The perceived notion that cultures other than your own exist is often an arduous concept for us to comprehend. We get caught up in our ideals of what culture should consist of that we either forget or choose to neglect the cultures others embrace. That being said, culture is not defined by one thing in particular. Culture ranges in a variety of aspects, from the sports team you play for, to the country from which you were born. The precise definition of culture presents with much ambiguity; however, a commonly accepted explanation is that culture consists of common beliefs, values, rules and behaviors shared by a given society or group (Bonder and Martin 2013). Over the past several weeks, I was offered the unique opportunity to explore a culture far different from my own through a cross-cultural course taught at Eastern Mennonite University.
The purpose of this cross-cultural course was to provide me with a sense of respect for cultural diversity and ultimately, to gain cultural competence. Cultural competence, which is an on-going process that in order to be successful, requires one to be fully immersed in varying cultures with an open mind and the desire to learn (Bonder and Martin 2013). Nicaragua, the country I had the pleasure of visiting, was full of rich culture, allowing me to learn not only about the people, but also about the geography, sociology, and health care system.
Nicaragua is a remarkable country located in Central America, directly south of Honduras, with a population of approximately six million and growing (Sequeira et al. 2011). In fact, it is the largest, yet most sparsely populated country in Central America. The dominant language spoken in Nicaragua is Spanish, and the primary ethnic group is the Mestizos; however, other languages and ethnicities exist. The health care system of Nicaragua is operated financially based on general taxes (Sequeira et al. 2011). MINSA, which stands for Ministerio de Salud (Ministry of Health), is the primary health care provider to Nicaraguans, providing up to approximately 70% of the population (Sequeira et al. 2011). MINSA’s mission is to provide Nicaraguan citizens with free, universal health services, as well as encourage preventative measures, to promote healthier lifestyles. There are three administrative levels in the public health system known as the central level, SILAIS level, and municipal level. The health services provided at the central and SILAIS level include national reference hospitals and departmental hospitals, while the health services provided at the municipal level include health centers, health posts and community-based clinics (Sequeira et al. 2011). There are roughly 32 hospitals, 28 health centers with beds, 144 health centers without beds, and 855 health posts, all of which are supported and financed through a community-based network. During our time in Nicaragua, we were able to observe first hand, how volunteer health posts function and how it benefits smaller communities within the country (Sequeira et al. 2011). In fact, for the duration of our trip, we participated in house visits, followed by clinics for treatment of patients.
During our initial house visits, we collected personal and medical history information from residents in the San Isidro Community, while paying close attention to specific living conditions to assess whether these conditions may potentially contribute to disease. Based on initial observations, the way people live in this area differs drastically from what I am accustomed to in many circumstances. For instance, the majority of the houses are built with basic materials such as wood, metal, and plastic. These materials, compared to more urbanized, wealthier locations in Nicaragua, appear less sturdy and enclosed. Also, the majority of these houses do not have material floors. The floors are the dirt/ground. According to the providers we were working with, the home is considered clean if the floor has been swept and is clear of debris/leaves. Laundry is washed by hand and hung to dry on a line connected to trees. Many people cook their food over burning wood. Overall, the concept of living is similar in that we cook food, we wash our clothes with water and soap, and we insist on living in a sheltered area for sleeping; however, the way we go about these things is different. Perhaps these differences contribute to health conditions prevalent in the area. Visiting the homes of San Isidro opened my eyes to how people can live so differently from what I am used to. Also, the house visits reminded me of the city of Lima in Mountains Beyond Mountains. Lima was a city, where the poor lived, that was described by dirt paths, convenience stores, metal tin roofs, and unstable housing, surrounded by disease and filth (Kidder 2013). Being a poorer community, it also actually made me wonder how accessible quality healthcare was for these people. The majority of them did not have cars, with most modes of transportation being a motorcycle taxi or by a horse. With San Isidro being about 20-30 minutes from town, and with transportation being limited, I would assume gaining regular access to healthcare would be difficult. This lack of access may also be contributed to the prevalence of disease in this area.
The clinics for San Isidro were held at the local church of San Isidro for three days. The organization of the clinics was two groups, each with three volunteers, a translator, a physician and a patient. We averaged approximately twenty patients per day and the patients we treated ranged in age from infants to the elderly. One of the most severe cases we saw on the first day of clinics was a 62-year old woman. She complained of pain in her leg, pain in her stomach/chest and fatigue. She told us she had her uterus taken out several years ago due to uterine cancer. During her physical examination, we noticed several abnormalities. First, her blood pressure was 160/90. Second, and perhaps most importantly, I palpated a large mass (probably the size of a grapefruit), in her pelvic region. Since her uterus had already been removed, we concluded that she most likely had metastatic reoccurring cancer. This could explain her symptoms of pain in the stomach/pelvic region as well as her fatigue. We recommended she go to the hospital for further treatment; however, she said she was not going to go for reasons unknown. This was hard to accept knowing the patient was in critical condition and we were unable to make a meaningful difference. Unfortunately, she was not the only patient experiencing life-threatening conditions.
Our next patient was a 34-year old female. She presented with pain in her chest, right breast, and right axillary region. She was aware of her history of gastritis, which most likely explained the chest pain. During her physical examination, I palpated a tender mass (probably the size of a grape) in the patient’s right breast. I also palpated swollen, tender lymph nodes in the right axillary region. We recommended the patient get further testing at the hospital, such as a mammogram and biopsy, but the patient said she could not go. It was upsetting to see so many people with complex medical issues that required further medical attention beyond our capabilities, knowing access to that medical attention was very limited. Fortunately, many of the patients we encountered were suffering from illnesses/diseases that are relatively easy to treat with the over-the-counter medications we had in stock. Some of the most common illnesses/diseases we found included asthma, fungal skin infections, parasites, and dry cough. Despite being able to give these medications, many of these individuals require these medications long term and therefore would need access to obtaining them. As mentioned previously, access is most likely limited due to not only transportation but also finances. Other factors, such as cooking with wood and lack of personal hygiene, may also be contributing factors to the persistence of illnesses/diseases.
Every patient we encountered seemed to have something new to offer to my expanding knowledge of the Nicaraguan culture.
Despite initially having automatic ethnocentric thoughts, I made a conscious effort to acknowledge, “my way is not the only way.” Cultural brokers also referred to as cultural translators, cultural clinicians, or cultural navigators depending on their precise role, aided us in our immersion by helping us adjust to the different culture to be able to provide quality health services (Bonder and Martin 2013). Another thing that I had the opportunity to pay attention to during my immersion is that people of our culture often consider people of poorer/sicker countries to not care about their health. In contradiction, however, I noticed quite the opposite. The patients we treated seemed to care about their health and just wanted to feel better. The problem appeared to be a lack of resources, such as transportation, money, and education. While MINSA visits these communities approximately once a month, it is not enough to sustain a healthy community given the conditions. The majority of these visits include preventative methods and house treatments for mosquitos. Aside from that, these communities only get occasional visits from volunteer associations, such as ISL. Many of the people in these communities do not have insurance and do not have adequate access to healthcare. There are public hospitals that give free treatment; however, they are overcrowded, not necessarily easy to get to, and do not appear to be the best of quality.
After three days of clinics in the community of San Isidro, we migrated to another community San Sebastian. In comparison to the previous community, San Isidro, it seemed as though the people were not quite as poor and the housing was improved in many ways. For instance, the materials used to build the homes appeared to be more permanent and sturdy, including the use of concrete cinder blocks. Most of the houses also had toilets, which was a significant upgrade compared to the latrines of the other community. Our clinic was held in a school.
One thing that I noticed during clinic was the language barrier between the physician and us, which in my opinion was a downfall to our experience. Not to say this is her fault by any means, especially since we are guests in her country; however, the doctor did not speak very good English, and we are not very fluent in Spanish. This made clear communication with the physician complicated, resulting in a less ideal learning opportunity from the physician. Don’t get me wrong; I believe she knows what she is doing and makes for an excellent physician; however, the language barrier appeared to make her easily influenced by our opinions of what the treatment options should be. This could be considered a type 1 or type 2 storti incident depending on how you look at it because it was somewhat expected for us to be able to communicate via language (Storti 2001). Having experienced difficulty understanding their language, I can now better understand how those who do not speak English may feel when seeking treatment in the United States.
Following clinics, we were able to visit the public hospital. It was extremely eye opening to see how incredibly lucky we are to have what we have in the United States. The hospital was extremely overcrowded, and the majority of the hospital did not have air conditioning, making for fairly miserable conditions. The bathrooms were disgusting and unsanitary. I asked the physician who was giving us a tour if we could see the operating room and he agreed to show us. Since I am a surgical technician in the United States, it was very intriguing to see the differences. First off, the equipment was outdated and scarce. Also, the operating rooms were not near as clean as they are where I work. The sterile technique, from what I could tell, was not nearly as sterile as what I am accustomed to in the United States. I asked the doctor what the infection rate was and much to my surprise, he said it was 3-5%, which is much lower than I thought it would be given the conditions. The emergency room was packed with hundreds of patients, and the space available was inadequate for the volume of patients. The amount of time people wait to be seen is unreal, especially given the conditions of where they are waiting. The patients are seen based on severity, as in the United States; however, most emergency rooms in the United States are blessed with air conditioning and adequate space for patients to wait comfortably. Visiting the hospital, along with house visits and clinics, was an invaluable learning experience.
During my experience in Nicaragua, I not only learned about a different culture but also about myself as a person and future professional. In personal reflection, I noticed an innate tendency to be somewhat close-minded about how medicine should be practiced. For instance, when a patient presented with insomnia, the physician prescribed Benadryl. I automatically disagreed with this decision because Benadryl, in my opinion, is not meant for helping people sleep but rather it is meant for people having an allergic reaction. I found myself so caught up in disagreement that it took me some reflection time to realize the reasoning behind why the physician prescribed Benadryl. It was the only medication available that she could prescribe the patient to relieve the patient’s symptoms; therefore, the physician made due with what was available. In the United States, we are privileged enough to have an abundance of medications available to us, whereas, in the areas we were serving, there was a very limited supply. As a future healthcare provider, I would hope that I can be more open-minded to things that may not be ideal to me and find ways to be frugal and make use of what I am blessed to have.
Aside from learning to have an open-mind, I learned several personal strengths that will make me not only a compassionate health care provider but also an overall, well-rounded person. For instance, my ability to recognize that patients with a different culture than my own may appear as though they do not care about their health, but in reality, are struggling to overcome barriers that prevent them from having adequate access to the services necessary. I would say another strength is my passion to understand the background of my patients and what they believe is important. It is important to me to make sure that my patients feel comfortable and can count on me to have their best interest in mind. In addition to cultural competence, I found myself able to easily solve medical problems by asking the right questions and observing the symptoms/vitals a patient had. I did not realize how much I have learned over the past several years through my education and work experience.
Some key takeaways from this experience that I would like to put into practice in the future are that cultural competence is an ongoing process, requiring much time, effort and persistence. The ability to adapt and accommodate when exposed to various cultures is an essential quality that every health care provider should have to provide the best care possible for their patients. Carefully respecting the views, beliefs, and lifestyles of every patient are imperative into determining what treatment will work best for that patient. It was an experience that forever changed my life and how I now view the world. Unfortunately, as mentioned in Mountains Beyond Mountains, once one problem is solved, another arises. No matter what we accomplish, there will always be another issue. There is no end. So, I guess the solution is to do the best we can and continue to push for a better world. The Millennium Development Goals (MDGS) are the efforts being enforced to solve global poverty, hunger, disease, etc. Kidder, in Mountains Beyond Mountains, discusses these goals and how Farmer was completely committed to accomplishing these goals (Kidder 2013). Our agency, although not quite as extravagant as Farmer’s efforts, was able to help in some ways by providing advice and some medications. Even though the trip was short and the idea of short medical trips is often scrutinized, we did everything we could to help in the best way we knew we could (Decamp 2007). We are such a small piece of a much bigger plan. I am so grateful to the communities we were able to serve in Nicaragua, and I cannot wait to be able to do it again since there is still so much for me to experience and learn. I was confident in my decision to become a medical health provider before the trip, and now after the trip, I am even more confident in that decision. My passion is helping people in any way that I can. I am so thankful to have been blessed with this experience.
1. Bonder, Bette and Laura Martin. 2013. Culture In Clinical Care. 2nd ed. New Jersey: SLACK Incorporated.
2. Decamp, Matthew. 2007. Scrutinizing Global Short-Term Medical Outreach. Hastings Center Report 37(6): 21-23.
3. Kidder, Tracy. 2013. Mountains Beyond Mountains. New York: The Random House Publishing Group.
4. Sequeira M, Espinoza H, Amador JJ, Domingo G, Quintanilla M, and de los Santos T. 2011. The Nicaraguan Health System. Seattle, Washington: PATH.
5. Storti, Craig. 2001. The Art of Crossing Cultures. Intercultural Press.
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