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CUBA IS THE FUTURE FOR LATIN AMERICA AND PERHAPS THE WORLD

CUBA IS THE FUTURE FOR LATIN AMERICA AND PERHAPS THE WORLD On my way out of Cuba, from La Habana, on COPA airlines flight to Panama, I w...

mercredi 30 janvier 2013

SIGN OF THE TIMES IN EUROPEAN CITIES

Walking along this pleasant city, I was amazed at the similarities (at least superficially) that meets a visitor to the central part of the city.
Retired moslem women from Maghreb, begging. More common in Paris.
Young Black men and Young Arab men and to a lesser extent women as well, asserting their marginalization thus guaranteeing their peripheral role in the society.
A Black person in Paris speaks French, in London speaks English, in Amsterdam speaks Dutch, in Berlin, German etc... but they are almost indistinguishable (once again superficially speaking)..I was told in more than vehemently while I was a student in London: Black People become British but not English..Black British is a common term but you dont hear people talk about Black English...Some other mixed nationalities are impossibilities, A Black Flemish? A Black Breton?

In Paris, both the young Blacks and young Arabs are trying but in a society so elitist, more tend to fall through the cracks than european French. I feel a strong affinity towards Arabs (even though my Israeli friends like to remind me that they are trying to kill us!) and feel a sense of solidarity when I see hard working, without a chip on the shoulder, young arab men and women.
Radical interpretation of Islam has made the outsiders view them with a jaundiced eye, especially when you see very young girls wearing hijabs and young men sporting religious beard. I like telling my Malaysian friends, until quiet recently Malay women and girls did not wear hijabs and cover themselves head to foot, is there another justification other than the relgion. I am told that Koran never mentions the need for a woman to covered up in hijabs, niqabs or burqas, but I am not familiar with any of the religious texts of any religion including my own.
I have been interested in the problem of cultural identity since very early on in my life I realized that my life would be, The Other who has got a name! By accepting my otherness, i have been accepted well in all the countries that I have lived in (less so in France where they are officially oblivious to otherness).
Also I began working with North American Indians soon after my graduation as an Endocrinologist and with them I shared many an idea about Cultural Identity. I never wanted to be an Indian because I am not an Indian. American Indians feel sympathetic yet critical of people who claim to be American Indian without any appreciable cultural identity. As my Kikapu informant told me many years ago: When we were living in Mexico, we did not become Mexicans but we were Kikapu and now we are living in USA but we are not American but Kikapu. All Kikapu speak their tribal language, regardless where they were/or born.
Each time I see a young black man or a woman, born in Europe, I am reminded of that, the loss of cultural identity in pursuit of something or other.
And a Meskwaki elder told me: I feel sorry for the Makada people (black), they dont even know which tribe they belong to!

Today there were also Gypsies from Eastern Europe with their distinct ways of dressing begging or harassing people but nowhere compared to Paris. A deported Gyspsy leader said to the Press: we like Paris because it is so easy to make a living begging because there are so many tourists! Roma would be the correct designation rather than Gypsies but paradoxically, American Indians prefer the term Indian to Native American (unless they are mostly white people claiming to be Indians, they prefer the term Native American)

One of the greatest gifts in my life has been my coming of age in Australia, where we were taught to think universally in a human fashion, not to be influenced by racial origin or cultural origin. At least that is the lesson I had and to this day, when I meet a person I dont categorize them in my mind, despite the fact that I am an Anthropologist and have spent months and months studying various cultures..also my good teacher Ronnie Frankenberg had taught me, Cultural does not mean Natural...A Kikapu behaves in a certain fashion because they are Kikapu and not brown skinned Mexican or American..

I did have a wonderful time wandering around this city crawling with diplomats from every country on earth. 
I could see Turks, Moroccans, Iranians, Arabs, Maghrebiens, African Blacks with varying physiognomy, an occasional Japanese, but plenty of Chinese..
Yes it is the sign of the times...
I was inside the library reading a magazine and there was a cartoon in it... (let me translate it vaguely):
The commonest surname in Flanders is Peeters and the most popular first name in Wallonia and Bruxelles is Mohammed... but I have never met a 
Mohammed Peeters!

samedi 26 janvier 2013

SYMBOLIC TALK AMONG AMERICAN INDIAN PATIENTS: THE NEED TO BECOME CULTURALLY COMPETENT


SYMBOLIC TALK AMONG AMERICAN INDIAN PATIENTS: A HEALTH CARE PROVIDER NEEDS TO BECOME CULTURALLY COMPETENT.
A Group of young girl athletes from an Indian reservation of Northern Plains Origin stood at attention with their hands over their hearts while the American National Anthem was being played. At the conclusion, two of the youngest ones, began ululating much to the horror of the white middle class audience. They later complained that the Indians don't respect the National Anthem and thus the USA, mocking the patriotism of the white people. (A bit ironic, when you think about it, it was the White People who stole the country from the Indians!)



What the white people, middle class and from a midwestern state, failed to understand or at least enquire was whether it had any cultural significance. Anyone from the tribe could have told them that ululating is much symbolic of their joy and Pride-exactly the opposite of what the white Americans had thought.
Lame Deer of the Lakota had said:
We Indians live in a world of symbols and images where the spiritual and commonplace are one. We try to understand them not with the head but with the heart.
In my experience, even Nurses and Doctors who had worked many years with the Indians, continue to think with their heads and not their hearts and perhaps the reason for a high rate of “non compliance” on the part of the Health Care Providers, and they very easily can transfer that failure on their parts to the Indians and wash their hands off.

I will write down the explanatory models of illness given in the course of a couple of days at a rural Clinic among the American Indians.
When I asked some of the patients attending Diabetes Clinic run by the tribe, why their blood sugars have been running high, these are the explanatory models they gave. (In Medical Anthropology we learn never to argue or negate a patients explanatory model but arrive at a negotiated explanatory model including your own)

1.   A 64-year-old Full Blooded Indian: There have been too many deaths in the community.
The explanation of the above would distinguish a western way of thinking with the head from an Indian way of thinking with the heart.
2.   A 45-year-old Indian father with domestic problems: My boys play Basket Ball after school.
3.   A 50 year old City Indian: I went to the movies this week
4.   I had a few drinks with my girlfriend just before Thanksgiving
5.   I moved into a trailer with my boyfriend
6.  We checked into a motel in the nearby town
Why the Blood sugar was running high was completely in resonance with their explanatory models and it is the only culturally competent Health Care Provider would understand the explanation and discuss it with them rather than reaching to the Prescription pad to prescribe more Insulin or any of the newer injectable medications!
Explanatory Models of Illness (Kleinman) are culturally moulded, interpretations of an illness phenomenon by the patient, which makes complete sense to himself. The conflict arises when the Health Care Provider fails to accept the patient’s EM but forces upon the patient his western oriented, biomedical explanatory model, which makes sense to the Provider. But this creates conflict in the patient who feels that the Provider is not paying attention to his needs and knowledge and that he is being forced to follow advice which he knows he wont. Thus, the failure of treatment in many cases.
As the Harvard University Medical Anthropology team had delineated (Kleinman, Goode, Eisenberg et al)
Patients suffer from ILLNESSES, their subjective feeling that something has gone wrong, doctors are taught to diagnose and treat DISEASES, which are functional abnormalities which can be objectified and corrected, most often by medications. There is no psychosocial resonance as the Doctor or the provider may not be aware of the context of the suffering of the patient.

The first patient, who said his blood sugars were high because there were too many deaths in the family.
A European mind would think, he is sad and he is eating too much. A non Indian Health care Provider who knows that there is plenty of food at funerals may think he has eaten too much. But a culturally sensitive person would know that this full-blooded Indian dances three to four times a week at various ceremonies. When there are deaths, these ceremonies are postponed and thus he has had no chance to dance and once he begins dancing every other day or so, his blood sugar would be back to its usual level.
Boys playing Basketball after school, but the practice is held at the nearest town which is 25 miles away and he misses out on his evening dosage plus the fact that they may stop by a fast food place before coming home to the reservation.
Going to the movies and the blood sugar going up is a bit tricky to explain but in this case, the patient who is a good friend of mine as well gave us the explanation. He goes to the movies not on a regular basis and when he does, he gets a large container of popcorn. The caveat is that the refills are free, so he takes a special bag with him in the car into which he returns to empty big bags of popcorns and at the end of the movie, he has the equivalent of four large containers of popcorn which he consumes slowly over the next few days.
The sober man who broke down his two yearlong sobriety to have a drink with a girlfriend had a sad story to tell. He was at a bar in a major city nearby, about 100 miles away, and he had been drinking with his girlfriend, when someone who knew him was afraid that he was overdoing it, called the Police. Police assured him that the matter was nothing but while they are there, they would like to see his ID, which he gladly handed it over. The police sternly informed him that there is an outstanding arrest warrant for him, about 10 years old, so they had to arrest him and he had to serve 45 days in a Prison. While he did receive his medications, he was in no mood to socialize and spent the entire time reading in his bunk, finishing 40 books! He walks normally about 5 miles per day and these sudden changes of no activity made him put on weight as well as make his good diabetes control take a wrong turn.
The next story was equally sad about a woman who had become homeless, her blood sugar control was excellent before the episode and had to move in with her boyfriend to a trailer on the grounds of his fathers house. The trailer had neither running water nor any electricity. Soon after she lost her job, partially initiated by her boyfriends father! Her blood sugar shot up to the sky with the incredible stress she was feeling from all sides.
While looking at the blood sugar graph over a course of one month, the last patient had a good explanation why his blood sugars spiked every weekend. But one weekend the blood sugars were normal with no spike. He said, we went and checked into a hotel in the nearby town. While we are at home, we are always reaching out into the fridge for food and drinks but when you are at a hotel there is much more of a discipline about food and drinks, plus they are more expensive.
I thank the Spirits that brought me to work with these ancient people of such great wisdom with which they look at life in non-chalant terms and part with words of wisdom on each of their visits. After each visits to various Indian Reservations I leave, even after these many years, with such a rejuvenation of my spirit.
This is a priceless life experience for a Doctor. Soon after meeting the first Indian group I realized that what I had learned at medical school and postgraduate hospitals would not be enough to take care of culturally distinct a population such as American Indians, so I found my way to Brunel University to study Medical Anthropology. The years of Medical Anthropological education has stood me in good stead as a Physician practising without Borders. Taught me not only about Medicine but also about life and culture in general while mingling with people from various countries…of which Indonesia is the latest one.
Thank you my dear Indian friends some of whom are my patients as well.


vendredi 25 janvier 2013

KLEISHAS. DEFECTS. YOGA. AMERICAN INDIAN PHILOSOPHY

Structural Defect (Kleisha) YOGA and Native American Indian concept of Character Defect

One pleasure of learning about YOGA from my friend MC in KL was the good understanding she had of KLEISHAS or structural defects of the mind.  Kleishas or Structural defects, which form the fundamentals of BUDDHISM as well, especially the three Kleishas: Ignorance, Attachment and Aversion.
Once we are aware of the five Kleishas, we can become adept at not being bothered by them or learn to contain them. There are many ways prescribed through the ages to contain them, but I like the idea of analysing them and thinking through. But I have learned that one has to be very careful, not to ask questions which would lead to further destruction of our minds and us.

These five can be thought of as the root causes of trouble and strife in ones life.
Ignorance
Ego
Aversion
Attachment
Fear of Change
Every one would agree that IGNORANCE is the root of the other Kleishas as well.
Yet another philosophy of life as ancient if not more than the Yogic philosophy, is the philosophy of the American Indians, natives of the Continent that we call the Americas: from Alaska to Tierra del Fuego.
Just listen to what a contemporary Quechua Indian from Peru has to say:
Also ask your heart to purify and cleanse this defect and harmful desire. Ask also the help of the inner father and mother. Every time we eliminate a defect we build our soul, our inner temple. We ascend.


My first lesson in the fear of change came when the teacher corrected me, please don't say you cannot sit in this fashion, it will become easier as time goes by and I got the message.
It reminded me of the poster message:  If you wait for the right time to do something, it would  never come..
Regarding aversion, my teacher MC corrected me when I said to her, I really don't like Singapore, she said, there is nothing wrong with Singapore, it is up to you to decide to be affected by those things that you do not like about Singapore! Believe it or not, on my next visit, I came to realize that Singapore has more leafy areas than a city like Bangalore in India and that Kaya and toast tasted good along with some Kopi in one of the shops in the Chinatown…Just a little change in your mind, and the life becomes bearable and even more beautiful.

When these defect arise in your heart, you tend to do say or do something that is unpleasant to you or those surrounding you. American Indians would advice: do not do a destructive review but a constructive review of your thought, and gives an example:
Destructive review is when we ask,
What is the matter with me?
How can I be so stupid?
They feel that this is morbid reflection of your action or remorse (a concept unknown to the Indians) and may affect your self-esteem. A constructive review would be to ask,
What will I do next time?
With constructive review as with the analysis of the Kleishas, we progressively eliminate the structural defects that stand between our minds  and the harmony of our lives.

It is 5 pm on a Friday as I write this, looking out at a park in Bruselas, Belgica.  Shabbat Shalom to my family and friends all over the World.


jeudi 24 janvier 2013

PATIENT CENTERED PEER EDUCATION: AMONG THE KICKAPOO/KIKAPU OF TEXAS/MEXICO


PATIENT CENTERED PEER EDUCATION AND HEALTH CARE…AMONG THE KICKAPOO/KIKAPU OF TEXAS/MEXICO
The 10-seater van was fairly new, had Mexican License plates. Mena stopped at various homes in the Kickapoo Reservation in Eagle Pass, Texas, sloping down to the river, which marks the border between USA and Mexico. We were on our way to Piedras Negras, Mexico, crossing river on specified bridges under the watchful eyes of Mexican Police and Military. During this short trip, the van was full of laughter, the heart felt laughter the Indians are capable of-the conversation was not in English or Spanish, the languages of the countries we were traversing but in ancient Algonquin tongue-Kikapu/Kickapoo. I was the only one that did not understand the language, but as a Physician-anthropologist it gave me a chance to observe or continue observing the social customs of this ancient people.
Nobody would ever guess that the van was transporting a group of patients to be seen, consulted and treated by three health care professionals.
A Mexican doctor, specializing in Family Practice, Homeopathy and Complementary Medicine who had virtually grown up with the Kikapu (her father was their doctor for many years until his untimely death)
An AUS/UK/USA trained Endocrinologist-Anthropologist who is a visiting Professor at the University of Havana, in Cuba as well as a Consultant Endocrinologist to various Indian tribes.

A member of the Kikapu tribe, who is a Peer Health Educator of many years experience and a good friend to both above. She is the central person in this narrative, who organized this trip, selected the patients from the long list of Kikapu who consult her at her home, she selected a few who were not satisfied by the medical care in Eagle Pass or San Antonio by GPs or Specialists (failure to resolve their sufferings). Mena had taken the day off from work as an accountant at the Tribal Casino plus sacrificed her family life by spending the Saturday following doing the same.
In this Peer Educator oriented Health Care, not just Disease care, the emphasis is on talking and expressing of emotions. Neither of the doctors could interfere nor interrupt the conversation since they did not understand the language, and also both were culturally competent. (In America, where an average medical consultation lasts only 7-12 minutes; the MD/FNP/PA interrupts the patient narrative in less than one minute, in the name of guiding the narrative, but more likely because of lack of interest).


Every now and then Mena would turn to me and explain the conversation with the patient and translate the symbolism inherent in the conversation, and hand over the bag of medications prescribed and purchased in the USA (which they may or may not be taking).
All Primary Care Providers could take a point from here: they have to be culturally sensitive and culturally competent, if you are looking after people in a mixed cultural setting, which most of the USA is. They also have to understand the symbolism, hidden in their expressions and have to be very polite when it comes to counselling the patient. He or She cannot afford to put self-pride before these.
On the average, the three of us, the Mexican MD, the Endocrinologist-anthropologist and Peer Health Educator Mena spent one hour, at least, with each of the Kikapu patient. We didn't finish our consultation, each of us taking turns in no particular order, until the patients were satisfied and their queries answered to their satisfaction. We could order and get the Laboratory tests as one was open nearby, and the patient could go home with the prescribed medications from the pharmacy around the corner, thus alleviating extra trips for blood tests or seeking medications from pharmacy. (Also saving money for the tribe because medications are only a fraction of the price in Mexico). From the point of view of the patient: (1) the sociability of the situation contributes to their wellness, they can socialize while the consultation is taking place, before and then some afterwards.
(2) The satisfaction that their problems are attended to in the manner that culturally and emotionally satisfactory to them.
(3) No need for an extra trip to draw blood for labs, another visit to the MD for him to explain it to you, and yet another visit to the pharmacy to pick up the medication
(4) During the entire time they were at the clinic, about four hours in all, they were not forced to speak either English or Spanish but could speak their traditional language and could explain their symptoms and suffering in symbols that the Peer Educator understood and translated it to the two doctors. They know the words for their suffering in their language but not in Spanish or English.
These descendants of an ancient culture, striving hard to maintain their cultural identity, are caught between their holistic belief systems and the technology/profit/time demand of an American civilization to which the doctors and other providers in Eagle Pass and San Antonio belong.
Not only it is the satisfaction of the individual patient where time and cultural appropriateness is attended to, the tribe also saves money because of the efficiency of the care and the absence of inappropriate tests and treatments.
It was more than 5 hours when we had finished with the last of the consultations, they were patiently waiting knowing fully well that each one is being attended to, and in the end they all got into the van and returned home.
(Later that evening, I was told that some of the older ladies were bent on preparing a traditional Kikapu meal for us when we returned to the reservation)
One case presentation to demonstrate the effectiveness of
This Peer Educator!

61-year-old lady with repeated visits to Emergency Room and Clinic for Anaemia and High Blood Sugar.
She was given what appears to be a standard treatment on the other side of the bridge in Eagle Pass, Texas
70/30 Insulin twice a day, 120 units
Metformin twice a day, 1000 mg twice a day
Lisinopril
Atorvastatin
Glimipride
Fenofibrate
She had received blood transfusions for her anaemia at the Emergency Room
By looking at the treatment regime, any Endocrinologist can tell you that the Primary Care Physician was treating the lab results in front of him, rather than the patient.
Using the anthropological approach, I directed the question at Mena.
Why does she think she has low blood? (Anaemia)
Then comes the revelation! She said:
I think it is because of my habit of peeling and then juicing and drinking the lemons!
How may Lemons do you peel, juice and drink?
At least 8! As if we were unconvinced, she shows us the nail bed of her right thumb, which is eaten away because of the corrosion! We could only wonder which other parts of her body were corroding!
She continued; after the last time I got a bag of blood I made the connection and stopped eating Lemons.
Did anyone ever ask you about this habit of yours?
No, you are the first one!
We will get a blood test and see how well your blood is responding after you stopped eating Lemons.
What about your sugar?
Are you taking all the medications prescribed for you?
Yes
Then why do you think your sugar is always over 200?
I think it is because I drink at least six cans of regular coca cola per day.
I mentally calculated, 149 calories per can, six cans 900 calories, 15 calories in one teaspoon of sugar, 60 teaspoons of sugar!!
I told her
She did not flinch.
Mena steps in. It would be good for you to reduce the number of cans you are drinking. She agrees.
That simple act will assist her body in more ways than all the Metformin/Glimepiride/Insulin!
The idea is not to increase medications, the MD had increased all the medications to their limits but none of which had shown any beneficial effects, these medications are probably not strong enough to ward off the dangers of High Fructose Corn Syrup or Maltodextrin or other chemical sweeteners in a can of coke.
(THE PEER EDUCATOR RECLINING WHILE CONDUCTING THE LAST OF MANY INTERVIEWS LASTING HOURS)

Thanks as always to the unselfish dedication of Dra Estela Rosales Garza of Muzquiz for her attention to the well being of the Kikapu. I consider her one of the best practitioners of the art and science of Medicine…anywhere in the world.