| Cross-cultural Medicine Culture Shock—A Review of Vietnamese Culture and Its Concepts of Health and Disease DUONG NGUYEN, MD, MPH Misunderstandings of Vietnamese culture and beliefs have led to many unfortunate incidents in the United States, including court cases for child abuse and even suicide. These can be avoided by an awareness of the cultural background of the Vietnamese, their philosophy of life and the influence of religion and beliefs on their personalities, both as individual persons and as members of extended family units. The Vietnamese concepts of health and disease are presented, along with brief descriptions of certain folk medicines that are frequently misconstrued by American physicians. From April 1975 through February 1982, about 1.4 million Indochinese refugees fled their homelands. Nearly 580,000 (40%) of these refugees, most of whom were Vietnamese, have settled in the United States.1 They have incurred, in turn, a host of cultural, economic, political, psychological and social upheavals.2 In contrast to the nearly 1 million Cuban refugees that have settled in the United States since January 1959, the Vietnamese refugees have had to confront more immediate problems: They had no previously settled ethnic group to offer initial support; their culture was more dissimilar to that of the Americans, and they have frequently been symbolically identified with the unpopular Vietnam war. In brief, their arrival in the United States marked the beginning of a long and arduous process of adjustment to a new life in a new country with an alien culture. Inevitably, misunderstandings have occurred. For example, a Vietnamese father took his 3-year-old son to an American hospital because of possible influenza.3 The child had many ecchymoses on his chest and back, and the father was suspected of child abuse. Although he explained that the ecchymoses represented cao gio—that is, a home treatment of coin rubbing—he was jailed and subsequently committed suicide. In the hope that such misunderstandings can be avoided, I will briefly review the cultural background of the Vietnamese; describe the Vietnamese both as individual persons and as members of extended family units; discuss Vietnamese religious beliefs and social heritage, and present the traditional Vietnamese health beliefs. The Oriental Heritage “East is east and west is west. ” The Oriental cultures and values differ considerably from those of Americans. For example, American civilization has thrived on overcoming and mastering nature, whereas the Indochinese cultures stress harmony with nature. Instead of towering skyscrapers, the ancient Asians constructed their houses not by height but to blend modestly with the environment, creating thereby a sense of tranquility with life. Even today, Indochinese persons aspire to have the trees, grasses, mountains and rivers provide warmth and protection for their houses, in the hope that nature will be supportive of their lives and their families.4 Moreover, the Oriental daily life-style is less stressful. People tend not to rush because their concept of time is much more elastic. In contrast to the almost compulsive punctuality of Americans, Oriental persons frequently arrive late for appointments. Vietnamese as Individuals Vietnamese have but a few family names for a population of 56 million persons (1982 figure), with Nguyen being the most common. Their names are always written in the following order; family, middle (sometimes twice) and first names. This order may create confusion for medical records keeping and is frequently a source of misunderstanding. Also, they are typically addressed by their first names (even by strangers), a practice that is occasionally denigrated by Americans. A person’s age is also a source of confusion. For Vietnamese, it is calculated roughly from conception. Thus, most children are considered to be a year old at birth and gain thereafter a year at every lunar New Year—that is, each Tet. For example, a child could be 2 years old by Vietnamese counting, but less than a month of age by American reckoning . Because of the strong influence of the Confucian code of ethics, proper form and appearance are very important to Vietnamese. For example, the head is considered to be the sacred part of the body; therefore, it is most impolite to pat the head of a Vietnamese adult. Similarly, the feet are the lowest part of the body; thus, a Vietnamese person will feel offended if an interlocutor places an imprudent foot on the desk pointing towards him or her. Again, to signal for someone to come by using an upturned finger is a provocation (usually done to a dog); waving the hand is considered to be more proper. Both Confucian and Buddhist beliefs urge Vietnamese persons to be shy and modest. They rarely display strong emotions in public. Hugging and kissing are not seen outside the privacy of the home, and the sight of a wife being hugged by casual friends in public is a major source of discomfort for a Vietnamese husband. The Vietnamese Family Unit Because American culture stresses individualism, Americans find it difficult to fully understand the power of kinship for Vietnamese. The family is the fundamental social unit— that is, the primary source of cohesion and continuity—in traditional Vietnamese society. Differing profoundly from the American nuclear family, the Vietnamese family should be perceived as “a superorganic unit existing across generations past and future.”5 The crux of family loyalty is filial piety, which commands children to honor their parents. One’s behavior, for better or for worse, reflects not only on oneself but also on the family itself. The family may be involved in health care decisions, and they may not leave such a decision solely to the patient. As Tran, a well-known Vietnamese psychiatrist, noted, “In most cases, the relatives, more than the patients, are the ones to be convinced before the patient can start or continue a therapeutic program.”6 Most Vietnamese refugees arrived with a large patriarchal household of 5 to 12 members, including the core (nuclear) family, the grandparents, some siblings (and their families) and even some in-laws. For those families that stayed together, life has not been without problems; Prolonged closeness often creates friction, cumpulsory intimacy may generate personal irritations, exposure of the younger generation to the American culture frequently becomes a source of conflict and incessant expectations of mutual dependency may become hateful obligations and a common origin of emotional illnesses. When such conflicts arise, the unhappiness will initially be suffered in silence and in privacy. Such behavior is fostered by an enduring Buddhist and Confucian pattern of conduct that encourages passiveness and personal reserve. But a gradual eroding of these cultural influences, coupled with increasing conflicts within families, may cause the unhappiness to evolve rapidly into overt crises. The eventual outcomes are more likelv to be radical and disruptive—such as separation or divorce—instead of being mediated by compromise, resignation or tolerance (as in the past in Vietnam). Religious Beliefs The Vietnamese are strongly influenced by several sets of religious beliefs.7 First, Buddhism was introduced to Vietnam as early as the second century ad. Its influence is essentially the creation of a state of mind (rather than compulsory attendance at an established church). Central to this faith is a concept of life in which suffering is caused by desire. Desire can be eliminated by correct behavior—that is, the “Eight-Fold Path”—which lessens one’s suffering in life. For example, some Vietnamese may quote Buddha’s teachings about the world as a cycle of ordeals: to be born, grow old, fall ill and die. Second, Confucianism is more a way of life than a religion per se. Involving a code of ethics and morals, it emphasizes the hierarchy of the members of society and stresses the worship of ancestors. Third, originating from Lao-tzu (a 6th century bc philosopher), Taoism has also had an important role in the development of the Vietnamese cultural personality. Taoism is “naturalism” in the sense that it advocates taking no unnatural action to achieve conformity to the Tao (“the Way”). This philosophy stresses that, when things are permitted to assume their natural course, they move toward perfection and harmony. Fourth, Catholicism and Protestantism were more recently introduced to Vietnam, but they are followed by only a minority of the Vietnamese. Finally, animistic belief is much less frequently invoked by the Vietnamese than in the past. However, it is still practiced by the mountain tribes—that is, the “montagnards”—in the highlands of Vietnam. The Vietnamese Cultural Personality Such religious concepts and beliefs as mentioned above have been transmitted through the generations to produce an attitude towards life that may be perceived as passive. For example, whenever confronted with a direct but delicate question, many Vietnamese cannot easily give a blunt “No” as an answer, because they feel that such an answer would create disharmony. In such a context, “Yes” tends to reflect either an avoidance of confrontation or a desire to please the addressee, rather than an affirmation of truth. Self-control is another traditional value of the Vietnamese. Emotions are typically kept to oneself, whereas expressions of disagreement that may irritate or offend are avoided. They may be in pain, distraught and unhappy, yet they rarely complain (except perhaps to friends or relatives). There are also deep cultural restraints against showing “weakness” of the mind. Emotions are considered weaknesses because they interfere with self-control. Superior persons, therefore, should not be swayed by emotions nor, even less, permit other persons to see that they are troubled by intimate feelings. Hostility is not usually expressed towards persons who are considered superior—such as parents, physicians or teachers. American health services personnel may comment that their Vietnamese patients rarely appear desperate or depressed, but seem reasonably content, frequently smiling and seldom complaining or demanding—that is, they have “the good patient look.”8 The next step in self-control for nearly all Vietnamese persons is denial and avoidance. If pain and sorrow inevitably occur, one should try to forget them and hope for the best. What often sustains this effort against being overwhelmed by desperation is a special form of rationalization: “destiny.” It was “destiny” when they were saved, when they were able to escape to liberty rather than being detained in a concentration camp. It is also destiny when misery is prolonged for some but shorter for others. Accepting one’s destiny means resignation, but it also suggests hope: Things may improve anytime, if it is one’s destiny for events to change at that particular moment. The final step is fatalism. When one’s life cannot be saved, this is accepted stoically. In the older Vietnamese generations, it was hardly uncommon to see a house with a coffin situated beneath the household altar. Knowing that the days were short, the owner bought his or her future coffin. That is, a person must think about impending death, foreseeable prepare for the final moment and accept the final coming of death. The burial site may even have been chosen, because the position of the land can have an effect on the children. So, during the final days of life, a person will polish the coffin and even decorate it for the future eternal trip. In summary, unlike Americans who look to the future and plan for progress, Vietnamese cherish and uphold their ties with the past and their historical heritage of “4,000 years of civilization.” While Americans are goal-oriented, Vietnamese prefer activities that develop the human essence, such as philosophy, poetry and meditation. Vietnamese Traditional Health Beliefs Vietnamese will frequently use folk treatments either concurrently or before seeking Western medical care.9 Those folk treatments are particularly influenced by the Chinese concepts of yin and yang. That is, the universe—and thus a human being—is composed of two dynamically opposing forces: the masculine (yang), as represented by light, strength and heat; the feminine (yin), as represented by darkness, softness and cold. An excess in either direction will lead to disequilibrium and the production of disease.10 Certain diseases are said to result from an excess of the cold element, such as diarrhea which is attributable to a “cold” stomach. Other diseases are ascribed to an excess of the hot element, such as pimples or pustules which are attributable to an excess of a hot element erupting through the skin. Similarly, foods are divided into two groups: hot—spices, coffee, beef, wild game—and cold—tea, most fruits, chicken, duck, seafood. Drugs and medicinal herbs are also carefully classified according to their properties along a scale of hot and cold effects. From this concept, a number of techniques for the cure of illnesses have evolved: Cao gio, “coin rubbing” with hot balm oil that produces ecchymotic marks and petechiae on the chest and back.11 (This has, unfortunately, been a source of many accusations of child abuse leading to court trials and even suicide.) The Centers for Disease Control have recently been asked to evaluate the effectiveness of this practice.12 Be bao (“skin pinching”), a derivative of the above practice. Giac (“cup suctioning”), with or without prior scarification. Xong (herbal steam fumigation). Balm application (Tiger’s balm, Mac Phsu Cula or Nhi Thien Duong oil). Ingestion of herbal concoctions, an influence of traditional Chinese medicine. Ingestion of organ meats. For instance, consumption of animal liver produces a strong liver, and so forth for brains, kidneys and testis. Many Vietnamese also believe that eating the gelatinous product of tiger bones (produced by prolonged cooking) will make them strong. Ingestion of hot food to cure cold illness and vice versa (chicken soup is recommended for the treatment of fever). Finally, other health practices have obscure origins. For example, a diet heavy in salt is believed to be good for pregnant women, and postpartum women should sleep over a charcoal heater to shorten the post delivery period. Besides these examples of folk medicine, Vietnamese readily use Western medicine (often both concurrently). Self- medication is a popular medical behavior in Vietnam. One does not need prescriptions to purchase medicines at drugstores in Vietnam, which may partially explain the increasing resistance of bacteria to several readily available antibiotics. Vietnamese also prefer drastic treatments: They believe strongly that a shot (intramuscular injection) is superior to a common oral preparation, and many ask for the 5% dextrose in water solution (called “sea water”) to be given intravenously for rapid recuperation from illness. Because medicine usually deals with invisible and immaterial elements, Vietnamese rarely feel a need for invasive techniques or surgical procedures. Surgical operations are perceived as a last resort; they are usually equated with admission to hospital, which is, in turn, associated with death (and thus to be avoided). Because of the previously mentioned religious beliefs and because of deep cultural restraints against showing a “weakness of mind,” an extremely small percentage of the Vietnamese population avail themselves of mental health services. Psychiatry and mental health are terra incognita for the vast majority. A psychiatrist is either a “nerve doctor”— which underscores the biologic label attached to the specialty—or a “doctor for the insane”—which emphasizes the bizarre, “out-of-this-world” character of mental diseases. In brief, then, delays in seeking medical care (both mental and physical) due to stoicism are a negative aspect of the Vietnamese cultural heritage. Conclusion Misunderstandings will inevitably occur whenever two cultures coexist. I have reviewed the differing aspects of the Vietnamese cultural heritage in the hope that further unfortunate incidences such as the child abuse accusations and subsequent suicides can be avoided. The Vietnamese in the United States are refugees—and, by definition, are involuntary immigrants. Their expatriation was unexpected, their trip was unplanned and their departure from Vietnam was precipitous. Hence, the absence of any material or psychological preparation meant that the impact of transplantation could not be cushioned. Of course, the Vietnamese will adjust, but the cost of adjustment will necessarily vary with the situations involved. The most sensitive situations require awareness of the basic values, beliefs and traditions that have been imprinted for an entire lifetime. For American health professionals, a knowledge about Vietnamese cultural heritage, even if sketchy, should further their capacities for empathy, tolerance and compassion so that they will see Vietnamese patients as persons culturally worthy of attention and respect. REFERENCES Report by the Comptroller General of the United States, GAO/HRD 82-65. Government Accounting Office, Aug 5, 1982 Masuda M. Lin KM. Tazuma L: Adaptation problems of Vietnamese refugees—II. Life changes and perception of life events. Arch Gen Psychiatry 1980; 37:447-450 Nong TA: ‘Pseudo-battered child’ syndrome (Letter). JAMA 1976; 236:2288Toan A: Phong tuc Vietnam (Vietnamese Tradition). Lancaster, Pa. Xuan Thu Library, n.d. Special Report: Physical and emotional health care needs of Indochinese refugees. Indochina Refugee Action Center 1980 (March 20), pp 30-31 Tran MT, quoted by Tripp-Reimer T, Theiman K: Traditional health beliefs/ practices of Vietnamese refugees. J Iowa Med Soc 1981; 71:533-535 Toan A: Tin nguong Vietnam (Vietnamese Religions and Beliefs). Lancaster, Pa, Xuan Thu Library, 1966-1967 Tran MT: The Indochinese refugees as patients. J Refugee Resettlement 1981; 1:53-60 Rocereto L: Selected health beliefs of Vietnamese refugees. J Sch Health 1981: 51:63-64 10 Hoang GN, Erickson RV: Guidelines for providing medical care to Southeast Asian refugees. JAMA 1982;248:710-714 Yeatman GW, Dang VV: Cao Gio (coin rubbing)—Vietnamese attitude toward health care. JAMA 1980; 244:2748-2749 Council minutes: Maryland Refugee Advisory Council, 1982 (December 2) Centers for Disease Control: A clinician’s guide to diseases of Indochinese refugees. Resident and Staff Physician 1979 (December), pp 76-82 14- Nguyen D: Culture shock- A review of Vietnamese culture and its concept of health and disease (Cross-cultural Medicine). West J Med 1985 Mar; 142-412) |
chúc mừng tác phẩm mới 