Travels in the Riel World

A new study is out with evidence that cultural differences and misunderstandings often lead to disparities in medical outcomes. According to this story in the NY Times, patients and doctors who have different cultural backgrounds are often on different wavelengths when it comes to dispensing and following medical advice.

… a new study of diabetes patients has found stark racial disparities even among patients treated by the same doctors.

The lead author of the study said in an interview that he attributed the differences less to overt racism than to a systemic failure to tailor treatments to patients’ cultural norms. The problem, said the author, Dr. Thomas D. Sequist, an assistant professor of health care policy at Harvard Medical School, may be that physicians do not discriminate in the way they counsel patients.

“It isn’t that providers are doing different things for different patients,” Dr. Sequist said. “It’s that we’re doing the same thing for every patient and not accounting for individual needs. Our one-size-fits-all approach may leave minority patients with needs that aren’t being met.”

For instance, he said, counseling black or Latino patients with diabetes to lower their carbohydrate intake by cutting rice from their diets may not be a realistic strategy if rice is a family staple. “We may be listing fruits and vegetables that are part of one person’s culture but not another,” Dr. Sequist said. “We’re not really giving them information they can use.”

In many of the world’s warmer climates, the mid-day siesta is a time-honored tradition. People have always taken time off to rest or nap in the mid-day heat and then tend to keep more active in the cooler hours of evening. But in many of these regions, modern life is causing the decline of the siesta, as noted in this NPR story about Greece.

For most of history, climate shaped the way people lived their everyday lives. In some of the world’s hottest places, people still take a midday siesta. But modern life is making that a rarity…

Even in the hottest climates, the midday siesta is a disappearing habit. With globalization, people work longer hours. Air-conditioning shields them from the heat. Many live in suburbs and farther away from where they work, which makes going home for a midday nap impractical.

Interestingly, just as the siesta is in decline, there is intriguing evidence that there may actually be health benefits to a mid-day nap.

“Napping is a response, an adaptation to the hot climate,” Trichopoulos says. “Siesta is a very pleasant habit. In a way, it doubles your day. Because you start all over again at 5 o’clock and you can go on until 11 or 12 o’clock which is not uncommon at all in our part of the world.”

Trichopoulos’ expertise is in cancer prevention. A courtly man at 68, he teaches both at Harvard and at the University of Athens. So he can’t help but notice the difference in the pace of life in Greece and in the United States.

“In the way life is organized here, you start with stress commuting,” he says. “And you finish with stress, which is again the commuting. So to have in the middle of the day a time when you can relax, it can only be good, or at least not bad.”

Trichopoulos looked specifically at whether taking a nap gives protection against heart attacks. The results were published earlier this year in an American medical journal. Greek men who napped at least 30 minutes a day were significantly less likely to die from heart attacks, compared with those who didn’t nap.

His theory is that napping helps reduce stress, which is known to increase one’s risk of heart attack. Trichopoulos cautions that more study is needed to confirm his findings — but he’s excited about the health implications.

As one travels around the world, it becomes obvious that different cultures have varying ideals of beauty. A recent Associated Press article touches on this subject, focusing on the West African nation of Mauritania, where some families force feed their daughters because obesity is considered a sign of beauty and wealth.

Mey Mint struggles to carry her weight up the flight of stairs, her thighs shaking with each step. It will take several minutes for the 50-year-old to catch her breath, air hissing painfully in and out of her chest. Her rippling flesh is not the result of careless overeating, though, but rather of a tradition.

In Mauritania, to make a girl big and plump, ‘gavage’ _ a borrowed French word from the practice of fattening of geese for foie gras _ starts early. Obesity has long been the ideal of beauty, signaling a family’s wealth in a land repeatedly wracked by drought.

Mint was 4 when her family began to force her to drink 14 gallons of camel’s milk a day…By the time Mint was 10, she could no longer run. Unconcerned, her proud mother delighted in measuring the loops of fat hanging under her daughter’s arms.

The government launched a public health campaign to warn of the health risks of obesity. It has had some successes, although more in urban than in rural areas.

Only one in 10 women under the age of 19 has been force-fed, compared to a third of women 40 or older, according to a survey conducted by the National Office of Statistics in 2001, the most recent available.

Those still forced to eat were overwhelmingly from the country’s rural areas. But although the canon of beauty is changing, entrenched values are hard to uproot. “My husband thinks I’m not fat enough,” complained Zeinabou Mint Bilkhere.

A simple conversation between a doctor and a patient can often cause problems when the two individuals are from different cultures. Due to a growing awareness of such challenges, some efforts are now underway to improve the cultural competence of health care providers. One such program has been launched in Maryland and was recently profiled in this article, which provides a few examples of how cultural confusion can occur.

For instance, the preference of some cultures to deal with individuals in positions of authority:

Marcos Pesquera of North Potomac left his native Puerto Rico behind nearly 30 years ago to study at the Massachusetts College of Pharmacy. As he moved from behind a People’s drug store counter into retail pharmacy and managed care administration, he sometimes found himself in a totally unexpected role as a translator for Spanish-speaking patients.

He quickly realized that clear communication depends on more than just words. Asked to translate between a young female doctor and an elderly Hispanic woman with congestive heart failure, he was baffled by the patient’s refusal to listen to the doctor’s advice.

‘‘[The patient] said, ‘She has no white on the top of her head, she looks like a kid,’” Pesquera said.

With the aid of an organizational chart showing that the doctor headed the department, he won the patient over.

Or, the way in which gender roles can influence decisions:

… while some doctors may be uneasy with the preference by some Middle Eastern women to have their husbands accompany them during consultations, to the patient it’s all about the husband showing a proper level of love and care.

‘‘There’s a clash of cultures at times, but it’s not about wrong or right. It just is,” Pesquera said.

For years now, those on the front lines of the fight against AIDS in Africa have focused on the most traditional means of transmitting the disease.  Now, though, there is evidence that AIDS may also be spread through some cultural traditions, such as local healing methods, tribal body markings and even child care practices.  The NY Times has a story on the topic in this morning’s paper.

As researchers spend more time studying Africa’s overwhelming pediatric AIDS problem, they are finding that the routes of transmission may be different than in the industrialized countries, and that strategies for preventing the disease’s spread must be adapted to local realities.

In some instances, the culprit is repeated use of one blade or medical instrument …

A 2004 study in the journal Tropical Doctor by Dr. Etete J. Peters at the University of Calabar in southeastern Nigeria concluded that there was “a serious risk inherent in the practices of Nigerian traditional healers” because of “the continuous usage of unsterilized instruments and cross contamination of patients’ blood and body fluid in their practices.” …

In much of rural Cameroon, tiny scars are made to identify members of different ethnic groups, with large numbers of children scarred simultaneously. … If just one child in a village had H.I.V., a common blade could spread the virus to dozens who come after him. The same is true for group circumcisions.

And, in other cases, the problem is simply a local child-rearing tradition…

Another traditional practice that government officials acknowledge could be spreading H.I.V. is communal breast-feeding, the norm in many rural villages.

Polygamy is legal in Cameroon, and a chieftain might have 30 or 40 wives, Mr. Biatcha said, because wealthy men routinely marry the wives of male relatives who have died. It is common for the wives — or even friends — to help out by nursing each other’s infants. In fact, it is an essential service if a mother has to go to work or take a trip into the city.

Medical facilities in the U.S. are becoming more aware of the need to adapt their practices to different cultures, as evidenced by this article about New York area hospitals.

(This) reflects a broader national shift in health care as urban hospitals move beyond the translation services that started becoming common in the late 1990’s and acknowledge that language is not the only barrier they face in treating people from all over the globe.

This movement is commonly referred to as cultural competency in health care.  Even the U.S. Department of Health and Human Services has recognized the need for this knowledge and awareness.  As I noted in a recent post, the government has developed a web page of cultural resources for health professionals.

This push for cultural awareness is understandably greatest in some of the country’s most diverse communities.  The article about New York hospitals points out:

…challenges can be more varied and daunting for hospitals in places like Brooklyn, home to insular communities of Orthodox Jews, Muslims from conservative Arab countries, recent immigrants from rural China and Hispanics from Central and South America, among many others.

“In each culture that we’re dealing with, there are different ideas, family values and beliefs, whether about medicine or life in general,” said Virginia Tong, a vice president at Lutheran Medical Center, one of south Brooklyn’s largest health care providers.

In the West, people lay out in the sun and try to darken their skin.  In Asia, it’s the reverse.  Light skin is all the rage.  When we were in Japan a few years ago, a friend told us that the Japanese like whiter skin because they want to look Western.  Then, last year in Vietnam, we were told that lighter skin was preferred because only lower class people had dark skin from working in the sun all the time. 

Apparently, both explanations have a whiff of truth to them.  This article in the International Herald Tribune looks at the Asian quest for lighter skin and the health costs associated with some skin whitening creams.

Thanks to Cross Cultural News for pointing out that the U.S. Department of Health and Human Services has developed a new web page of “Cultural Competence Resources for Health Care Providers.”  In explaining the need for these resources, they note:

The increasing population growth of racial and ethnic communities and linguistic groups, each with its own cultural traits and health profiles, presents a challenge to the health care delivery service industry in this country.

It’s always good to see more awareness of the need to understand cultural differences.