Sudan – Marilyn R. Gardner

There were 6 of us in a small examining room designed for two people — the doctor and the patient. In this case there were two women from the Sudan, two nurses, one patient navigator, one interpreter, and one baby.

It was crowded.

To say I was invited to come to this community health center was something of a delusion, it was more as if I had been challenged to come – challenged with strong words: “This program isn’t working! You try to use this life-style education tool with culturally diverse patients”

To give context the “challenger” was referring to a health assessment that my office had developed to gauge whether a person is ready to make changes to their lifestyle. It included questions on weight, healthy fats, exercise, fresh fruits, vegetable consumption and more.

I was not a fan of the questionnaire – I had worked with people from different cultural backgrounds my entire professional career and knew that this tool had been developed from a bias of western biomedicine. As such, it had limited use.

But I accepted the invitation knowing that at least they would see I was on their side.

So there we were: health professionals, patients, and a culturally biased assessment. Speaking through an interpreter I began talking. I introduced myself and asked if I could ask them a few questions. They nodded in assent – no problem.

And so I began:

“Are you a healthy weight?” Blank looks.

The interpreter tried again, and then looked at me. “This is not relevant,” she said. “They do not weigh themselves.” Of course, they didn’t. What was I thinking? They were women who had escaped the Sudan, made their way through the arduous process of refugee camps and resettlement and I was asking them about healthy weight. Wow. But determined to continue I pressed on.

“Do you eat healthy fats?” More blank looks. My problem-solving mode switched on and I thought – ok, I’ll ask if they use olive oil – that’s a healthy fat.

“Do you use olive oil?”

Their eyes lit up. They smiled. “Oh yes! We use olive oil all the time”. Good, I thought! We’re making some progress…..

“Yes olive oil. We love olive oil! It is wonderful. We use it every day…..on our hair”

I began to laugh, and they with me. The whole encounter was so absurd. I would have gotten more information on their health and eating habits by having a normal conversation and inserting the right questions at the right time instead of following this biased and culturally illiterate tool.

The story is a great example of some of the challenges presented in working with patients from different countries and cultures. The healthcare professional (whether nurse, doctor, social worker or any other) comes into the clinical encounter with his or her own predetermined biases, values, and beliefs. Added to that is the often inflexible culture of western biomedicine under the umbrella of the institution. All of this mixes into a potentially difficult interaction with the patient. We then wonder why patients won’t come back…or get offended…or don’t do as we want them to.

Culturally responsive care is critical to healthy outcomes.

But changing this dynamic is not easy. It’s a journey and as such takes time, preparation, and mile markers.

One of the first mile markers in learning to communicate across cultural boundaries is to understand one’s own cultural beliefs and values. Only then can we better interact with those from different backgrounds. If we don’t know what we believe and value, what is unique to our cultural backgrounds, we are ill-equipped to forge into relationships with those vastly different from us, even less ready to offer them good health care.

And after that it’s about listening to the stories and constantly being willing to learn and adapt.

It’s interactions like the one I’ve described that help me on this journey of communicating across cultural boundaries. They remind me that I have to be ever flexible and willing to see from the other person’s perspective; recognizing both literally and metaphorically the many uses of olive oil.

Got Olive Oil, Honey, and Sugar? Then You Have a Great Scrub (bellasugar.com)

A few years ago I was working on a project called “People Profiles” for my job at a busy healthcare organization. The goal of the project was to create informative one-page fact sheets representing some of the ethnically diverse groups in the greater Boston area. These would then be used with healthcare providers to help them better understand how to serve patients who have differing views of health and illness.

It was an interesting and challenging project, not least because for each people profile I had the privilege of working with someone from the country represented.

China, Cambodia, Vietnam, Haiti, Puerto Rico and more were my world for a few weeks and the people who I worked with were amazing. The personal and informational things they shared were invaluable, not only to the project but to me. I learned about immigration patterns and warring groups; gender roles and views of the elders in community; herbs and teas; tiger balm and hot/cold theories;dual causality and fate. The writers worked to educate; initially me and ultimately future readers of the profiles, to help us think beyond the surface and give excellent care.

One of those I worked with was a lovely Sudanese woman named Shahira. With beautiful prose she helped to write the “people profile” on the Sudan. She helped to give personality to a place I knew only from limited interactions with people in Cairo, where Sudanese have struggled as a minority group of refugees, without a country and at the lowest levels of society. At the top of the page she posted a proverb that I will never forget.

Our wasted days are the days we never laugh

I was struck by this for a couple of reasons. One was my appreciation for laughter and humor to get me through the difficult times, what Madeleine L’engle calls the “Holy Gift of Laughter”. The other was the contrast between what I knew and read on the fact sheet, and the proverb. It made no sense. How can people laugh when they have faced war, rape, starvation, and other untold horrors? What can possibly be the foundation for the resilience of their human spirit through such times, allowing them to see this proverb as representative of their spirit? It makes my difficult times look like a hot day at Disney world when the lines are long. Uncomfortable and not pleasant, but when compared, embarrassing.

These are the times when I am utterly confident that we are created in the image of God for there is no other explanation.

On Monday, July 9th, there was cause for much laughter and celebration as South Sudan was welcomed to the world as a new country. While there are enormous challenges that I couldn’t begin to analyze, after fifty plus years of war the celebration is welcome. The Sudanese proverb above gives me insight into the perseverance of a people who will continue to move forward, despite the challenges of illiteracy and poverty, determined to move past surviving to thriving as a new country.

Today is a reminder that after the darkness of war, the light of a new dawn is possible. A proud flag flies over Juba and the map of the world has been redrawn. These symbols speak to the blood that has been spilled, the tears that have been shed, the ballots that have been cast, and the hopes that have been realized by so many millions of people. The eyes of the world are on the Republic of South Sudan. And we know that southern Sudanese have claimed their sovereignty, and shown that neither their dignity nor their dream of self-determination can be denied. – President Obama, July 9, 2011