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Some thoughts on cultural competency for
those coming to work in Southern Belize
By Norman Gregory RN MN
May, 2004
The Toledo District of Southern Belize is an area of amazing
cultural variety in and of itself. To a
person arriving from a different culture such as exists in the
United
States
and trying to function in the area it
can be an exceptional challenge as he or she must be prepared to adjust to
multiple cultures that are different from each other and very different from
the culture they are leaving behind. Within the bounds of the Toledo District will be found Ketchi Maya, Mopan Maya, Garifuna, Belizean East Indian and a variety of other mixed culture
cultural groups. Languages encountered
will include Creole, Mopan, Ketchi,
Spanish, and the lingua franca (but 2nd language to most everyone) Belizean version of English. After working in this environment for the
past 5 months my wife and I have some suggestions to offer but still feel like
cultural neophytes ourselves as will most people when they start working here
and find that they frequently make cultural guffaws due to lack of
understanding of the peoples they are encountering.
On arriving in
Belize
most people from northern climates soon feel a general sense of being tired and malaised especially if they have come from a cool or
cold climate during the north American winter
months. Not only are they faced with the
usual travelers’ problem of jet lag but they also are faced with a sudden
climate change from potentially sub-zero temperatures to mid 80’s (Fahrenheit) and very high
humidity. Sleep becomes a problem as
they move onto new beds in new sleeping arrangements with loud monkey and bug
noises keeping them awake at night in addition to the unaccustomed heat. I mention these issues as they may add to a
feeling of being overwhelmed that can occur on arrival as the reality of
working in Toledo sets in. Luckily the excitement of the moment usually
helps overcome negatives of this period as people delve into their new
assignments but it is helpful to remember that it is appropriate to give
oneself some breathing room or the frustration of working in the new cultural
setting can be somewhat magnified.
Many people come to
Belize
expecting that Belizeans speak the King’s English as their first language. In reality we have met few Belizeans who
consider English to be their first language; most speak Belizean Creole (which
is not recognized as a language by the Belizean government) by choice whenever
they are with other Belizeans. While
Belizean Creole contains many English words there are very few non-natives that
can understand it. When Belizeans do
speak English it takes some time to get used to as the syntax is somewhat
different than American or British English but can be easily understood in most
cases. In Toledo
the two distinct Mayan languages of Ketchi (also
spelled Q’echi) and Mopan are encountered frequently and in many cases are the sole language of the
speaker. As one gets to the outer villages near the Guatemalan border some
persons are mono-lingual with Spanish. An outsider coming to Southern
Belize finds that they are not only faced with significant
cultural barriers but language barriers as well that they may not have
expected.
The first thing we advise visitors to recognize is that in
our observation of Belizean culture few things are written and many things “are
known”. It is fairly uncommon for
example to find street signs in many areas of
Belize
. It is expected that people will know the
hours that a store is open and that it will be closed from noon to 1:00 PM. If a sign does say that a restaurant will be
open on Friday and the owner doesn’t open it that evening then that is
understood – the actual situation always trumps over the written
information. We have gone into
restaurants and been handed menus only to be told that the only thing available
that evening is stew[ed] chicken, rice and beans but only after we had
requested everything else on the menu – we should have known. I remember one day being told to go to a “Witz” store and straining my brain to think if I had ever
seen a sign for Witz store. The person giving me the information couldn’t
believe I didn’t know where Witz store was. After talking for a while we realized that
the store that has a huge sign reading, “Southern Grocery Supply” is known to
everyone as Witz – now we know. I read a magazine for visitors to
Guatemala
discussing the cashew nuts. The writer
had run into a similar situation in that he had discovered the hard way that
the hull of a cashew nut contains the same poison as poison oak. When he asked at the market if they ever
warned visitors how to prepare the nut the vendors were dumbfounded that anyone
would not know such a basic fact! Recently we were handed cashew nuts at a church function and again the
local Belizeans had a hard time understanding how we would not know this
information. Reading
an article on the internet from a writer who had encountered a similar
phenomenon in
Niger
and refers to it as High Context cultures verses Low Context
Cultures. She was told she should
mow her grass. She didn’t mow it and
nearly stepped on a snake that was hiding in the grass. The people who had told her to mow her grass
assumed that she would know that they were telling her to mow the grass to
avoid having snakes hide outside her house. In what she refers to as a High Context culture a large part of messages
are unspoken. It is frustrating to
expect to be told a detailed answer to a question (asked or unasked) and to
only get a partial answer. One needs to
remember in these situations that it is the outsider that has the problem, the Belizean is very comfortable with this
communication style and will have a hard time understanding why you would want
it any other way.
We initially thought that the following situation was
related to a communication problem we were not able to figure out with our
Mayan clients. We would ask a parent
arriving with a group of children, “who needs to be
seen” and be told that, “this child needs to be seen”. We would then ask what was wrong with the
child and fill in the answer we were given on our intake form only to be told
of a second or third problem just as we were about to close the chart. After admitting the child we would tell the
family to move back to the waiting room only to find out that a second, then
third child needed to be seen. By the
time the family had left the waiting room we were exasperated. I later read a book about a Mayan Bush Doctor
and laughed when I read a description of a very similar situation with a family
visiting him for care. Clearly we were
observing a cultural pattern that felt uncomfortable to us but is “normal” to
our clients. We have since learned to
point to each family member and ask if, “this person will need to be seen”
resulting in much lower stress on our part. We have learned from our past
cultural heritage to plan ahead based on the initial information we receive and
were having a hard time with the cultural clash we were feeling. This is an example of recognizing and
accepting a cultural pattern for what it is and then trying to develop
strategies that lower our own stress levels while meeting the needs of our
clients in a way acceptable to them.
We have also learned that in
Belize
the concept of patient privacy is very different than we are used to. It is very hard to convince children AND
adults to move out of earshot while we ask potentially personal questions of
our patients. They find it fascinating
to watch what is happening on the nearest thing they have to reality TV. On the other hand many of our patients are
very shy and find it embarrassing to do something as basic as bring us a urine
sample. We have also been consistently
told that Belizeans’ are very concerned about confidentiality from the “my best
friend” network. One man explained that the country is so small that it is very
easy to have a health care worker tell “only their most trusted friend”
something who then tells “only their most trusted friend” the story and in
short order it gets to their wife’s brother in law and so on. We have found that having a consistent person
working with the patients helps gain trust. My wife started being the intake nurse at the clinic shortly after we
arrived in
Belize
. Only now are patients asking her very
personal questions after five months of observing that she listens without
judgment and does not let information get into the “my best friend” network. In the field I have learned to firmly establish patient
interview areas and consistently push back the crowd of onlookers and as the
villagers have come to recognize me they are more willing to accept the
boundaries. I am convinced that they also
appreciate the tiny bit of privacy the boundary allows for. In this situation we are trying to introduce
a concept that we feel will be appreciated in their culture but we have to do
it very slowly and only after the host people have come to know and trust us.
Perhaps the biggest cultural guffaw we see is when
healthcare providers assume that ordered medications and procedures will be
followed. Recently I was in a village
where a lab test was ordered for a client the month before. The client had taken the time to go to the
Punta Gorda hospital lab (a two or three hour bus ride) and was told that the
test would cost $100. As this is about
one-third of a typical Mayan’s monthly income (with NO “disposable” income at
all) the client refused the test and very possibly came to the conclusion that
we were unable to provide any kind of care within her financial reality. On several occasions well meaning health
care providers have suggested that diabetic clients not drink orange juice and
avoid tortillas in a culture that has virtually no other source of nutrition or
vitamins. The clients smiled and nodded
and went back to eating the only food sources that they had available. It is also not unusual to have clients get a
second (often dissenting) opinion from the local bush doctor and then to take
that advice without letting us know of the change in plans even though in many
cases we would try to work with the bush doctor’s treatments if we could. It is frustrating but absolutely necessary to
adjust healthcare practice to recognize the realities within which the host
culture clients live. To not do so in
many ways may be worse than doing nothing as the clients are likely to leave
and never return to listen to such foolish people give advice about their
chronic problems.
Common in
Belize
and many other cultures is the belief that one goes to the healthcare provider
to get “medicine”. If one leaves the
clinic without medicine then one will not get better. We have been told by clients that they need
an injection because an injection is always better than a pill. Recently we had a client who was quite
surprised (and very suspicious) to find that his chronic problem responded
better to 1 tiny pill rather than the two big pills he had been taking. These beliefs have been fostered over many years. Traditional bush doctors are very aware of
the value of positive talk and action in creating what we would call a placebo
effect. They would seldom start a
conversation by saying anything less than, “yes, of course I can help you” and
then making sure the patient left with something to take which might or might
not be chemically active as a drug. Physicians in this part of the world often give an injection of
antibiotic when an oral medication would be quite adequate and patients seldom
leave their offices empty handed. Missionary groups bring down health care teams who dispense vitamins
with the assurance that they will make the villagers feel better whether they
have any indication of vitamin deficiency or not. It is a very slow process to teach information
which disagrees with a long held belief especially in a traditional
culture. Change will only occur if
consistent messages are given and the people understand that the schooling they
are being given has more value than the pills they have come to expect. We have been pleasantly surprised to see a
change in how our client base is approaching health care as that consistent
message has been given out by a staff who is obviously
very concerned with providing high quality health care. We do recognize that it is also likely that
we have caused some of our clients to quit “experimenting” with a modern health
care model and to return to providers who are willing to give them “pills” for
whatever complaint they have.
The message that we wish to leave the reader with is that we
are guest in another culture. That
culture is interested in how we do things and willing to accept some of the
changes we suggest but only after we have taken the time to gain their trust and
to demonstrate the value to them of the changes. By definition we believe that our culture
does many things better or we would not be part of that culture but that
doesn’t mean that we can’t learn to see the value in the ways others live. It also doesn’t mean that we have to accept
that the normals of the other culture are best for
us. It does mean that for the people of
the culture we are visiting that even though they do things that seem strange
to us that those same things are very normal to them AND they will resist
changing them unless they clearly see advantages for themselves. In many cases they are responding to a
different reality than we experience in the
United
States
. Getting a work permit in
Belize
is an exasperating process and involves multiple visits to several offices and
as an American from the
United States
it is easy to want to yell at the officials involved that it would be better
for everyone if the process was more efficient. We also come from a nation with a relatively low unemployment rate where
it is not necessary to make complicated processes in order to maintain jobs
such as is the case in many countries like Belize. If you want an easy time getting a work
permit then go back to your home culture, if on the other hand you want to
experience and learn about another culture then go through the lengthy process
and when you have a private moment scream and let your frustration out. That is often what cross culture work
requires, accepting that which you cannot change, very slowly changing that
which you can, and respecting that you have a real need to express your
frustration in private with others of your home culture at times in order to
release some of the aggravation before it overwhelms you and you end up
insulting your host.
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