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Common medical issues and cultural concerns of Bhutanese patients
Nearly all Bhutanese refugees in Minnesota speak Nepalese, with 35 percent estimated to know some English. Most are identified as farmers or students, but also list other occupations, such as teachers, social workers, tailors, weavers, and housekeepers.
A caste system practiced in Bhutan separates people into social levels. In the refugee camps, caste systems were banned and no longer exist in most daily activities, although it still may be reflected somewhat in marriage practices, arranged and early marriages, the occasional practice of polygamy, and in death rituals.
A typical Bhutanese household consists of a father and mother, elderly parents, children, and the wives and children of married sons. Aunts, uncles, and cousins are considered part of the immediate family. Men tend to hold a larger role in the family, with women having less access to information and resources and less decision-making authority in the family and in the community. Women and girls often carry a heavier household workload.
After marriage, women traditionally move to their husband’s home. If polygamy is practiced, the two wives often are sisters or other blood relatives, or one of the women may be disabled. Widows cannot remarry, and often become dependent on their sons. Divorced and widowed women have a low position within the family and often raise their children alone, without the support of family members. A female victim of sexual abuse and her family may be harassed and ostracized by the community.3,5
A typical meal includes rice, lentils, and curry. In accordance with Hindu beliefs, the Bhutanese believe the cow to be sacred and do not eat beef (or pork). Non-vegetarians may eat chicken or goat. Most refugees are unfamiliar with modern cooking appliances and have a limited knowledge of urban life and life in the West. In the refugee camps, they cooked with charcoal and solar rice cookers.
Although nearly all Bhutanese arrivals to Minnesota are Hindu, some believe in Buddhism and Shamanism. A shaman is a religious leader who acts as a medium between the visible world and an invisible spirit world. He practices rituals and makes all decisions related to spiritual healing and religious ceremonies. Hindus believe in one God, but also worship many forms of gods and goddesses in temples or at home and read from holy scriptures, such as Vedas, Upanishads, and Gita. Among many festivals and celebrations, they celebrate births with naming ceremonies, deaths, the lunar new year, and the Festival of Lights. Animals are frequently sacrificed during festivals and marriage ceremonies.
According to the World Health Organization, in 2006, the most common health problems in Bhutan were the common cold, skin infections, diarrhea, peptic ulcers, tonsilitis, as well as musculo-skeletal diseases, digestive system diseases, respiratory disease, and conjunctivitis. Other health concerns include Dengue Fever, malaria, tuberculosis, pneumonia, intestinal worms, and hypertension. Rates of influenza, diabetes, cancer, and HIV/AIDS tend to be low in this population.6
Health care providers should be aware that illnesses may go undiagnosed in this population because many Bhutanese refugees are reluctant to seek care. They often practice a traditional medicine of faith and spiritual healing, but also have been exposed to modern medicine while living in refugee camps. They have experienced physical exams, screenings, transfusions, and surgeries.
Traditional Hindu belief attributes illness to karma—the result of wicked or unscrupulous actions performed in past lives. Hindu medicine may employ astrological readings, use of spices and herbs, recitations, yoga, and other ritual practices.
The processes of pregnancy, birth, and death are commonly believed to be spiritually impure. A pregnant woman is not allowed to visit another home until a certain ritual is performed. If she visits a neighbor’s house and sickness or death of the neighbor follows, she can be held responsible. The Bhutanese also consider issues such as physical and mental disability, illiteracy, and experiences of torture to be shameful and should be hidden.
Elderly Bhutanese who speak no English are prone to depression, having little opportunity to go outside and feeling isolated in their apartments. And Minnesota’s cold weather is a shock to a population accustomed to a warm climate.
End of life
Health care providers caring for members of this population should be aware that Bhutanese families often prefer not to tell their loved one that death is imminent.
Nearly all Bhutanese in Minnesota are Hindu. Hindus believe in reincarnation—that although the body dies, the soul lives on. When a loved one dies, family members often take an active role in performing religious rituals, conducting astrological readings, and washing and dressing the body before it is cremated. Autopsy and organ donation are unacceptable to practicing Hindus.
Astrological readings are most crucial at the time of death. The astrological reading dictates when a dead body can be taken out of the house, the direction, by whom, and when it can be cremated. Rituals are performed on the 7th, 14th, 21st, and 49th days. It is believed that any ritual performed for the benefit of the dead has to be done by the 49th day, after which the soul of the person realizes that he or she is dead and moves on to the next birth, or that karma then will decide his or her fate. After one year, and for three consecutive years, an anniversary ritual is performed, after which families believe the soul has finally moved on into its next stage.
Bhutanese in Minnesota
The Bhutanese are a refugee group new to Minnesota. Since 2008, nearly 400 Bhutanese refugees have settled in the Twin Cities area, primarily in East St. Paul, Minneapolis, Roseville, and Lauderdale. Bhutanese refugees have also settled in Texas, New York, Georgia, Arizona, Pennsylvania, and California.
Most Bhutanese refugees in Minnesota are from Southern Bhutan. Bhutan is a tiny, isolated country, located in the Himalayan mountain range between China and India. Although a small country, Bhutan has generated one of the highest numbers of refugees in the world in proportion to its population, and is one of the largest refugee groups being settled by the U.S. Refugee Program. In 2008, the U.S. began to resettle 60,000 Bhutanese refugees, primarily the Lhotsampas (“loh-CHAHM-pahs”) people, one of Bhutan’s three main ethnic groups.1,2
Since the early 1990s, thousands of Lhotsampas have been forced to flee persecution in Bhutan. More than 108,000 people, including 40,000 children, have spent nearly 20 years living in U.N. refugee camps in Nepal. Often portrayed as a “Shangri-la,” or “jewel of the Himalayas,” Bhutan is responsible for severe human rights abuses of its own people. To maintain a dominant political position and the traditional culture of the Druk people, the ruling elites passed denationalizing laws, known as Bhutanization, to impose a one-nation, one-people system. The government established new eligibility requirements depriving the Lhotsampas of their citizenship and civil rights. The Lhotsampas language and culture were outlawed, books were burned, and television was banned. Thousands were arrested, tortured, raped, and killed. After forcing the Lhotsampas to sign voluntary migration certificates, they were expelled from the country.
Recently, the government lifted some restrictions and even instituted an official quality of life measurement, called the “Gross National Happiness.” Many refugees would like to return to Bhutan, but despite 16 years of negotiations, not one refugee has been allowed to return.3,4
Culture in context
Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community.
Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients.
In order to provide equitable and effective health care, clinicians need to be able to function effectively within the context of the cultural beliefs, behaviors, and needs of consumers and their communities. According to the 2002 Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, racial and ethnic minorities tend to receive lower quality health care than non-minorities even when access to insurance and income is provided. Failing to support and foster culturally competent health care for racial and ethnic minorities can increase costs for individuals and society through increased hospitalizations and complications.
Resources regarding Bhutanese in Minnesota
Following are some of the Minnesota organizations that are aiding in Bhutanese refugee resettlement:
Bhutanese Refugee Families. A cultural backgrounder on Bhutanese refugees focused on early childhood, with discussions on health and mental health. Created by Bridging Refugee Youth and Children's Services and the Office of Head Start’s National Center on Cultural and Linguistic Responsiveness. (4-page PDF)
Bhutanese Refugee Health Profile. From the Centers for Disease Control and Prevention (CDC). (20-page PDF)
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