Travels in the Riel World

Perhaps it’s the interest sparked by the ongoing debate in Washington, but I’ve been stumbling across a number of health care-related articles these days and several of them delve into the intersection of policy and national culture. There was a recent story in the NY Times about T.R. Reid’s new book, The Healing of America, in which this foreign correspondent went to doctors in 10 countries with a chronic shoulder problem and then wrote about the results of these health care travels. His book reports both on the different treatment options offered to him and the different systems of health insurance that he encounters:

When Mr. Reid presents his shoulder to his own orthopedist in Colorado, the doctor is quick to recommend a shoulder replacement. It will cost his insurer tens of thousands of dollars (assuming it agrees to pay), with unknown co-payments for him. Risks include all those of major surgery; benefits include a restored golf swing.

The same shoulder gets substantially different reactions elsewhere in the world.

In France, a general practitioner sends him to an orthopedist (out-of-pocket consultation fee: $10) who recommends physical therapy, suggests an easily available second opinion if Mr. Reid really wants that surgery, and notes that the cost of the operation will be entirely covered by insurance (waiting time about a month).

In Germany, the operation is his for the asking the following week, for an out-of-pocket cost of about $30.

In London, a cheerful general practitioner tells Mr. Reid to learn to live with his shoulder. No joint replacement is done in Britain without disability far more serious than his to justify the expense and the risks, and if his golf game is that important, he can go private and foot the bill himself.

In Japan, the foremost orthopedist in the country (waiting time for an appointment, less than a day) offers a range of possible treatments, from steroid injections to surgery, all covered by insurance. (“Think about it, and call me.”)

In an Ayurvedic hospital in India, a regimen of meditation, rice, lentils and massage paid for entirely out of pocket, $42.85 per night, led to “obvious improvement in my frozen joint,” Mr. Reid writes, adding, “To this day, I don’t know why it happened.”

But the comparative merits of different orthopedic philosophies are secondary here: Mr. Reid’s attention is focused on a meticulous deconstruction of the history and philosophy of the policy decisions behind them.

From a shoulder replacement to toughing it out to meditation and massage. Different cultures, different treatments. What do you think, do these different health care philosophies have some connection with what you know about the different cultures that the author encounters?

It’s no secret that culture plays a role in health care, from our systems of medicine to our personal decisions. When a person receives health care in his or her home country, there are unlikely to be many clashes over culture because it’s a medical system that he or she knows and understand well. The United States is not a homogeneous culture, though, but rather one that attracts a regular influx of immigrants from around the world. Health care misunderstandings are more likely to occur when individuals or families from other cultures, particularly non-Western cultures, meet American medicine. So I read with interest this recent story about a California hospital that makes allowances for Hmong immigrants from Laos to receive treatment from a shaman as well as from a physician.

The patient in Room 328 had diabetes and hypertension. But when Va Meng Lee, a Hmong shaman, began the healing process by looping a coiled thread around the patient’s wrist, Mr. Lee’s chief concern was summoning the ailing man’s runaway soul.

“Doctors are good at disease,” Mr. Lee said as he encircled the patient, Chang Teng Thao, a widower from Laos, in an invisible “protective shield” traced in the air with his finger. “The soul is the shaman’s responsibility.”

At Mercy Medical Center in Merced, where roughly four patients a day are Hmong from northern Laos, healing includes more than IV drips, syringes and blood glucose monitors. Because many Hmong rely on their spiritual beliefs to get them through illnesses, the hospital’s new Hmong shaman policy, the country’s first, formally recognizes the cultural role of traditional healers like Mr. Lee, inviting them to perform nine approved ceremonies in the hospital, including “soul calling” and chanting in a soft voice.

The policy and a novel training program to introduce shamans to the principles of Western medicine are part of a national movement to consider patients’ cultural beliefs and values when deciding their medical treatment. The approach is being adopted by dozens of medical institutions and clinics across the country that cater to immigrant, refugee and ethnic-minority populations…

A recent survey of 60 hospitals in the United States by the Joint Commission, the country’s largest hospital accrediting group, found that the hospitals were increasingly embracing cultural beliefs, driven sometimes by marketing, whether by adding calcium- and iron-rich Korean seaweed soup to the maternity ward menu at Good Samaritan Hospital in Los Angeles, on the edge of Koreatown, or providing birthing doulas for Somali women in Minneapolis.

By the way, if the story of Hmong immigrants dealing with American doctors sounds vaguely familiar, that’s because it was also the subject of an excellent book about 10 years ago, called The Spirit Catches You and You Fall Down. If you’re at all interested in cross-cultural topics, especially as they involve health care, you should check out the book.

One of the big debates going on in Washington and around the U.S. these days, of course, revolves around the nation’s health care programs. I’m no policy wonk, so I’m not going to wade into a debate about issues here, but rather point out that even health care is related to national culture and values. Jacob Weisberg described this connection in a recent issue of Newsweek. A good chunk of his column is devoted to exploring the pros and cons of our current system, but he also does a nice job of showing how culture and health care are related.

In his new book The Healing of America, the journalist T. R. Reid employs a clever device for surveying the world’s health systems: he takes an old shoulder injury to various countries. In the United States, a top orthopedist recommends joint-replacement surgery, costing tens of thousands of dollars. In France and Germany, doctors steer him instead toward a regime of physical therapy. In Britain, they tell him to go home. In India, he is treated, quite effectively, with herbs, massage, and meditation…

He’s right that we can learn much from practices elsewhere. But the lesson I took away from his book was somewhat different: health-care systems are not just policy choices, but expressions of national character and values. The alternatives he describes work not just because they’re well designed but because they reflect the expectations and traditions of their societies.

All advanced, wealthy countries have health systems that are more egalitarian and cost-effective than ours. Each also has its quirks, which reinforce familiar stereotypes. Britain, land of the stiff upper lip, provides what to us seems shockingly minimalist treatment…The Japanese, on the other hand, love doctors and visit them, on average, 14.5 times per year, three times the U.S. rate. They do this in an orderly, ritualized way, usually bringing a bottle of sake or cash in an envelope as a gratuity.

Interesting stuff. And if you want to know more details about culture and health care in the U.S., check out his piece.

As we talk about differences in cultures around the world, it’s easy to forget that there are also many cultures and worldviews residing all around us. Among the various racial and ethnic groups in the United States, there are of course different foods, music and traditions, but there are also different ways in which people perceive the world and their place in it. An example of this can be seen in a recent Arizona Daily Star article, which profiles an Hispanic man who struggled with the question of whether or not to place his Alzheimer’s-afflicted mother in an assisted living facility because it went against his cultural beliefs and values.

Two days before he was to visit his mother, Guillermo Goodman cried at the thought of her in the care of strangers. Raised in a traditional Hispanic family, where his grandmother’s every need was tended to by his father at home, Goodman, 59, never imagined making a different choice for his own mother.

But the effects of Herminia’s Alzheimer’s disease and Guillermo’s own failing health took a toll. Earlier this month, Goodman placed his mother in a private assisted-living home — an option that few Hispanic families pursue, sometimes to the detriment of the elder and the caretaker.

“I remember my grandmother living with us and the love that my father had for her,” said Guillermo, a native of Nogales, Ariz. “I thought I, too, would take care of my mother her whole life and that’s one of the reasons I didn’t want to make this choice.”…

Lupe Salas, an outreach coordinator with the council who works with the Hispanic community, said there’s a lack of information about resources for elder care. She said many Hispanics frown upon government programs such as the Arizona Long Term Care System because of a long-held reluctance to place loved ones in the care of the government.

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.