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.
