More Similar Than Different: Discoveries in Medical Culture when Practicing Global Health at Pediatric Hospital in Ethiopia

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Sharla Rent and Stephanie Kukora

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ABSTRACT

In this narrative essay, a neonatologist considers “culture” and cultural competency while engaging in a global health partnership with a neonatal intensive care unit in Ethiopia. The shared medical culture between clinicians in the partnership was surprisingly unifying; experiences differed from expectations with regard to being an outsider. Ethiopian physicians, nurses, and midwives routinely encounter cultural challenges created by language barriers, an urban vs rural divide, and differences in education that impact the patient-provider relationship. Despite limitations in personnel and resources, these clinicians have devised approaches to overcome these barriers to best serve their patients. Hearing and observing how providers bridge these divides reveals important lessons for managing cultural challenges at home. Clinicians and trainees engaging in global health work should reflect on how cultural barriers experienced abroad are mirrored within their own communities, and utilize this these experiences to better inform their patient care practices.

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“They don’t like to take the baby out because of Evil Eye… Even it can be someone looking at the baby and it makes the baby sick. They have a fear that if they take the baby outside of the house, someone will give the baby this look, and the baby will be sick.” 

—Resident in Addis Ababa, Ethiopia

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Cultural competency is extolled as a key facet of medical education in the United States. As trainees engaging in clinical practice, we are told that our patients will differ from us in aspects of culture, race, religion, socioeconomic status, and worldview. We learn that it is our responsibility to bridge these gaps to improve health care delivery for our patients. When preparing medical trainees for global immersion experiences, however, our approach to cultural competency is different. Again, we are taught to identify and respect cultural differences, with heightened emphasis placed on not imposing our views. However, this education in cultural humility is coupled with the message that we should defer to our physician hosts the navigation of many cultural divides between us, as foreign medical providers, and patients, who they, as “local” providers are better equipped to manage.
Though this education in cultural competency and global ethics guards against the preclusion to judge another society through a strictly American lens, it has the unintentional effect of increasing the perceived distance between our medical cultures in an “us versus them” juxtaposition. Indeed, upon traveling to Ethiopia during my neonatology fellowship, I expected to be an outsider—a firenge poised to observe all of the differences between their hospital and my own, rather than the similarities. As with my past global health trips, I was looking forward to once again immersing myself in another culture and hospital system and feeling the invigorating mix of excitement and disorientation that flows through me upon entering into a foreign medical environment. I expected to rely heavily on my Ethiopian counterparts to explain any unfamiliar aspects of Ethiopian culture and local health practices.
In Addis Ababa, I was engaged in a qualitative research project exploring providers’ perspectives on neonatal care. Both in conducting semi-structured interviews and my day-to-day experiences in the hospital, my conversations with healthcare providers often took an unexpected direction. Ethiopian pediatricians and nurses described experiencing cultural barriers between themselves and their patients. They emphasized how this gap impacted the hospital’s provision of newborn care. As my new colleagues described the cultural clashes they faced in Ethiopia, I considered how those challenges mirrored my own experience in clinical practice in the United States: language barriers, social divides in socioeconomic status and education, and differences in deeply rooted health beliefs.
Among the most surprising, and fundamental, challenges I witnessed was the lack of a shared language. The ‘hospital language’ in Ethiopia is English; I assumed that although I would be unable to communicate with many of the patients, the Ethiopian physicians would easily bridge this language chasm. The reality could not have been more different. Ethiopia is rich in cultural and ethnic diversity, with over 80 different ethnic groups and over 200 spoken dialects (See Figure 1). [1,2]
Ethnic diversity around the world

Figure 1: Ethnic diversity around the world

Many Ethiopian physicians described the struggle of tracking down ‘the one nurse who speaks that language’ when no other staff member present spoke the same dialect as the family they were trying to update or counsel. While in my home hospital I have the luxury of interpreters to help me communicate across language divides, in Addis Ababa communication often depends on luck—whether someone fluent in the language happens to be working that day.
Even when the physicians and parents were speaking the same language, I observed challenges with communication that pervaded even the most basic aspects of care in the neonatal intensive care unit (NICU). This included explaining to families what a NICU even was. Historically, as the capacity to provide care to this population became available in low-resource settings, one of the most common reasons infants required intensive care was hypothermia. The colloquial term for the NICU, Mamokia Kifel, thus arose from the Amharic term for “someplace to warm the baby.” One nurse explained that this causes confusion for families, stating, “so they think that they came here because they are cold. They don’t think that they have some severe illness or anything.” Families would become confused and ask, “if they are here for warming treatment, why are you giving them medications?” As in the United States, infants in Ethiopia are admitted to the NICU for diverse conditions, including infections, prematurity, congenital anomalies, respiratory distress, birth trauma, and seizures – and often the diagnoses are much more serious and complex than “being too cold.”
Upon further discussion with my Ethiopian colleagues, I realized that families’ misunderstanding of the of the NICU’s purpose was likely more deeply rooted than its colloquial misnomer. I had anticipated social divides in Ethiopia between the urban and rural populations; this concept is widely discussed in global health literature and I was well prepared to encounter this division. [3,4,5] The same divide exists in other African nations where I had done work, and, indeed, is present to some degree in my home country. [6] Compounding this was the far more pronounced disparity between those who had received a formal education and those who had not, with my Ethiopian physician hosts being among the most highly educated. Their many years of western-influenced medical training and English fluency set them apart from their countrymen. During her interview, one pediatrician remarked, “The staff here is trained in a medical institution, so they have to know where the clinical condition comes from, the pathophysiology, so I hope they will not be affected by culture.” I had expected the local physicians to be my guides into traditional Ethiopian beliefs surrounding birth and newborn care; instead, I noticed a subtle, but constant, pressure amongst providers to remain free from cultural influences and approach problems from a more scientific perspective.
Throughout my interviews people referenced traditional practices including the need to keep infants in a dark room for many days after birth, the use of herbs placed in the nose or rubbed on the chest to help infants breathe, the recommendation to feed infants butter during the first few days of life, or how cow dung or dirt is placed on the umbilical cord after delivery. Although many of the nurses and doctors I spoke with admitted some familiarity with these beliefs, and the descriptions were fairly consistent amongst providers, few claimed to truly understand these practices, with one physician stating, “none of us here [in the hospital] can understand why they do these things.” Whether intentional or not, there was status derived from being removed from the traditional, primarily rural, medical beliefs.
Though many of the Ethiopian physicians expressed pride in their education level, I witnessed mixed emotions around their separation from the patient base. While their rejection of traditional medicine was unequivocal and intentional, the barriers in effortlessly relating to their patients arising from doing so also caused them distress. As one provider commented, “Most of our moms here are not educated. So, when you try to tell them that their child has something that can be repaired [like a neural tube defect] or something that can heal, it is hard.” In my home NICU I occasionally struggle to find common ground with parents who come from a very different social, economic, or religious backgrounds than myself, and it was eye-opening to see how physicians around the globe responded when faced with this same challenge. I had presumed that the ethnic diversity amongst the staff would more closely mirror that of the patient population, but in reality, the ethnic milieu of Ethiopia was far more diverse than I anticipated. I had falsely assumed a baseline level of homogeneity that simply does not exist in Addis Ababa.
Though the Ethiopian providers accepted their role in navigating language and cultural barriers, I found them struggle the most when conflicts between “modern” and “traditional” practices arose. Most notably, they were anguished when health beliefs of families contributed to late recognition of illness and increased morbidity in their patients. Many times, the delay in presentation to a hospital was based on cultural perceptions about infant illness and its causes, as well as reliance on traditional healers as opposed to “modern”, or hospital-based, medical care. Many of the physicians with whom I spoke had grown up with these traditional medical beliefs but felt that Ethiopia as a country needed to move beyond these practices. When describing why rural newborns present late to the hospital with severe, and often life-threatening, jaundice one pediatrician explained:
“Most of the time here, as a tradition, they keep [the newborn] in a darker room… They think that their eyes are not well developed so they cannot tolerate light… By the time someone sees that there is something wrong with the skin of the baby, it will be too late.”
A resident elaborated on the cultural context by stating:
“They don’t like to take the baby out because of Evil Eye… Even it can be someone looking at the baby and it makes the baby sick. They have a fear that if they take the baby outside of the house, someone will give the baby this look, and the baby will be sick.”
Providers shared with me their frustration with the inability to combat this local belief in “Evil Eye,” alarmed by the danger such beliefs imposed upon their patients. I also witnessed providers feeling troubled that difficult to dispel health beliefs had psychological impacts on families. For example, in much of Ethiopia, congenital anomalies are believed to have a spiritual cause. When asked how mothers react to having an infant born with an anomaly, a neonatology fellow commented:
“For herself, of course she will feel that she is cursed. So, she doesn’t want to show it because she feels guilty of having that baby … like it is her mistake.”
During my interviews, I noticed that providers almost always used “they,” as opposed to “we,” to distinguish between themselves and their patients when explaining local cultural practices surrounding neonatal care to me as an outsider. During my time in Addis Ababa, I learned quickly that, in many ways, the physicians held beliefs more similar to my own than to their patients. We shared a common medical culture, a mutual set of scientific beliefs, and years of training in systems that rewarded empirical evidence. There was an unmistakable ease with which the Ethiopian physicians interacted with our team. Indeed, the familiarity felt between our two physician groups made me more aware of the medical versus non-medical divide present within my own institution. While I often feel a sense of “sameness” with patients and families from a similar background as myself, my time in Ethiopia made me mindful that this “sameness” does not negate the gap between myself and these families due to my role as their child’s doctor, whether that be related to medical knowledge or status differences within the hospital.
Though the distance between myself and the Ethiopian pediatricians was smaller than I anticipated, and the distance between the local providers and their patients was larger, I was inspired by the manner in which the Ethiopian physicians approached the cultural challenges they faced daily. In the United States, we have a system of translators, social workers, chaplains, and patient affairs advocates to acclimate families to our medical system and help physicians communicate with patients of different cultures. Without the aid of this infrastructure, the Ethiopian physicians take ownership of bridging these barriers. They depended on themselves and each other to be cultural brokers, relying on whichever member of the medical team can best communicate, both linguistically and culturally, with a given patient’s family. This sometimes meant taking the time out of a busy clinical load to search the hospital for one specific provider. I was also particularly impressed with the providers’ efforts to patiently explain the complexities of and rationale for NICU care and educate families about the dangerous aspects of certain traditional practices. Though they had distanced themselves from these beliefs through education, their compassion in these encounters may have stemmed from some level of familiarity—for a few of the people I interviewed, the “they” to which they referred to were not only their patients, but their own mothers, grandmothers, and other relatives.
My experiences in Ethiopia highlighted for me some of the inherent limitations of training in cultural competency prior to immersion in a new culture. Teaching that we, as trainees from the United States, will be immersed in a single “foreign” culture while abroad is too simplistic. Yes, I was a firenge, but I was also a fellow neonatologist and newborn health advocate. Yes, significant language and cultural barriers existed between me and the NICU families, but many of these same divides existed for the Ethiopian nurses and physicians. Yes, many traditional medical practices were surprising to me, but the majority of my Ethiopian counterparts found the persistence of these same traditional practices challenging. Overall, my time in Addis Ababa left me with a few main take-aways:
  • In global health partnerships, we must remember that culture is not binary. It is not “us” and “them”. Beyond our national identities, we all are also part of other “cultures” – those not based on country or ethnicity, but on profession, education, or shared beliefs. Specifically, the medical community is a culture in and of itself and can be a stronger unifier than national identity.
  • Trainees engaging in global health work need to become cognizant of the heterogeneity that exists within the country they are traveling to and anticipate how they will work with local partners to navigate this linguistic and cultural diversity.
  • Cultural barriers experienced abroad are often mirrored in our own communities and physicians should feel empowered to play an active role in bridging these cultural gaps.
My immersion in Ethiopia substantially altered my perspective on the breadth and depth of cultural barriers that exist in neonatal care, globally and within my own community, and empowered me to take ownership of these divides and better bridge cultural barriers both in my home NICU and on future trips abroad.

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IRB Approval

IRB approval for the referenced interview study, from which providers were quoted in the narrative, was obtained both from the University of Michigan in Ann Arbor, MI, USA, and from St. Paul’s Millennium Medical College in Addis Ababa, Ethiopia.

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The authors have disclosed no conflicts of interest.

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Affiliations

Sharla Rent, MD1
Stephanie Kukora, MD2,3

1. Duke University School of Medicine
Division of Neonatology
Department of Pediatrics
Durham, NC

2. University of Michigan
Division of Neonatal-Perinatal Medicine
Department of Pediatrics
Ann Arbor, MI

3. Center for Bioethics and Social Sciences in Medicine
University of Michigan

Correspondence

Sharla Rent, MD
Assistant Professor of Pediatrics
Division of Neonatology
Department of Pediatrics
Duke University School of Medicine
3643 N Roxboro St., Durham, NC 27704
sharla.rent@duke.edu

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Endnotes

1 Ethiopia. 2007 Census. http://www.csa.gov.et/census-report/complete-report/census-2007#. Accessed May 12, 2019.

2 Ethiopia. Ethnologue. https://www.ethnologue.com/country/ET/languages. Accessed May 12, 2019.

3 Babalola, S, Fatusi A. Determinants of use of maternal health services in Nigeria–looking beyond individual and household factors. BMC Pregnancy Childbirth. 2009;9:43. https://doi.org/10.1186/1471-2393-9-43.

4 Gabrysch S, Campbell OM. Still too far to walk: Literature review of the determinants of delivery service use. BMC Pregnancy Childbirth. 2009;9:34. https://doi.org/10.1186/1471-2393-9-34

5 Abubakari A, Agbozo F, Abiiro GA, Factors associated with optimal antenatal care use in Northern region, Ghana. Women & Health. 2018;58(8): 942-954, https://doi.org/10.1080/03630242.2017.1372842

6 Lichter DT, Brown DL. Rural America in an urban society: changing spatial and social boundaries. Annual Review of Sociology. 2011;37:565–592. https://doi.org/10.1146/annurev-soc-081309-150208.

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