EDITORIAL

Culture and health: why we need medical anthropology in family medicine in Portugal

John Yaphe*

*Associate Professor, Community Health, University of Minho

Endereço para correspondência | Dirección para correspondencia | Correspondence

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Culture is the framework for our beliefs and practices as a society. This includes our health beliefs and behaviours. Medical anthro­pology, as the study of culture and health, has a great deal to teach us about what we value in health, how we view disease, and how we cope with changes in our health. In this editorial, I would like to reflect on how we may use this discipline to enrich teaching and learning in family medicine in Portugal.

When I first arrived in Portugal and suggested adding medical anthropology to the undergraduate medical curriculum, I was met with curious questions. Colleagues asked: “Why do we need that? Aren’t we all from the same culture and don’t we all speak the same language?” Looking around the waiting room at the SEF (Immigration and Borders Service), when I went to renew my residency status, I found evidence to the contrary. I was rewarded with a view of eager immigrants of every possible skin colour, from many countries. I enjoyed the sounds of a mix of languages. Some of the hopeful migrants came from former Portuguese colonies in South America, South East Asia and Africa. Others were recent arrivals from Eastern Europe, seeking a better life here. I imagined how their initial contacts with the health care system here might lead to misunderstanding. They might also provide valuable opportunities for learning.

All encounters in family medicine are cross-cultural encounters. The family culture of the patient and the ways the patient sees health and disease are different from the family culture of the doctor. Their codes and symbols and their values regarding health are products of their culture. In order to understand this and to improve outcomes of the consultation, we need to use the tools of medical anthropology.

Expressions such as “feed a cold and starve a fever” reflect these popular beliefs.¹ When a patient tells us that “going out in the cold with wet hair caused my cold”, that sitting in a draft (“correntes de ar”) causes illness, or that carrot soup is good for children with diarrhea, they are drawing on ancient myths that infuse our culture. Many of these health beliefs can be traced back to the Greek belief that the world was composed of four elements. Earth, air, fire and water and their corresponding qualities of hot, cold, wet and dry were all you needed to know. An excess of hot and dry produced a disease like fever, which required a cold, wet treatment. Similarly and excess of cold and wet produced upper respiratory illnesses known as “a cold” in English and “resfriado” in Portuguese. These names reflect the belief in the thermal origin of the disease. Ayurvedic medicine from India and some forms of traditional Chinese medicine still use this system of dualities. They refer to hot and cold diseases requiring hot or cold foods or treatments. Chi-cken soup (the Portuguese “canja”) is a panacea in many cultures, known for its medicinal properties. There may be a solid immunological basis for this.²

The patient-centered care model is one adaptation of the cross-cultural approach.³ It draws on the methods of medical anthropology in understanding the distinction between disease and illness. Disease is the medical conception of the issue at hand, as it is defined in the textbook. The illness is the lived experience of the patient. In order to understand the patient’s unique experience we need to ask about their fears and feelings, their ideas about the illness, the effect of the illness on their daily function and their expectations of care.

Arthur Kleinman, through his study of traditional Chinese medicine, developed a series of questions that any doctor may ask to facilitate cross-cultural understanding.⁴ If you ask the patient: “What do you think is causing your problem? What do you call this in your language? What do you require to treat it? What will happen if you treat it? What will happen if you don’t? How long do you think this will this last?”, you may form a powerful link with the patient and learn a lot about their conception of disease.

When family doctors in Israel were confronted with the influx of patients from Ethiopia in the 1980’s and 1990’s, they were helped greatly by the open-minded approach provided by anthropologists.⁵ This helped in understanding and coping with requests for traditional surgery such as uvulectomy. It provided tools to promote concordance with long-term treatment plans for tuberculosis⁶ and promoted shared understanding of public health programs like immunization.

Family medicine in Portugal can also benefit from this approach, given the increasingly multicultural nature of the society. Recent immigration data describe about 5% of the population as foreign residents.⁷ Ethnic minorities such as the Rom, and descendants of Brazilian and African immigrants form distinct communities, each with different health needs. Dias’ study of 320 health professionals in Lisbon found that there is a need for capacity building in order to train the cultural competencies needed for immigrant health.⁸

However other communities also have a special identity and special needs. Migrants from the Azores and Madeira to continental Portugal may be different from their host community and not only in terms of their accents. Regional variations from the Minho region to the Algarve make life interesting on the continent as well. There are urban and rural differences, distinctions between rich and poor, and differences between patients by education and profession. To repeat the opening message, every encounter in medicine is a cross-cultural encounter.

At the University of Minho we have attempted to meet the needs for culturally sensitive medical education by raising this issue early in the curriculum. A three-hour seminar on medical anthropology introduces the students to key concepts relating to culture and health. Excerpts from entertaining films such as My Big Fat Greek Wedding and Monsoon Wedding help to illustrate the differences and similarities between marriage customs in different cultures. The ways that universal rites of passage affect our health require understanding by doctors. The seminar also includes a discussion of popular health beliefs in Portuguese culture. We explore folk explanations of acute illnesses like upper respiratory and urinary tract infections and chronic conditions like depression and coronary artery disease. Some young medical students are surprised to learn that cystitis does not come from toilet seats, so it is never too early to start exploring popular myths.

There is little published research in medical anthropology from family medicine in Portugal. A search for publications on Indexrmp using the term “culture” reveals more studies about bacteria than about people. Berta Nunes’ study of the use of alternative medicine in rural and urban populations is a noticeable exception.⁹

Health beliefs and behaviours are fertile ground for medical research. Both qualitative and quantitative methods can be used to enrich our understanding of our patients. This may prove to be a key to achieving better outcomes of care. Reports of this exciting new research have a good chance of finding a home on the pages of this journal.

 

REFERENCES

1. Johnson G, Helman C. Remedy or cure? Lay beliefs about over-the-counter medicines for coughs and colds. Br J Gen Pract. 2004;54(499):98-102.         [ Links ]

2. Rennard BO, Ertl RF, Gossman GL, Robbins RA, Rennard SI. Chicken soup inhibits neutrophil chemotaxis in vitro. Chest. 2000;118(4):1150-7.         [ Links ]

3. Stewart M. Towards a global definition of patient centered care. BMJ. 2001;322(7284):444-5. doi: http://dx.doi.org/10.1136/bmj.322.7284.444        [ Links ]

4. Kleinman A, Benson P. Anthropology in the clinic: the problem of cultural competency and how to fix it. PLoS Med. 2006;3(10):e294. doi: http://dx.doi.org/10.1371/journal.pmed.0030294        [ Links ]

5. Yaphe J, Schein M, Naveh P. Ethiopian parents’ perception of their children’s health: a focus group study of immigrants to Israel. Isr Med Assoc J. 2001;3(12):932-6.         [ Links ]

6. Griffiths C, Barne M, Saxena P, Yaphe J. Challenges of tuberculosis management in high and low prevalence countries in a mobile world. Prim Care Resp J. 2014;23(1):106-11. doi: 10.4104/pcrj.2014.00019        [ Links ]

7. Dias P, Machado R, Bento AR. Relatório de imigração, fronteiras e asilo, 2013. Oeiras: Serviço de Estrangeiros e Fronteiras; 2014.         [ Links ]

8. Dias S, Gama A, Silva AC, Cargaleiro H, Martins MO. Barreiras no acesso e utilização dos serviços de saúde pelos imigrantes: a perspectiva dos profissionais de saúde (Barriers in access and utilization of health services among immigrants: the perspective of health professionals). Acta Med Port. 2011;24(4):511-6. Portuguese.         [ Links ]

9. Nunes B, Esteves MJ. Therapeutic itineraries in rural and urban areas: a Portuguese study. Rural Remote Health. 2006;6(1):394.         [ Links ]

 

Endereço para correspondência | Dirección para correspondencia | Correspondence

yonahyaphe@hotmail.com

 

Conflict of interest

None reported