Session 8. Health in a cross-cultural context
Step 1. (10 minutes)
Step 2. (20 minutes)
Step 3. (20 minutes)
Step 4. (15 minutes)
Step 6. (5 minutes)
Step 6. (5 minutes)
Step 7. (20 minutes)
Step 8. (20 minutes)
Step 9. (10 minutes)
INTRODUCTION AND GOALS OF HEALTH AND NUTRITION COMPONENT
Basic to every society are shared perceptions about well-being and illness that comprise the knowledge applied when a member of the group becomes ill or is believed to be in a vulnerable state of health. Appropriate technologies for health refer to the various means and systems for maintaining or restoring the state of well-being according to cultural norms and realities. Therefore, it is important that the effective overseas development worker accept such health perceptions as valid, integral parts of the culture and respect the tradition they represent. For a development effort to be appropriate, it is crucial that there be an understanding that the concepts and customs regarding health and nutrition are intimately related to every other component of the total culture; there can be no separation of one part from the whole. The issues of development -- including technology, health and nutritional status, participation and integration of women, the role of the overseas worker -- are all inter-related and any change in one area ripples out to affect all others.
It is necessary that a broad background in development issues be provided and that adequate health and nutrition information -especially in a cross-cultural context -- be made available to future development workers. In a training program that concentrates on alternative and appropriate technologies, the health and nutrition component must reflect deep concern with the relationships between technology and health status and with women and health, particularly the impact of change upon women and children in the developing world and the important role that women play in determining and maintaining family and community well-being.
A health/nutrition education plan should emphasize the cultural relativity of what constitutes appropriate knowledge, attitudes and applications. It should focus as many activities as possible on attaining high-level cognitive skills in order to facilitate providing the type of assistance that fosters community self-reliance and self-determination. Perhaps most important, it should instill the trainee with a sense of understanding how basic and universal is the need to maintain well-being and how connected it is to every aspect of life.
Goals of the Training Plan
Consistent with the health training philosophy established by the Peace Corps for all volunteers, this training plan is based upon the following goals:*
(* Stated in the Peace Corps Trainers' Guide for Basic Health Training for all Peace Corps Volunteers (compiled by N. McCharen, OPTC, July 1978))
* To enable volunteers to maintain and promote their own health and well-being while overseas
* To improve the quality of life of the people in the volunteers' communities (based on the WHO definition of health: "... a state of complete physical, social and mental well-being and not merely the absence of disease or infirmity.")
* To aid trainees in the development and/or practice of experiential learning processes
* To ensure that trainees fully understand the cultural context of health and disease as it is exemplified both in themselves and in their host communities
* To be sure that volunteers understand that they are not "barefoot doctors"
In addition, certain other goals have been identified as crucial to an integrated training program that emphasizes appropriate technology transfer, community development and the role of women in the development process. These are:
* To provide the trainees with an understanding of the syergetic relationship between health and technology
* To help trainees recognize the important role that women play in maintaining and restoring family and community well-being
* To facilitate the trainees' acquisition of skills and attitudes that encourage community well-being, self-reliance, self-determination and creative problem solving abilities
* To sensitize trainees to the concept that all aspects of a culture are inter-related and must be considered when introducing change in any one component
CULTURE SHOCK AND THE PROBLEM OF ADJUSTMENT TO NEW CULTURAL ENVIRONMENTS
I would like today to make a few remarks about culture shock, a malady which I am sure has afflicted most of us here in varying degree. We might almost call culture shock an occupational disease of people who have been suddenly transplanted abroad. Like most ailments, it has its own etiology, symptoms and cure.
Culture shock is precipitated by the anxiety that results from losing all our familiar signs and symbols of social intercourse. These signs or cues include the thousand and one ways in which we orient ourselves to the situations of daily life: when to shake hands and what to say when we meet people, when and how to give tips, how to give orders to servants, how to make purchases, when to accept and when to refuse invitations, when to take statements seriously and when not. Now these cues which may be words, gestures, facial expressions, customs or norms are acquired by all of us in the course of growing up and are as much a part of our culture as the language we speak or the beliefs we accept. All of us depend for our peace of mind and our efficiency on hundreds of these cues, most of which we do not carry on the level of conscious awareness.
Now when an individual enters a strange culture, all or most of these familiar cues are removed. He or she is like a fish out of water. No matter how broadminded or full of good will you may be, a series of props have been knocked from under you, followed by a feeling of frustration and anxiety. People react to the frustration in much the same way. First they reject the environment which causes the discomfort: "the ways of the host country are bad because they make us feel bad." When Americans or other foreigners in a strange land get together to grouse about the host country and its people, you can be sure they are suffering from culture shock. Another phase of culture shock is regression. The home environment suddenly assumes a tremendous importance. To an American, everything American becomes irrationally glorified. All the difficulties and problems are forgotten and only the good things back home are remembered. It usually takes a trip home to bring one back to reality.
Some of the symptoms of culture shock are: excessive washing of the hands; excessive concern over drinking water, food, dishes and bedding; fear of physical contact with attendants or servants) the absent-minded, far-away stare (sometimes called the tropical stare); a feeling of helplessness and a desire for dependence on long-term residents of one's own nationality; fits of anger over delays and other minor frustrations; delay and outright refusal to learn the language of the host country; excessive fear of being cheated, robbed or injured; great concern over minor pains and eruptions of the skin; and finally, that terrible longing to be back home, to be able to have a good cup of coffee and a piece of apple pie, to walk into that corner drugstore, to visit one's relatives and, in general, to talk to people who really make sense.
Individuals differ greatly in the degree in which culture shock affects them. Although not common, there are individuals who cannot live in foreign countries. Those who have seen people go through culture shock and on to a satisfactory adjustment can discern steps in the process. During the first few weeks most individuals are fascinated by the new. They stay in hotels and associate with nationals who speak their language and are polite and gracious to foreigners. This honeymoon stage may last from a few days or weeks to six months, depending on circumstances. If one is a very important person, he or she will be shown the show places, will be pampered and petted and in a press interview will speak glowingly about progress, goodwill and international amity and if he returns home may well write a book about his pleasant if superficial experience abroad.
But this Cook's tour type of mentality does not normally last if the foreign visitor remains abroad and has seriously to cope with real conditions of life. It is then that the second stage begins, characterized by a hostile and aggressive attitude towards the host country. This hostility evidently grows out of the genuine difficulty which the visitor experiences in the process of adjustment. There is maid trouble, school trouble, language trouble, house trouble, transportation trouble, shopping trouble and the fact that people in the host country are largely indifferent to all these troubles. They help but they just don't understand your great concern over these difficulties. Therefore, they must be insensible and unsympathetic to you and your worries. The result: "I just don't like them.'' You become aggressive, you bank together with your fellow countrymen and criticize the host country, its ways and its people. But this criticism is not an objective appraisal but a derogatory one. Instead of trying to account for conditions as they are through an honest analysis of the actual conditions and the historical circumstances which have created them, you talk as if the difficulties you experience are more or less created by the people of the host country for your specific discomfort. You take refuge in the colony of your countrymen and its cocktail circuit which often becomes the fountainhead of emotionally charged labels known as stereotypes. This is a peculiar kind of invidious shorthand which caricatures the host country and its people in a negative manner. The "dollar grasping American" and the "indolent Latin American" are samples of mild forms of stereotypes. The use of stereotypes may salve the ego of someone with a severe case of culture shock but it certainly does not lead to any genuine understanding of the host country and its people. This second stage of culture shock is in a sense a crisis in the disease. If you overcome it, you stay; if not, you leave before you reach the stage of a nervous breakdown.
If the visitor succeeds in getting some knowledge of the language and begins to get around by himself, he is beginning to open the way into the new cultural environment. The visitor still has difficulties but he takes a "this-is-my-cross-and-I have-to bear-it" attitude. Usually in this stage, the visitor takes a superior attitude to people of the host country. His sense of humor begins to exert itself. Instead of criticizing, he jokes about the people and even cracks Jokes about his or her own difficulties. He or she is now on the way to recovery. And there is also the poor devil who is worse off than yourself whom you can help which, in turn, gives you confidence in your ability to speak and get around.
In the fourth stage, your adjustment is about as complete as it can be. The visitor now accepts the customs of the country as just another way of living. You operate within the new milieu without a feeling of anxiety, although there are moments of strain. Only with a complete grasp of all the cues of social intercourse will this strain disappear. For a long time, the individual will understand what the national is saying but he is not always sure what the national means. With a complete adjustment, you not only accept the foods, drinks, habits and customs but actually begin to enjoy them. When you go on home leave, you may even take things back with you and if you leave for good, you generally miss the country and the people to whom you have become accustomed.
Now before going on to consider the nature of culture shock, it might be well to point out that the difficulties which the newcomer experiences are real. If individuals come to a tropical area from a temperate one, they quite often suffer from intestinal disturbances. Strange foods sometimes upset people. In Rio, for instance, water and power shortages are very real. When these physical difficulties are added to those arising from not knowing how to communicate and the uncertainties presented by strange customs, the consequent frustrations and anxieties are understandable. In the course of time, however, an individual makes his adjustment. You do what is essential about water, food and the other minutiae of daily life. You adapt yourself to water and power shortages and to traffic problems. In short, the environment does not change. What has changed is your attitude towards it. Somehow it no longer troubles you. You no longer project your discomfort onto the people of the host country and their ways. In short, you get along under a new set of living conditions.
Another important point worth considering is the attitude of others to a person suffering from culture shock. If you are frustrated and have an aggressive attitude to the people of the host country, they will sense this hostility and, in many cases, respond in either a hostile manner or try to avoid you. In other words, their response moves from a preliminary phase of ingratiation to aggressive ridicule and on to avoidance. As you feel weak in the face of the host country people, you tend to wish to increase your dependence on your fellow countrymen much more than is normal. Some will try to help you; others will try to avoid you. The better your fellow countryman understands your condition, the better he is able to help you. But the difficulty is that culture shock has not been studied carefully enough for people to help in an organized manner and you continue to be considered a bit queer -until you adjust yourself to the new situation. In general, we might say that until an individual has achieved a satisfactory adjustment, he is not able to fully play his part on the job or as a member of the community. In a sense, he is a sick person with a mild or severe case of culture shock as the case may be. Although I am not certain, I think culture shock affects wives more than husbands. The husband has his professional duties to occupy him and his activities may not differ too much from what he has been accustomed to. The wife, on the other hands, has to operate in an environment which differs much more from the milieu in which she grew up. Consequently, the strain on her is greater.
In an effort to get over culture shock, I think there is some value in knowing something about the nature of culture and its relationship to the individual. In addition to living in a physical environment, an individual lives in a cultural environment consisting of man-made physical objects, social institutions and ideas and beliefs. An individual is not born with culture but only with the capacity to learn it and use it. There is nothing in a newborn child which dictates that-he should eventually speak Portuguese, English or French nor that he eat with a fork in his left hand rather than in the right or use chop sticks. All of these things the child has to learn. Nor are the parents responsible for the culture which they transmit to their young. The culture of any people is the product of history and is built up over time through processes which are, as far as the individual-is concerned, beyond his awareness. It is by means of culture that the young learn to adapt themselves to the physical environment and to the people with whom they associate. And as we know, children and adolescents often experience difficulties in this process of learning and adjustment. But once learned, culture becomes a way of life, the sure, familiar, largely automatic way of getting what you want from your environment and as such, it also becomes a value. People have a way of accepting their culture as both the best and the only way of doing things. This is perfectly normal and understandable. To this attitude we give the name ethnocentricity a belief that not only the culture but the race and the nation form the center of the world. Individuals identify themselves with their own group and its ways to the extent that any critical comment is taken as an affront to the individual as well as to the group. If you criticize my country, you are criticizing me; if you criticize me, you are criticizing my country. Along with this attitude goes the tendency to attribute all individual peculiarities as national characteristics. For instance, if an American does something odd or antisocial in a foreign country which back home would be considered a purely individual act, this is now considered a national trait. Instead of being censured as an individual, his country is censured. It is thus best to recognize that ethnocentrism is a permanent characteristic of national groups. Even if a national criticizes some aspect of his own culture, the foreigner should listen but not enter into the criticism.
I mentioned a moment ago that specific cultures are the products of historical development and can be understood not by referring to the biological or psychological peculiarities of its human carriers but to an understanding of the antecedent and concomitant elements of the cultures themselves. Brazil and the United States, for instance, have different cultural origins and different culture histories which account for present day differences. In this case, however, the differences are not great, both cultures being parts of Western civilization. It might be useful to recognize here that the study of culture per se is not the study of individuals. Psychology is the study of individual personality. Sociology is the study of groups and group behavior. the student of culture studies not human individuals but the inter-relationships of cultural forms like technologies, institutions, idea and belief systems. In this talk we are interested not so much in the study of culture as such but its impact upon the individual under special conditions.
Now any modern nation is a complex society with corresponding variations in culture. In composition, it is made up of different ethnic groups, it is stratified into classes, it is differentiated into regions, it is separated into rural and urban settlement, each having its distinctive cultural characteristics. Yet superimposed upon these differences are the common elements of official language, institutions and customs which knit it together to form a nation.
These facts indicate that it is not a simple matter to acquaint oneself with the culture of a nation. Similarly, the culture of one's own nation is complex. It, too, differs by region and class. Americans, for instance, who go abroad in various government and business capacities, are usually members of the middle class and carry the values and aspirations of this class, some of which are an accent on the practical or utilitarian work as a means to personal success and suspicion of personal authority. Accustomed to working in large hierarchical institutions like business corporations, governmental agencies or scientific foundations which have a life of their own and persist in time, Americans tend to become impersonal. Individuals, no matter how able, are replaceable parts in these large institutions. To Americans, personalism which emphasizes a special individual, like a political leader or a business leader or a religious leader as solely responsible for the existence and success of an institution, is somewhat strange. To the American, it is the organization that counts and individual beings judged according to their ability to fit into the mechanism. This difference in inter-personal relationships often comes at least as a minor shock. A new pattern has to be established which has to take into consideration class society, the symbols of individual status, the importance of family relationships and the different importance given work, leisure and the values people strive for.
The rather sketchy remarks I have made here about culture and its elements is for the purpose of showing how important an objective treatment of your cultural background and that of your new environment is for understanding culture shock. There is a great difference in knowing what is the cause of your disturbance and not knowing. Once you realize that your trouble is due to your own lack of understanding of other people's cultural background and your own lack of the means of communication, rather than the hostility of an alien environment, you also realize that you yourself can gain this understanding and these means of communication. And the sooner you do this, the sooner culture shock will disappear.
The question now arises. what can you do to get over culture shock as quickly as possible? The answer is to get to know the people of the host country. But this you cannot do with any success without knowing the language, for language is the principal symbol system of communication. Now we all know that learning new language is difficult, particularly to adults. This task alone is quite enough to cause frustration and anxiety, no matter how skillful language teachers are in making it easy for you. But once you begin to be able to carry on a friendly conversation with your neighbor or to go on shopping trips alone, you not only gain confidence and a feeling of power but a whole new world of cultural meanings opens up for you.
You begin to find out not only what and how people do things but also what their interests are. These interests are usually expressed by what they habitually talk about and how they allocate their time and money. Once you get to know this value or interest pattern, it will be quite easy to get people to talk and to be interested in you. When we say people have no interests, we usually admit the fact that we have not bothered to find out what they are.
At times, it is helpful to be a participant observer by joining the activities of the people, to try to share in their responses, whether this be a carnival, a religious rite or some economic activity.
Yet the visitor should never forget that he or she is an outsider and will be treated as such. He or she should view this participation as a role playing. Understanding the ways of a people is essential but this does not mean that you have to give up your own. What happens is that you have developed two patterns of behavior
Finally, a word on what your fellow countrymen can do to help you get over culture shock: It is well to recognize that as the persons suffering from culture shock feel weak in the face of conditions which appear insuperable, it is natural for them to try to lean heavily on their compatriots. This may be irritating to the long-term resident but he should be patient, sympathetic and understanding. Although talking does not remove pain, I think a great deal is gained by having a source of pain explained, some of the steps toward a cure indicated and the assurance given that time, the great healer, will soon set things right.
Many people who enter and live in a new culture for more than a month experience what has been labeled "culture shock." This means the newcomer will experience feelings such as not belonging, alienation, unworthiness or inadequacy and may lose touch with his or her own real feelings. In many ways, the person will be experiencing real mental distress but what must be recognized is that culture shock is a normative process. It is something we all may experience to a greater or lesser degree.
We to experience culture shock differently, however. Some people tend to get very depressed. This may mean they withdraw from people of difference and have little energy to put forth in doing anything that is new or requires much effort. They feel victimized and they look at others -- particularly those in the new culture -as being the cause of their pain and torment.
Others may search desperately for similarities with their own culture or background and then try to rely upon these similarites for support to the exclusion of other activities. Those just out of a university environment may try to recreate some of the dominant qualities of that environment in their new situation. If they were involved in sports, for example, they will try to get involved in similar activities in the new culture. If they previously relied a lot upon books, they will spend much of their time in the new culture simply reading. The tendency is to seek out something familiar from the past in an effort to dominate and exclude the present as well as to preserve one's own ego or sense of identity. This is normal and sometimes, in fact, useful to do.
Old-timers say culture shock can only be lived through, not dealt with. This does not seem to be true if you can just take the first step of recognizing that you are in culture shock. The whole thing is usually so deceptive (and we are so clever at inventing games to screen out the reality) that we cannot or will not admit what we are going through.
If we can get through to our real feelings, the best thing to do is to face the reality and then deal with it. At this point, we can acknowledge that we feel terrible (which is O.K. because it's what everyone feels in a similar situation) and we can look for actions we need to take to overcome these feelings. Action is terribly difficult for people in depression because they feel so ambivalent about things but it is only action that will help. Action cuts through ambivalence and begins to resolve it.
An important question to ask when you recognize that you are feeling "down" and lonely is simply, "What can I do to make myself feel more positive about things?" People in culture shock tend to be very puritanical and demanding of themselves, which only heightens the sense of discomfort and inadequacy. Think of the things that you could do which would be positive first steps. Then change something which is appropriate to the culture and place you are in.
Following are some of the signs that may (but don't always) indicate you're on the old culture shock trip:
* Yearning constantly for certain foods or personal comforts not readily available in the new culture
* Escaping to maximum structure/minimum contact situations such as movies or formal restaurants
* Hanging around with fellow volunteers or others of your own ethnic group
* Finding yourself talking about "them," "these people" and blaming "them" for all the problems you're having in your work or in your personal adjustment
* Finding yourself drinking excessively or spending unusual amounts of time --
* Avoiding contact with people of the new culture in any of a hundred other ways which all boil down to one fact: you may be in culture shock. You owe it to yourself as well as to those around you to start doing something about it.
One final note: the term "culture shock" is a very apt and descriptive term. However, it may also imply that there is something so alien about other cultures that they "shock" newcomers. We do not mean to imply that at all. Instead, when an individual enters a different culture, it is often the absence of the taken-for-granted, everyday things from the native culture which causes the shock. These everyday things can be such items as access to newspapers, television, books, friends, certain kinds of foods, etc. Because these are taken for granted, it may cause discomfort or "shock" when they are no longer available, or at least not as automatically or in the familiar form. Generally, it is during this period one realizes something is missing or different. Culture shock may be experienced before one has substituted and/ or accepted new "everyday things" available in the new culture.
Resolving Culture Shock
Simply take note of the conditions present or absent when you experience happiness or discomfort.
THERE IS NO "BEST" ORDERING OF NEEDS.
Nor is the question of why our needs are as they ire of any particular importance. In fact, perhaps the most central idea to be conveyed here is that WE SHOULD SATISFY OUR NEEDS, RATHER THAN SUPPRESS THEM.
Any other course of action leads to frustration, unhappiness and even an inability to continue in our roles.
The trick, of course, is to find ways to satisfy our needs in situations where our previous sources and techniques for need-satisfaction are impossible or inappropriate to employ.
Here are a few very general suggestions that many volunteers have found to be practical ways of satisfying their needs in a foreign culture. Check off the ones you think you might do and in the space below each section, list others you may want to try.
* * *
Ways of satisfying the need for affiliation:
Ways of satisfying the need for achievement:
Ways of satisfying the need for control:
____Settling in comfortably, arranging your belongings
From: ACTION Pamphlet 4200.14, May '76, "Adapting Overseas in the Peace Corps"
[Ukrainian] [English] [Russian]