Going Abroad on Health Research? Then get some cultural sense.

Posted By Damjan DeNoble

Back in 2006 I made a fateful journey to Gaborone, Botswana. At that time Botswana was thought to have the highest reported HIV infection rate in the world – 37%. I wanted to see how a program called ACHAP was being implemented in the rural and the urban areas of the country. My subsequent and never finished senior thesis would come to be called “The Lion and the Elephant, how Botswana’s environment is shaping healthcare delivery in urban and rural parts of the country.” This six week ‘research’ trip ended up convincing me that I wanted to spend at least a part of my life as a writer. But, that part of the story is fodder for another time - what I really want to share is that I made many mistakes in dealing with people and researchers there.

I made all the classic mistakes that young researchers – especially idealistic and naive, still-in-college ones- make. I did not make contact with people before I went; I had no plan for what kind of research I was going to collect; I expected people to help me because I was ‘doing research’; I expected people to help me because I was coming from the United States; I packed for a resort not a research trip; and I expected to do three months of work in six weeks.

In the end, I basically ended up semi-illegally observing the ACHAP program, and allowing a local man and his family to become semi-dependent on my money. Of course, while all this was going on, I was having a lot of fun. And, that’s just the problem, its fun until you look back and realize how harmful some of the things you did were . Below you will find one of the letters I wrote home from Botswana, and below that is part of a guide that the University of Michigan School of Public Health is working on for both undergraduate and post-graduate students wishing to do healthcare research abroad. I am indebted to Annalies Heinrichs for sharing this guide with me and I sincerely hope that UoMSPH’s work helps students going abroad avoid some of the pitfalls I made.

You can keep reading by clicking the ‘continue reading’ button at the end of this article (ignore this message if you have landed on the page with the full article).

LETTER:

Hello friends,

This is part deux of my ‘Letters from Botswana‘ series. To those of you new to the list – welcome. To put it mildly, it has been an exciting three days. To explain in great detail, it will take me at least four paragraphs…probably more.

My last night at the Grand Palm hotel I ran into a guy called Maghile Omphemetse Diphenko. I quickly settled for calling him ‘Gili’ and through the beauty of miscommunication he settled for calling me ‘Gili’ as well. I should go ahead and put it on all my official documents because I have been introduced as Gili to everyone I have met in Botswana since that day. Gili (Maghile) works a small security business in Botswana – he is an ex-mercenary…or something…and he never takes off his glamourwood sun-glasses.

Anyway, on that particular night, after asking for a cigarette, he offered to take me out on the town. He had been having a drink with his bosses in the hotel casino but he said he was happy to have met a friend as good as Gili (me) and he would fore-go his social engagement with the bosses to take me out. Saromotso, my security guard buddy at the hotel said that Gili (Maghile) was a good customer and I assumed this to be his endorsement of my night out. I quickly took 200 pula, roughly 40 dollars, out of the ATM and met Ghili in front of the hotel. I told him to pick the bar.

As luck would have it, the first bar was just closing, it was only half 12 (12:30), so this was surprising. I wasn’t too disappointed since this was a place for foreign tourists anyway – I had only accepted his invitation in the first place, hoping that he would take me to a local bar, with local people. Our taxi driver had left by the time we figured out the bar was closed, and this was a shame since I had already paid him 40 pula for getting us there and back (paying for the taxis and the drinks is a recurring theme for this night). So we found another taxi and drive to West Gabs – the Harlem of Gaborone.

The bar resembled something out of a Hollywood western, except this was Africa (so dont think John Wayne, but do think Don Cheadle), and loud house music was blasting through every crevice of the house. We parked in red dirt, we walked up to the place in red dirt, we were even patted down in red dirt -at which point I padded myself to make sure my wallet was still there, and luckily it was. The club was like any other in the world, more guys on the dance floor than girls, lots of beer, very dark, lots of hormones. Of course, this country has a 40% HIV/AIDS prevalence rate so in my mind at least, this was nothing like anywhere I have ever been.

We were quickly approached by a couple of girls who worked at the hotel – they knew me, i knew them, we took some shots of this drink called Zambuka – it burns green, and tastes like liquorice candy. After a few shots- few being three – Maghili and I finally sat down with a cold beer. Among other things I asked him if people would leave together tonight – i.e. would guys pick up girls for one night stands and vice versa. He said “yes, it happens.” So then I asked him if people were afraid of AIDS. And at that point he looked at me and said that he knew to be careful but that many people forget - its as if they are only scared of AIDS when they are in a place, like a hospital, where many people have it. And in all honesty I had to believe him. Apart from having condoms for sale behind the bar – there was little else in this bar that offered one a sense of an epidemic affecting nearly 800,000 people in this country of 1.7 million.

This is getting long…ill get to the point. It turns out that Maghile himself is HIV positive. He has been taking ARV medications since last August when his CD4 count fell to 44. (A CD4 count of below 200 means that HIV has transitioned into AIDS). So from the moment that he told me that he also became, in effect, my community partner.

He took me to the ACHAP HIV clinic yesterday morning and got names of patients that we will interview in the following days to come. He has also pledged to help me carry out a documentary study for the time that I have remaining here (and this was his idea by the way) and he wants to continue the work after I leave. Provided, of course, that I pay him. I have only told him that we can try it and that we have to take it one step at a time, but it is an exciting prospect nonetheless. As to what that study will be – from what I understand its less of a study and more a collection of stories, in Setswana, something that could be played on the radio (the number one media outlet in the country) and published as a series of pamphlets or newspaper articles. The stories being tales of survival, struggle, and rehabilitation of AIDS/HIV patients in the country. Again, this was Maghiles idea and, well, if opportunity comes a knockin’ i guess you have to answer the call….

Tonight we (Maghile and I) are going on a sort of observational triip into the villages surrounding Gaborone. He will show me, how he thinks, AIDS is getting transmitted throughout Botswana – prostitution, youth unemployment, youth drinking, and lack of transportation which prevents people who want treatment from getting it. “I will show you. You will record.” he says. Well, I’ll try my best.

I spent most of this morning and this afternoon obtaining government statistics – I visited three government ministries before someone managed to tell me that there was a government book store. Hopefully with the information that I have gathered through books combined with the information that I find in the field, I will be able to put together something that will help someone, somewhere. If not, well, im sure this will come in handy somewhere down the line.

Thanks for reading,

See you (or hear from you, as the case may be) all soon,

Best,

Damjan

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Cultural Competency:

Again, Thank you to Annalies Heinrichs for this…

What is it?

Cultural competency is the ability to interact with people of different cultures. In the global health setting—or in any health care setting—cultural competency specifically refers to your awareness of the regional specificities of the area serviced by the organization or clinic with whom you will be working. Such a competency does not require expertise. Rather competency suggests that you are conscious of the region’s unique cultural, economic, political, and historical attributes.

Why is it important?

Background knowledge will ease your transition into the new community. Furthermore, sensitivity to regional customs and manners will help impart your sincere interest to the community members and will ensure that your project/research is appropriate, respectful, and applicable.

Real-Life Example and Suggested Reading

If you haven’t already, read The Spirit Catches You and You Fall Down. Author Anne Fadiman delves into the life of the Lees, a Hmong family forced to leave their home country of Laos after cooperating with the Americans in the Vietnam War to resettle in Merced, California. The Hmong were perceived by the Americans as a people with alien and sometimes even revolting customs.

The Lee’s actions—their inconsistent administration of some of her anti-seizure medications, for example—were incomprehensible to Lia’s doctors. Conversely, the doctors’ seeming cultural insensitivity (burning the placenta, placing tubes in Lia when she was sick, keeping Lia from her family) and stringent adherence to Western biomedicine and Cartesian thinking was abrasive to the very core of their Hmong mindset and beliefs. Fadiman ultimately argues that this lack of cultural competency lead to Lia’s untimely and unwarranted death.

In Summary

This account of an immigrant family’s encounter with the American health care system may not have occurred in a “global” setting, but Fadiman’s account of a foreign family’s encounter with the American health care system delineates many of the obstacles to providing beneficial services (education, clinical care, pharmaceuticals, research) in the global arena. These obstacles may crop up anywhere that those supplying health services are unfamiliar with the cultural, linguistic, political, historical, and economic context in which they are working. In entering a foreign—read unfamiliar—setting it is essential that one enters as enlightened as possible with respect to the region’s sociocultural, historical, and political environment.

Places to start:

Read a book dealing with cultural competency in health care to get a sense of some of the more subtle problems encountered.
Recommendation: The Spirit Catches You and You Fall Down by Anne Fadiman.
- Ask around for the best local guidebook. Non-profits who work frequently in your locale of interest may have good suggestions. Get a sense for the following in general and as relates to the particular problem you are addressing (these questions are provided as a guide, but are by no means comprehensive):
- Religion:

i. What is the predominant religion in the area? Are there many conflicting religions? What position do religious leaders hold in society?
ii. What gender roles are dictated by the religion(s)?
iii. What is the religion’s approach to health care?

Government and Politics:

i. What kind of political system is in place?
ii. Has there been political instability or is it relatively stable?
iii. How long has there been turmoil/stability? Has this affected government-run entities such as public hospitals?
iv. How are people with your background perceived in the community?

Economics:

i. What is the main economic engine of the region?
ii. Is there subsistence farming or do residents rely on store-bought goods?
iii. Have there been devastating natural disasters recently? Is the area disaster-prone?
iv. Does the general population receive its share of the nation’s wealth or is money funneled from the populace?
v. Are there are a lot of NGOs working in the region? Have they been welcomed? Have they been effective?

History:

i. What is the historical context into which you are walking?
ii. What historically might affect the way the people approach health care? Foreigners? Men? Women?

Assess the local health conditions and barriers to health care via generally available databases, such as those supplied by the WHO.
Search for publications compiling research already done in your area of interest
What does this research tell you about the problems faced by communities in the area?
Has anyone looked at cultural barriers to health care?
Has research been done into local healing practices and perceptions of health?
- Does it seem to you that the problem you wish to address or the research you want to conduct is really needed or will be welcomed by the community?
- Contact someone involved in your project in-country to gain first-hand advice.

Potential Resources

Unite for Site has an online learning module on cultural competency in the international and clinical setting. This online module is free and open to all and is designed to help individuals better understand their impact on the communities in which they work. The module can be found at: http://www.uniteforsight.org/cultural-competency/
“An integrative tool that can be used to identify and remove biases in health research that derive from any social hierarchy.” Mary Anne Burke and Margrit Eichler, The BIAS FREE Framework: A practical tool for identifying and eliminating social biases in health research (Global Forum for Health Research, 2006). Available online at: http://www.globalforumhealth.org/.
Nationmaster is a site that has extremely detailed information on all matter of country specific information. You can create your own data sets and compare how a country you are heading to might compare culturally, geographically or otherwise to places you might have visited previously. Available online at: http://www.nationmaster.com

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