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Common medical issues and cultural concerns of Karen patients
The Karen are known for their friendliness, hospitality, and their traditional red or blue woven shirts and dresses. Men display elaborate, extensive tattoos, which are believed to denote character and offer protection against harm. Karen people are often recognized for the brass neck rings worn by women from the Padaung tribes. The neck rings distort the growth of their collarbones and make them look as if they have long necks. The rings do not actually stretch their necks, but squash the vertebrae and collar bones. A woman may have 20 or more rings around her neck.
Traditionally, Karen people do not have surnames, which may cause some confusion in a health care setting. They normally address each other by terms that denote kinship. Men and women are considered equal in this community. They trace their lineage through the mother and maternal ancestors. Parents, children, and grandparents often live under the same roof. In Burma, most Karen were farmers. They have little formal education and find the Western educational system and strict attendance requirement difficult and confusing.
Karen people avoid confrontation and don’t usually like talking about themselves. Public displays of anger and other negative emotions are considered shameful. They often communicate indirectly; rather than coming straight to the point, they may discuss other subjects first and may say “no” as a demonstration of modesty. Although Karen people don’t engage in public displays of affection, women are often physically affectionate with each other, naturally holding hands or hugging a female visitor. Men may hold hands with one another. Unmarried women and men do not touch, although handshaking is common when greeting Westerners.
Dress is usually conservative, with women wearing sarongs and both men and women carrying woven shoulder bags. Shoes are usually removed and left at the door. Women may sit with their feet faced away from others. When walking between others, it is considered polite to bend over so that one’s head is not above others. Stepping over people or passing things over others is considered impolite.
Many Minnesota organizations support the Karen, including the Karen Organization of Minnesota and the Karen Community Minnesota. Several churches as well as Karen people already living in Minnesota help new refugees find food, clothing, social services, and housing. Other organizations that support the Karen people in Minnesota:
Meals are served in family groups that also may include neighbors. A large container of rice is accompanied by smaller bowls of meat or fish, vegetables, chilis, fermented fish paste, and other foods and spices. In Minnesota, when Karen refugees arrive, they receive welcome packages of rice, other traditional foods, and a rice cooker from the Karen community.
In the U.S., most Karen are Evangelical Christians, with a small percentage of Buddhists and Animists. Karens make up the majority of the congregation of St. Paul’s First Baptist Church, where they participate in choirs and bands. The church helps newly-resettled refugees connect with American Baptist-U.S.A. and Cooperative Baptist Fellowship churches throughout the U.S. so they can reconnect with families across the country and around the world.
Infectious disease is the greatest health problem for Karen refugees. Other health concerns resulting from torture, rape, and other horrors of war include post-traumatic stress disorder, chronic mental health problems, injuries, and malnutrition. Karen people also are at risk of developing Type 2 diabetes, anemia, and hypertension. Chewing a derivative of the betel nut, which stimulates the nervous system and helps relieve dental pain, is a common practice among women and men. However, this practice is associated with submucosal fibrosis, oral leukoplakia, and squamous cell carcinoma.
Many Karen hold traditional beliefs about health and illness, but also believe that Western medicine can cure anything. Many became familiar with Western medical practices after receiving care from traveling medical staff working in refugee camps. Karen people seem to prefer a warm, yet business-like approach from health care providers. They often evaluate their provider from the moment of first contact.
Like many groups from Southeast Asia, Karen attribute illness to imbalance in the natural forces of wind, fire, and water. Many believe the abdomen is significant in causing and understanding illness. Menstruation is very significant among Karen women.
Providers are encouraged to choose the simplest treatment routine possible for this population, to thoroughly explain prescribed medications, and to ask the patient to repeat or demonstrate the treatment routine. Giving the patient a copy of the treatment plan may be helpful; even if the patient does not read, he or she may have a neighbor who does. Follow-up and home visits may be required. Patient education should include:
End of life
Most Karen people in the U.S. are Christian and acknowledge death according to the practices of their churches. For Buddhists, death marks transition from this world to the next. Karma, which the deceased accumulated during life begins a process of determining the next in a series of rebirths. Death provides an opportunity for family and friends to assist the deceased into a new existence. Ceremonies honoring the deceased can be held for up to 100 days after death as a reminder of life’s impermanence. A monk may offer a sermon on behalf of the deceased, and survivors may hold an almsgiving ceremony to relieve suffering and assist in rebirth. The corpse is cremated to allow the spirit to escape.2,3,4,5,6
Karen in Minnesota
Roughly 4,000 Karen (pronounced kuh REN) refugees live in Minnesota. They came to Minnesota from Myanmar, which is located in Southeast Asia between India and China, and from refugee camps in Thailand. Formerly Burma, Myanmar is still referred to as Burma by the Karen people. Karen are the largest ethnic group from Burma to be resettled in the U.S. According to the Karen Organization of Minnesota, St. Paul is home to the largest population of Karen outside Southeast Asia. Other states with significant Karen populations are California, Texas, New York, Michigan, Arizona, Indiana, Georgia, and South Carolina.1,2
The Karen people, an ethnic minority in Burma, arrived in Burma more than 4,000 years ago and have lived primarily in the eastern hill country and in western Thailand. Karen people have been fighting for independence from Burma for more than 60 years. Since 1962, Burma has been a military dictatorship. The military has tortured, raped, and killed thousands of Karen people. Many died under conditions of forced labor and month-long walks to refugee camps. In 1989, Burma was renamed Myanmar, but because of the name’s negative military overtones, most minority ethnic groups, like the Karen, refuse to use the new name.
The Karen are often referred to as the indigenous people, or hill tribes, of Burma—but they do not refer to themselves as Burmese—they identify themselves with their ethnic group. The Karen population consists of smaller subgroups of people who speak different dialects. A common interpretation problem is expecting one person from Burma to understand another, and because the cultural rift between Karen and ethnic Burmese runs very deep, Karen often prefer no interpretation assistance to assistance from another Burmese ethnic group.
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.
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 accounted for. 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.
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