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.