Culture and Context

Physicians working in the developing world must recognize cultural context to deliver high-quality medical care.

By Bonni Curran, MD

Women in developing countries face many of the same health issues as we do. Problems, however, are exacerbated not only by a lack of diagnostic care, medicine, and nutritious food and an environment plagued by sanitary nightmares but also by the restrictions of social conventions, misplaced faith, and shame. In the time I’ve spent working with health providers in developing countries, I have learned that what at first glance appears to be an easy fix will many times be buried in layers of complexity.

During a recent visit to our friend Rashid’s clinic in Uganda, we met Nagato. Nagato is not a given name in Uganda; it is earned—the name conferred upon a woman who has given birth to twins. Tall, with red-rimmed eyes, Nagato was about my age—but then again everyone here is “50” or “32” it seems. Like me she had grown twin girls. And, like me, she lives with arthritis.

But while I may miss my running days, I’ve been able to modify my recreational sports, ultimately taking my ibuprofen and dealing with it. Nagato, on the other hand, is crippled—physically and socially—by the disease. She can’t afford ibuprofen. She can’t crouch to go to the bathroom, causing her to soil her one skirt. She can’t squat to wash clothes or dishes, earning her husband’s wrath and the scorn of her community. A problem that, for me, is basically an annoyance makes it impossible for this woman to go on living her life in her community.

As foreign medical aid workers, we do our best to address these unique circumstances and help patients like Nagato. We ask ourselves, How can we effect some relief and change in a sustainable way? Are a few ibuprofen—short-term palliation—better than nothing? The answer isn’t always clear, but our hope is that the teaching we do carries on and continues to have a positive impact on the lives of the people we serve.

Ultimately, we are guests in another country. We bring certain skill sets, but none are more important than the ability to watch and listen. Sometimes, a simple solution to what seemed like a massive problem will become evident.

During a visit to a hospital in Liberia, it was the patients’ family members—who camp outside the hospital to help with feeding, cleaning, and caring for their loved ones—who provided us with a solution. With postoperative infection rates upward of 60 percent, the gynecologic wards of the hospital were in dire need of basic sanitation (such as hand washing between patients, cleaning of beds and cribs between admissions, emptying of garbage regularly). But this need is countered by the stark realities of a facility where electricity is limited, water is hand pumped and carried, and the dedicated staff is overworked. In visiting with the families here, we took note of the vile-looking concoction of homemade alcohol that they passed around to sip. Turns out—while not perfect—it provided us with a reasonable alternative sterilizer.

When working under these harsh circumstances, it becomes very clear that diseases cannot be treated out of context of environment. To do so effectively, we return to one of our first and most important lessons from medical school: Take a good history and physical exam. But we can’t stop there. We must remember that the exam does not end with the patient alone. The process is more complex, as the environmental and cultural layers that surround our patients mean that we are constantly redefining our expectations and creating new solutions. Like the countries we visit, our practice of medicine is developing all the time.