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Put Yourself in My Shoes


Noel O'Hare

An understanding of the patient's culture may be necessary to find the best treatment.

The term "cultural safety" has become such a byword for political correctness that it is often dismissed out of hand. Yet, health professionals who lack cultural competence, to use a broader and less emotive term, are failing some of their most vulnerable patients and not living up to the high standards of their profession.

Treating everyone the same might seem a fair and ethical approach for any health practitioner to take, but sometimes it's entirely the wrong thing to do. For anything more complicated than a broken leg, an understanding of the patient's culture and background may be necessary to come up with the best treatment. Nowhere is that more true than in mental health. Mental disorders, such as depression and schizophrenia, take on very different hues when filtered through different cultures. For example, successive surveys suggest that depression as we know it in the West is an apparent rarity in China. Chinese, and other non-Western patients, simply don't report the same symptoms of depressed mood, feelings of worthlessness and guilt and general lethargy that Westerners do. Instead, they are more likely to complain about sleep problems, physical pains, concentration difficulties, headaches or dizziness. Researchers theorise that this is because Chinese are less likely to make distinctions between mind and body and attach a greater stigma to mental illness.

Schizophrenia is another disorder that expresses itself differently according to culture. In Ireland, which used to be a pious country, patients with schizophrenia would often have delusions of sainthood (their delusions of grandeur today no doubt feature Dublin real estate agents). In technologically advanced places like the US, patients would report that they were being spied on by television or secretly x-rayed, whereas in Japan, which prizes social conformity, those with schizophrenia may have delusions of being publicly humiliated. In some non-Western cultures, schizophrenic delusions single out the person as spiritually gifted. Doctors can't always assume that a patient's family will share their view of mental illness.

Then there are culture-bound syndromes, conditions that are only found in specific locations. To take a familiar example of a Western culture-bound syndrome, anorexia nervosa, the fatness phobia, first appeared among daughters of the Western bourgeoisie in the 19th century, but with the spread of Western influence now affects young women in places such as Japan and Hong Kong. (In medieval Europe, anorexia mirabilis or holy anorexia was associated with devout women.)

There is a long list of syndromes specific to particular cultures. Boufee delirante, an affliction peculiar to West Africa and Haiti, presents as a sudden outburst of agitated and aggressive behaviour, confusion, sometimes accompanied by visual and auditory hallucinations. In countries such as Malaysia, Singapore and China, there have been epidemics of koro (shook yang), an intense anxiety among men that their penises are shrinking and receding into their bodies (a condition that Dunedin joggers will be familiar with in winter). Singapore had a major koro epidemic in 1967. Men resorted to clamps, pegs, and even weights to ensure that their tackle remained in its rightful place.

Another largely male syndrome is brain fag or fog, a condition that affects high school and university students. Symptoms include difficulties in concentrating, remembering and thinking. Brain fag affects students regardless of intelligence and is said to be related to the delivery of Western-style education that is at odds with the traditional African ways of acquiring knowledge.

In Latin America, people may succumb to locura, a severe form of chronic psychosis, triggered by multiple life difficulties (hence the word "loco" meaning crazy).

In New Zealand, cultural safety has focused on Maori and Paheka and "there's a lack of understanding about the broader issues of culture," says Ruth DeSouza, an Auckland nurse educator who has written extensively on culture and mental health. Although cultural safety is sometimes viewed with suspicion, it's invaluable in getting people to think about their own biases and assumptions about the way the world works, "and how do I [as a health professional] work to support people who might have different ways of being".

DeSouza believes that the health system has yet to catch up with the influx over the past 10 years of migrants and refugees, and the diversity of cultures that now exist here. "People wing it and hope for the best. They hope that all those things that New Zealanders do really well, like being respectful and treating everybody kindly, will do the trick." It's not always enough. Far from being dismissed as politically correct, cultural safety, she argues, needs to be broadened and deepened to improve the quality of health care for all who live here.

Copyright 2004, Used with permission from the New Zealand Listener.

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