them simultaneously with pharmaceuticals. There is usually a close, personal relationship between the patient and the healer. By using medical knowledge and adapting it to the patient's beliefs, you can gain the patient's confidence and encourage cooperation.

Candles play an important role in traditional healing. The votive candles are for specific deities or saints or for specific requests, such as money, love, health, and success. The candles are lit, and prayers are recited. Figure 3-11 shows some of the candles for sale in a botanica.

Two important values in the Latino culture are respeto and dignidad. Respeto is demonstrated to a Hispanic/Latino patient when the health-care provider dresses in the traditional garb of the profession expected by the Latino patient and communicates an interest in his or her life and health. Hispanic/Latino people also enjoy a brief social conversation before a discussion of their illness. This helps to develop a sense of confianza, or trust.

The belief in Santería originated more than 400 years ago in Cuba out of traditions of the African Yoruba people from Nigeria and Benin. These people were transported to Cuba to work as slaves on sugar plantations. From Cuba, this religious cult spread to the neighboring islands and to the United States;it arrived in New York in the late 1940s. Santería blends elements of West African beliefs with Roman Catholicism. Once a ghetto religion, Santería has a growing following among middle-class professionals, including white persons, African Americans, Latinos, and Asian Americans. The followers believe in one Supreme Being but also in African divinities known as orishas, each of which represents a human characteristic, such as power, or an aspect of nature, such as thunder. Each of these deities is worshiped in the image of a Catholic saint. There are several orishas related to health problems: the orisha Chango is linked to Saint Barbara,* who is the god of thunder, lightning, and violent death; orisha Bacoso, with Saint Christopher (infections);and orisha Ifa, with Saint Anthony (fertility). Statues of saints or deities are commonly purchased for the home.

Figures 3-2 and 3-12 show some religious statues sold in a botanica. The believers pray to these idols to intervene with God to improve their lives and obtain blessings. Many of these idols are used for prayers for health. Notice the African elements blended with Catholicism in the idols. The seated figure with the red tie is Maximon, a Guatemalan believed to have powers for producing health, tranquility, protection, happiness, wealth, and improved sexual performance. The standing figure in the black suit to the right is the Venezuelan physician Dr. Jose Gregorio Hernandez Cisnero. He was known for his health-related miracles, and patients pray

*St. Barbara's father was struck by lightning as he beheaded her for her faith.

to him for health. The figure in the reddish-pink and gold robe with the crown is the famous statue of Baby Jesus of Prague, known in Spanish as El Niñito Jesus de Prague (also, Atacha). Figure 3-13 shows the orisha Chango.

There is a very structured hierarchy in the practice of Santería. In charge is the babalow; next is the presidente, the head medium;and the third practitioner is the santero. The santero, an important, respected member of the Latino community, is said to possess the magical power of the orishas, known as ache. Ritual devotions involving African rhythms and dancing; offerings of food and animal sacrifice; divination with shells, bones, and eggs; trancelike states; and other rites are thought to reveal the sources of problems and to help in their resolution. During the ritual, the santero dresses in white robes with beaded necklaces and bracelets. Santería can be practiced in homes, parks, storefronts, or basements.

La partera or la comadrona is the traditional midwife or birth attendant in the Latino culture. These women are described as warm, caring, and cooperative. Their role is to give advice to pregnant women, to treat pregnant women for illnesses with herbs and massages, and to be in attendance during labor and delivery. The women offer both emotional and instrumental support during and after childbirth. Most parteras have birthing rooms in their homes.

There are several traditional, or culture-bound, illnesses of the Latinos. A culture-bound illness is one that is culturally defined. It may or may not have an equivalent from a Western medical perspective. Emotional trauma and strong emotions are recognized throughout Latin America as causes of illness. Conditions such as mal de ojo, empacho, ataque de nervios, susto, male aire, and caida de mollera are examples of Latino culture-bound syndromes.

Mal de ojo,* or evil eye, is the result of dangerous imbalances in social relationships;illness is blamed on the ''strong glance'' of an envious person. Fever, sleeplessness, and headaches are common symptoms. Empacho, or upset stomach, occurs when a Latino patient is psychologically stressed during or immediately after eating. The main symptom is a feeling of a ''ball in the stomach'' associated with abdominal pain. Ataque de nervios is manifested by a sudden outburst of shouting or swearing, accompanied by a variety of symptoms that include dyspnea, chest tightness, memory loss, trembling, sense of heat, palpitations, dizziness, and paresthe-sias; it may be accompanied by, or caused by, hyperventilation. It is often seen when the patient is confronted with stressful life events, such as an accident, an acute severe illness, a funeral, or a death. During the episode, the person may fall to the ground with convulsions or lie motionless. An ataque de nervios may progress to susto, which is a prolonged condition that a patient experiences after having been exposed to a traumatic event. The patient is depressed, lacks interest in living, is withdrawn, and has a disruption of eating and hygienic habits. Susto, a nonkinetic fugue state, is a common stress reaction and may be described in part as a state of disorientation and confusion. Ritual prayers and herbal remedies are the common treatment. Mal aire, or bad air, is said to cause pain, facial twitching, and paralysis in children. Mothers are concerned that their young children will develop mal aire when exposed to cold air. It is therefore important to keep Latino children covered during an examination. Caida de mollera, or fallen fontanelle, affects infants; the fontanelle is displaced from its normal position at the top of the head. Diarrhea and restlessness are associated symptoms. It is important to reiterate

*Also used by some groups to refer to actual eye disease.

that beliefs in folk healing cannot be generalized to all Latinos. These traditional beliefs vary from generation to generation and depend largely on the extent of assimilation into the mainstream culture.

Asian Americans

Asian Americans place much emphasis on obligation, authority, and honor. Those who have disgraced their families consequently suffer guilt. This guilt can be transformed into psychosomatic disease, which is common in this culture. Asian-American patients rarely complain of pain. They may suffer with it, but their complaints are few. If the health-care provider suspects that a patient is having pain, it is fitting to ask whether pain is present. In general, after being asked, the patients acknowledge the pain. Older-generation Chinese individuals tend not to display emotions openly to strangers, nor do they usually accept any type of comforting physical contact, such as touching a shoulder or hand, as a form of empathy. In contrast to the Chinese or Japanese, in the Korean culture touching is common among men and women. In fact, it is far more common than in Western cultures.

Titles are important in communicating with the Japanese patient, as with other groups. The family name is usually written first. Bowing is very common and indicates respect; it is used when greeting and leaving. Avoiding eye contact, particularly with older Japanese patients, demonstrates respect. Another aspect of dealing with Japanese or Korean patients relates to the ''yes-no'' question and the infrequent use of the word ''no.'' Most older Japanese and Korean persons believe that to answer ''no'' puts an individual on the defensive. Therefore, they may answer ''yes,'' meaning that they understand, not necessarily answering in the affirmative to the question. Nodding the head generally indicates attentiveness of the Japanese patient and not necessarily agreement. With some Japanese patients, as in other cultures, giggling is often a sign of embarrassment. Interviewers require patience and may need to proceed more slowly when questioning the Asian patient about intimate information, such as sexual behavior. It is generally best to avoid humor when interviewing a Japanese patient, especially an older patient.

Many Asian Americans believe in traditional medicine and distrust Western medicine. The ''hot-cold'' theory of disease is still accepted by some Asian Americans. Another example of the balancing of internal forces is seen in the Chinese belief in yin and yang. Everything in the world consists of both yin and yang forces. Yin is dark, female, and negative;yang is light, male, and positive. The key to good health is the balance between yin and yang; Chinese herbs and acupuncture help restore this balance. A common problem among Chinese patients is related to medication. According to traditional Chinese medicine, one dose of an herbal remedy usually ''cures'' an illness. Prescriptions of Western medications may require multiple doses over longer periods. Chinese patients may have difficulty in complying with this schedule. It is the clinician's responsibility to explain carefully this difference in ''medical'' therapy.

Figure 3-14 is a picture taken in a traditional herbal pharmacy in San Francisco; it shows jars containing medicinal Chinese herbs. Deer antlers, mercury, turtle shells, bull testicles,

snake meat, seahorses, and rhinoceros horns are other popular Chinese cures. The interviewer must respect the patient's belief and, by attempting to understand it, is equipped to provide better care.

Many Chinese and Vietnamese persons, like other people, have an intense fear of being admitted to a Western hospital. This anxiety stems from the language barrier, inability to find a translator, fear of isolation from the family, different practices, and even food; many Southeast Asian persons are lactose intolerant. The health-care provider must explain in detail the plan of treatment to the patient and the family members. If an interpreter is needed, the provider must ensure that the interpreter speaks the same dialect.

As in other traditional cultures, Asian Americans have several important culture-bound syndromes: hwa-byung, taijin kyofusho, hsieh-ping, amok, wagamama, shinkeishitsu, and koro. Hwa-byung is a common, multiple somatic and psychological disorder, seen usually in married Korean women. Epigastric pain is the presenting symptom;it is feared that the pain will lead to death, and associated symptoms include insomnia, dyspnea, palpitations, and muscle aches. It often appears that anger is the precipitating cause. Taijin kyofusho is a syndrome in Japanese patients in which the patients complain that their body parts or functions are offensive to others. Hsieh-ping is a trancelike state in which Chinese patients believe themselves to be possessed by a dead relative or friend whom they have offended. Amok, which afflicts Malay men, is a sudden spree of violent attacks on people, animals, and objects. Wagamama, seen in Japanese patients, manifests with apathetic childish behavior with emotional outbursts. Shinkeishitsu is a form of severe anxiety and obsessional neurosis seen in young Japanese patients. Koro, a name of Malay origin, is a delusional condition seen in Southeast Asian and Chinese male patients; the patient suddenly grasps his penis, fearing that it will retract into his abdomen and ultimately cause his death. Family members are frequently called on to hold the penis. This disorder may continue for several days. The condition may be linked to another associated belief called ''semen anxiety,'' in which the patient feels that he has a deficiency of semen, which is believed to be a fatal condition.

Asian Indians

Asian Indians are people from India, Pakistan, Nepal, Bangladesh, and Sri Lanka. Although most Asian Indians speak English well, some idioms may produce confusion. The most common religious groups among Asian Indians are Hindus, Muslims, and Sikhs. Hindus believe that life is a circle, continuous, without a beginning or end. There is also a strong belief in astrology. The Hindu family is a very strong unit, and health-care decisions are commonly made by the senior members of the family. The cow is considered sacred; eating beef or veal, therefore, is strongly prohibited.

Muslims follow the teachings of Mohammed and Islam. The main principles of Islam are generosity, fairness, respect, cleanliness, and honesty. The consumption of alcohol, pork, and lard is strictly prohibited. Sex education and cremation are also commonly forbidden. Older Muslim patients may have a fatalistic attitude, which can interfere with compliance with medical therapy. Many Muslim women wear a veil over their head when in the presence of men outside the family and prefer female health-care providers. In some cases, if a patient's husband is present, a male clinician may be allowed to examine her.

Sikhism started in the 15th century in northern India. Sikhs believe in a single God and in reincarnation. Baptized Sikhs do not cut their hair and do not smoke or drink alcohol; many are vegetarians. A traditional Sikh greeting, similar to that of other Asian Indians, is with the palms of the hands pressed together in front of the chest. Women generally do not shake hands, and eye contact may be considered disrespectful.

The Asian-Indian population relies heavily on a wide-ranging pharmacopeia. Remedies can come from almost any natural substance. Ayurvedic medicine is an ancient Indian medical system; it teaches that imbalance in the body humors results in illness. Treatment is to restore the balance. Although Western medicine is recognized in India, it is estimated that there are nearly 4000 people for every Western-taught physician.

It is important for the clinician to recognize that taste and food are important parts of Asian-Indian beliefs. Each taste is believed to have special properties: sweet increases phlegm and appeases hunger and thirst; acid increases salivation and improves digestion; salt purifies the blood; pungent food provokes the appetite; bitter food also stimulates the appetite and clears the complexion. The study of medicines is more important than the study of illness; the traditional healer deals with symptoms and usually ignores the disease.

Native Americans

Native Americans constitute a heterogeneous group that comprises more than 400 federally recognized nations. American Indians, Aleuts, and Inuits (and Inupiats)* are the largest groups of Native Americans. The traditional belief about health is that it reflects living in total harmony with nature and having the ability to survive under dire circumstances. People must treat their bodies with respect. Many Native Americans believe that there is a reason for every illness;illness is the price paid for something bad that had occurred or will occur. Several tribes associate illness with evil spirits. Illness may also result from breaking a taboo or the attack of a ghost or witch.

The traditional healer is the medicine man or woman. Often, the medicine man or woman uses meditation and crystal balls. On occasion, the medicine man or woman uses the root of jimsonweed to produce a trance to enable him or her to treat the patient better. The cause of illness is diagnosed by three types of divination: motion of the hand, star gazing, and listening. Chanting is a major part of the process. Many Native Americans also believe in witchcraft. Herbal remedies and an act of purification are major steps to curing illness.

Two important problems among Native Americans are alcohol abuse and domestic violence. Alcohol abuse is a critical health problem that is widespread and immeasurably costly to the Native American community. In historical, traditional Native American homes, alcohol abuse was not common. Currently, domestic violence is a major problem, and it is frequently related to alcohol abuse. The rate of suicide is also high among this population. In addition, there is a higher proportion of postnatal deaths among Native Americans, presumably because the women have inadequate prenatal care.

The Jewish People

Approximately 6 million Jewish people live in the United States. There are two large groups: the Ashkenazim, whose origins can be traced to Eastern or Northern Europe, and the Sephardim, whose origins are from the Mediterranean countries or the Iberian Peninsula. The majority of the Jews in the United States follow the Ashkenazi traditions. The Ashkenazim are linked linguistically through Yiddish, and the Sephardim are linked by Ladino, Spanish, Portuguese, French, or Arabic.

In the United States, there are three main divisions of the Jewish people, based on adherence to traditional practices and interpretation of Jewish law: Orthodox, Conservative, and Reform. Although most Jews dress indistinguishably from others, many Orthodox individuals observe Jewish law by covering their heads with a skullcap called a yarmulke or kippah. Many married Orthodox women cover their heads with hats, wigs, or kerchiefs. Because of tradition, men and women are commonly separated in social situations. Another division of Jewish people is the Hasidim. This group broke off from mainstream Judaism in the 17th century in order to serve God without the necessity for immersion in religious study that was the standard in the Eastern European Jewish community at that time. Hasidim usually wear 17th century-type black robes or suits with black hats. The men twirl their hair into ringlets at the sides of their face. Hasidim are generally passionate about their worship and adhere strictly to the biblical laws. These laws include restrictions regarding permissible foods (kosher laws, or Kashrut{) and forbidden foods (pork products or shellfish).

The Sabbath (Shabbat or Shabbos) is a strictly observed day of rest. When scheduling appointments, be aware of the Sabbath and do not schedule tests or clinic visits from Friday afternoon until after Saturday evening. Many religious Jews do not use anything electrical on the Sabbath. Therefore, when visiting a religious Jewish person in the hospital, an interviewer may find that the rooms are dark because the patient and his or her family are not allowed to turn on the lights;the interviewer, however, may turn them on. Despite the many rules of

*The Eskimo people are identified by place of residence. The Eastern Eskimos live from eastern Greenland to northern Alaska. The Western Eskimos live to the west of Alaska: the Bering Sea, St. Lawrence Island, and the northern Pacific. The term Eskimo is now thought to be unflattering. Speakers of the Eastern Eskimo language call themselves Inuit, on the basis of the Inuit language they speak. Although the term Inuit has been used to describe all Eskimos, it is appropriate only for those speaking the eastern language. In Alaska, the Eskimo people call themselves Inupiat, on the basis of the Inupiat dialect of the Inuit language. The Western Eskimos are now referred to as Yupik, on the basis of the language they speak. {The rules of the kosher diet mandate the exclusion of shellfish and pork products. Dairy products may not be eaten with meat products. In addition, only fish with scales and fins and only certain types of meat from animals with a cloven hoof and that chew the cud can be eaten.

Orthodox Judaism, health always comes first. Even on fasting days, pills may be taken, and ill and elderly persons, as well as children, are permitted to eat.

Many Jewish holidays are not marked on calendars. The health-care provider should ask the patient about them when scheduling tests, to determine whether holidays will conflict with appointments. Many Jewish people may want to consult their rabbi before having a certain test performed or taking some form of medication. This should not be misconstrued as a mistrust of the health-care provider; it is often culturally motivated.

There are several genetic conditions that appear more frequently in the Jewish population. These include Tay-Sachs disease, Gaucher's disease, Bloom's syndrome, ataxia-telangiectasia, Creutzfeldt-Jakob disease, familial Mediterranean fever, Glanzmann's thrombasthenia, pemphigus vulgaris, polycythemia vera, and Niemann-Pick disease.

When an Orthodox Jew dies, the body is never left alone from the time of death until burial; Orthodox friends and family pray around the body. The body is not embalmed, and the burial is usually within 24 hours. One exception to this rule would be if the death occurred on a Friday evening (the Sabbath);the burial would then be on Sunday. Autopsies usually are not allowed unless approved by the family's rabbi.

The primary group targeted for annihilation in World War II was the Jewish people. Because of these experiences, Jewish patients, especially the older generation and older immigrants, may manifest greater discomfort, fear, and anxiety when confined in a hospital and when decisions are made about them. For more information, refer to the discussion of post-traumatic stress disorder in Chapter 2, The Patient's Responses.

International Society for Krishna Consciousness

An important, small, originally Indian group in the United States is the International Society for Krishna Consciousness. Its members believe in four rules of conduct: (1) no eating of meat, fish, or eggs;(2) no illicit sex;(3) no intoxicants;and (4) no gambling. They believe that the body is ruled by passion and the soul by serenity. The Krishna lifestyle is strictly regulated, and illness should never interfere with these activities. Followers seek medical assistance only when they are extremely ill.

Romanies

The tradition of the Romanies (or ''Gypsies'') poses important health-care problems. According to the Romany culture, the sources of all disease are demons, the evil eye, breaking taboos, and the fear of disease itself. Several Romany treatments involve transferring disease symbolically to another person or object. In general, Romanies turn to organized health care only during times of crisis. They do not hesitate to come to the hospital for serious illness; often, the extended family or entire tribe may accompany the patient. Preventive medicine and follow-up care are rarely used. Romany women are extremely reluctant to expose their bodies to male health-care providers.

In order to protect their anonymity, Romanies are reluctant to identify themselves as such, often use assumed names, and may not provide truthful answers to non-Romany interviewers. Once a trusting relationship with a health-care provider has been established, however, many Romanies feel more inclined to rely on that individual.

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