Ethnic Matters

In the 19th century about one third of the map of the world was coloured pink to indicate that it was part of the British Empire. Our nation has been a mixture of races over the millennia but the past 50 years have seen considerable immigration, mostly but by no means entirely, from countries that were formerly part of the Empire. The cultural mix of this country is a very rich tapestry. Some people are recently arrived and perhaps asylum seekers fleeing persecution and severely traumatised. Recently we have seen an influx, not from the Commonwealth, but from Eastern Europe with new members of the EEC. Some have a different culture and race from the majority in this country but have been here for generations.

People from different ethnic backgrounds are not spread evenly throughout the country. Some areas have high levels of ethnic mix and certain groups tend to congregate in certain areas.

The General Practitioner has to have a holistic approach to patients and that includes an insight into cultural background and beliefs. This is not merely political correctness but may have an important bearing on medical practice.

Communication is fundamental and a clinician has to be certain of understanding the patient and being understood. Regional accents can be difficult enough for those brought up with English but for someone whose first language is not English, they may be quite incomprehensible. Sometimes it is necessary to use interpreters but there are problems attached. Not only do they represent an obstacle to patient confidentiality but they may have a tendency to put their own interpretation or "spin" on what both the patient and the doctor say so that what is repeated is not a faithful translation.

It is also important to remember that if everything that is said needs to be translated the consultation will take at least twice as long.

Sometimes a doctor will come across such problems as a woman who speaks no English and so she brings her 12 years old son to interpret for her about her menstrual problems and he has no idea about the concepts involved.

The NHS has provided a very comprehensive translation service for a number of years. If a patient calls NHS direct and is able to say in English the name of the language he or she wishes to use, a consultation in that language is available.¹ This service has been severely criticised on two grounds. Translation services cost the NHS alone at least £55 million each year and as the NHS has a finite budget, money spent on translators is money not available for clinical activity. It is also argued that the ready availability of this service discourages some from learning English as they should.

People from different cultures tend to be very deferential towards doctors. There may also be an expectation that the doctor will be able to solve all their problems, even if they are not strictly medical, and the expectation that every consultation will end with a prescription. It was not long ago that this was true of the indigenous population too.

We may find the attitude of some cultures to pain is somewhat histrionic and be scathing of it. The British tradition of "the stiff upper lip" is not shared by all. Other peoples are rather more flamboyant in their expression of pain or grief. Findings on physical examination such as guarding, may be more important. It may also be necessary to distract the patient during examination to get relaxation and then a spontaneous response.

In most cultures the family unit is rather stronger than our own. This may portray the father figure as rather arrogant and authoritarian whilst women are very meek and submissive. They may be discouraged from independence including work, association outside their own narrow sphere and even learning English. This can produce psychosomatic problems. Children may be overprotected at an early stage but then expected to take on adult responsibilities such as working late in a shop in ways that we would find unacceptable. In the tight family unit, it would be seen as a failure to have an elderly relative admitted to a residential home and they will look after their own old people.

Education is highly valued amongst immigrant communities as the way up in their new society. This is to be admired but it can lead to unrealistic expectations and pressures on young people whose academic abilities may not match expectations. This may manifest itself in illness or even suicide.

There may be pressures and cultural clashes at school if they try to behave like their peers. In many cultures, including ours until quite recently, virginity was expected at marriage. There may be antagonism from their parents towards dating across racial boundaries and this may occur on both sides of the line. There are bound to be clashes and resentment when they see their friends having freedoms, including choosing whom they shall marry, when they are expected to have an arranged marriage. A doctor may even be asked to perform an intimate examination to confirm a girl's virginity. The ethics of this need careful consideration.

Culture and religion may cause problems in the field of physical examination, especially intimate examinations, if the doctor and patient are of opposite sex. Respect the patient's dignity and try to find ways around the problem.

We live in a secular society in which most people have no particular adherence to any religion but we must be aware of the implications of religion where there is impact. Adherents of any religion vary in their zeal. It is important not to stereotype. The portrayal of Moslems and Jews is sometimes no more real than to pretend that the "Religious Right" in the USA represents Christianity.

The dietary demands of Moslems and Jews are similar with Halal and Kosher respectively. Both religions regard anything from a pig as profane. Hindus revere the cow and like Buddhists are usually vegetarian.

Many Sikhs keep their hair short but the orthodox teaching is that they should never cut their hair or shave their beard.

Islam has a fast called Ramadan that lasts for a month. The time of year varies as it is based on the lunar calendar. During the hours of daylight, that might be quite extensive in the summer, they are forbidden from ingesting anything. They are not allowed to eat, drink or smoke. It may cause problems with regard to medication or the control of diabetes. It is important to realise that Ramadan is a discipline and is not expected to make the adherent ill. Those who are ill are not expected to conform. If a Moslem patient needs to take medication including injections during the fast he should do so. Ask him to discuss it with his religious leaders if there is doubt. The following are exempt from fasting:

• Children under the age of puberty although they may have a limited fast
• People who are mentally incapacitated or not responsible for their actions
• The elderly
• The sick
• Travellers who are on journeys of more than about fifty miles
• Pregnant women and nursing mothers
• Women who are menstruating

Those who are temporarily unable to fast should make up for it later.

Jehovah's Witnesses are a small sect of Christianity who maintain that the spirit is in the blood and hence it is unacceptable to perform blood transfusions. They also reject organ transplantation. They are often of Afro-Caribbean descent. If they wish to suffer ill-health or even death by refusing blood transfusion that is their right but they do not have the right to let their children die. If parents refuse a blood transfusion for a child and the doctors maintain that it is necessary to save the child's life, it is possible to have the child made a ward of court to give the court the right to make that decision.

Many religions are opposed to termination of pregnancy, and not just Christianity. The official position of the Church of England on this matter is not much different from the Roman Catholic Church. Any decision about TOP in almost any culture may be against a background of religious guilt, even from those whose religious adherence is distinctly lapsed. The woman must be allowed to make up her own mind without undue pressure from others and the doctor should be very careful not to try to impose his or her own moral view. It is the woman who has to live with the decision whichever way it goes.

The Roman Catholic Church is renowned for its opposition to contraception. It does allow use of the woman's menstrual cycle to permit sexual intercourse without great risk of conception but it does not permit barrier methods including condoms or caps, hormonal contraception of IUCDs. The permitted methods are often referred to as "natural contraception"² although such techniques as being a DIY Gynaecologist to test the viscosity of one's own cervical mucus before making love may seem anything but natural. The opposition of the Church of Rome to contraception has led to disinformation about condoms undermining the fight against AIDS. This is discussed much further and with references in the article about AIDS.

Problems of culture and religion may make it difficult for patients to admit to such matters as homosexuality, premarital sex, alcohol abuse or even depression. Sensitivity is required.

Circumcision may be performed for religious, hygienic or medical reasons. Jewish boys are circumcised on the 8th day of life. Moslems usually do it between 10 and 12 years old. It is not a requirement for Christians. It is often practised as a coming of age ritual in adolescent boys in sub-Sahara Africa. Usually the operations are performed by the ministers of religion for whom the appropriate surgical training is part of their theological studies. If parents want a medical practitioner to perform the operation, it may be done although if the operation is not for medical reasons, it should not be done under the NHS. However, many doctors have ethical concerns about circumcision for reasons that are not medical, especially as the child is not able to give consent.²

Male circumcision performed by an unskilled person risks complications. Usually these are remediable by revision surgery. What used to be called female circumcision is another matter and it is nowadays more correctly referred to as female genital mutilation. It involves damage or destruction to the whole clitoris and the surrounding area. Complications include dyspareunia, dystocia and other psychological and physical problems. It is practised in parts of Africa, especially Sudan and Nigeria. It is estimated that there are about 132 million cases worldwide. It is discussed more fully and with references in vulval abnormalities and their management.

The diversity of racial groups produces not just diversity of culture, but we are more likely to see new diseases. Some diseases are commoner in people of certain races. Inter-racial marriage (or at least reproduction) may spread the gene pool to those who do not at first seem to be from the vulnerable race.

Sickle cell disease occurs in people whose ancestors lived in West Africa. That may have been many generations ago but the gene persists. Thalassaemia is also more prevalent in people of certain races, the type and prevalence varying between places of origin. Diabetes is especially common amongst those whose origins are from the Indian subcontinent.

Both immigration and foreign travel, which for some people may mean "returning to their roots", may introduce exotic tropical diseases. This country sees over 2,000 cases of malaria³ a year. Many are travellers who failed to take prophylactic medication for the full time as prescribed but some have returned to their homeland and not bothered as they had not formerly needed it. They must be told that without constant exposure their immunity is lost. We may see diseases such as schistosomiasis or amoebiasis. A history of travel may be important from people of all races.

Dark skinned people who habitually cover up may lack vitamin D in temperate climates and rickets⁴ has been reported, especially with a high consumption of chapattis that are high in phosphate. The race of the patient may be a consideration in deciding the best treatment for hypertension.

As doctors we have to consider the race, culture and religion of our patients. That is not to condone bigotry. We see the patient as a whole person and do what is best for the welfare of that person. We communicate. We understand. We do not impose our views but understand the needs and beliefs of our patients. This does not prevent us from expressing an opinion when we feel that someone is severely misguided.

Being liberal in outlook does not mean that culture or religion can be used to tolerate any behaviour. The GMC, the law of the land and many others take a very firm line on female genital mutilation. An adult Jehovah's Witness may be permitted to refuse a blood transfusion and to die but the state will override a parental wish that a child should be allowed to die. If a doctor learns that one of more of his patients is inciting violence or planning terrorism he has to consider the balance between patient confidentiality and duty to the community. Under such circumstances, duty to the community will almost certainly prevail.

Tolerance is a great concept but it must be a two-way process. Many people who wish to be tolerated must also learn to tolerate others.

Large numbers of immigrants, many of different race and cultures, are bound to be the subject of concern and even antagonism and outright hostility. So far, the British people have been comparatively tolerant, despite the best efforts of certain sections of the press. Fear and hatred result from ignorance and when people get to know one another they realise that they are not as bad as they may have seemed from afar. One of the songs from Hair, a musical from the 1960s, proclaimed that "What we need is a great big melting pot", "turning out coffee-coloured people by the score." This is totally untrue. Racial harmony does not require interbreeding or a pretence that there is really no difference between us. It means accepting people for what they are. However, when communities are too separate and aloof and appear to live in ghettoes, distrust and suspicion abound.

In recent years there has been a feeling amongst some members of the Moslem community that the British government's foreign policy is anti-Islamic, particularly after the invasion of Iraq. Analysis of policies towards Israel and the rest of the Middle East may show some justification in this view. There is no justification for acts of terrorism that have threatened to alienate large sections of society. The moderates within those societies must condemn most vocally those who pervert their religion to preach hatred.

There is no reason why people should not choose to bear some emblem of their religion just as some choose to advertise the football team that they support. Wearing jewellery in the shape of a cross or a Star of David is distinctive but discreet. Hindu women have a dot in the middle of their forehead to show that they have been at prayer. The beard and turban of a Sikh is most distinctive but it does not prevent communication. Neither does a headscarf but a full veil or a burka do. Would anyone have commented if Jack Straw had asked a motor cyclist to remove his crash helmet? A veil sets the wearer apart and aloof from those around. The concept that it is necessary to prevent unwelcome advances is grossly insulting to men.

We need to understand the roots of anxiety and enmity but this needs reciprocation. Tolerance must be bilateral. The zealots of political correctness who imply that only white people are racist, that only men are sexist and that there should be freedom of religion so long as it is not Christianity must also be expunged. All giving with no reciprocation will only encourage extremists. There are times when we need to stand firm to the principles of common sense and the freedom of the majority, not just the few. People have rights but also responsibilities.

Doctors can set an example by the way they practise and the way they run their practices. They are also respected in society and can use their position to advocate sanity.