Cross Culture Medicine
Cross cultural medicine offers unique opportunities for service and at the same time it offers individual growth for those serving. While new employees of the Navajo Area Indian Health Service may have been exposed to cross cultural environs as they grew up, during academic training, or previously in their professional careers, exposure to diverse peoples only partially prepares one for life among the Diné (the Navajo People). The subtleties of interpersonal relationships (which, when understood by health professionals make them more successful in caring for patients) are particularly important among the Navajo.
In NAIHS healthcare facilities the following situations or realities may be encountered.
- Direct eye to eye contact with others is not common on the Navajo.
- Handshakes (when a hand is extended to someone) is a touching of hands as opposed to a firm handshake.
- The perception of time is different in that problems may have begun "awhile ago" and menses may be marked in their relationship to lunar cycles. The history of present illness for an acute illness may result in a story which relates the cause to events in the patient's personal life as far back as 50 or more years.
- History taking is perceived particularly by Navajo elderly as unnecessary. Traditional healers "know" what the problem is without oral history taking sessions. Combining the history while a physical examination is underway can yield better results.
- The review of systems can be particularly problematic in that if the patient felt they had concerns about a particular organ system they would have informed the practitioner of such at the outset of their interaction. Again, combining ROS with the P.E. can be helpful.
- Most often the answer to a question like "you don't have a headache do you" will result in an answer of "Yes", which means "Yes, I do not have a headache".
- Religious beliefs should be understood so that therapies of education can be appropriately tailored to each individual. Counseling emphasis for a prenatal patient is best given once religion is determined as the approach would be different for a Navajo who believes traditionally, for Navajo American Church members (who use peyote) and for Navajos who have converted to Christianity.
- Providers should offer tissue to patients for disposal such as toenails (after removal), scalp hair (if removed to suture a laceration), and even normal placentas. Traditional Navajos know what is appropriate for the disposition of these.
- Many Navajos still point directionally with their lips and not with their fingers and arms.
- Family decisions regarding health matters are common place. This is particularly true of surgery and delays in surgery may be misunderstood by those not appreciative of the fact that families require time to gather and weigh the options with the patient.
- Therapies may be delayed by the patient so that a traditional healer can be consulted and on occasion a ceremony performed in their hogán (home).
- Practitioners should always ask (especially the elderly) before showing X-Rays with patients as some have strong beliefs about any pictures of themselves and X-Rays have certain meaning to some patients.
- Assessing the home environment is essential before therapies are prescribed. Many people still have no electricity (no refrigerators) and no in door water source (no bathroom). Alternatives exist seasonally for ice/heat treatments and storage of medications and these should be appreciated by the practitioner.
- Conversational "courtesies" which are common in non-Navajo society (thank-you, excuse me, etc.) are infrequently heard on the Navajo but appreciation is felt and expressed by patients particularly after they get to know their provider over time.
- Translation into the Navajo language (which is descriptive) is extremely difficult and many health related terms have no single word counterpart in Navajo. A "simple" question when interpreted into Navajo takes much longer to ask in Navajo than in English.
- Patients may arrive for healthcare with their skin blackened with charcoal which mean they have recently had a ceremony performed for them by a traditional healer.
- After ceremonies, patients have to observe certain practices outlined by the healer (only eat certain foods, avoid anything dead, etc.). These do not generally interfere with prescriptions by non-Navajo practitioners.
- Pinon tree sap and herbs may be placed on wounds prior to arrival in the E.R. and harsh criticism of this (which represents a belief system) will adversely affect the relationship with the patient.
- Patient encounters with spider webs cause problems for some patients even though the non-Navajo practitioner may not be able to see a rash or believe that shortness of breath is a spider web induced.
- Avoidance of the phrase "there is nothing wrong with you" is best. Advising the patient that one can't determine the nature of their problem at this time is better.
- Many Navajo believe that by stating something may happen in the future (potential complications including death for example) will cause the event to occur. This has obvious implications for health education efforts.
- Navajo concepts of being, health, disease, and the environment are deeply intertwined with Navajo religion.
- There are many types of traditional healers (crystal gazers, herbalists, stargazers, hand tremblers) and the right one must be sought out for the patient (by the family) for specific problems.
Navajo Area Indian Health Service employees must respect the patients served which includes their belief systems. Doing so will lead to mutually satisfying relationship among patients, families, community members and those who choose to live among and serve the Diné.
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