An Excerpt of 

A Case of Culture

Introduction

I couldn’t breathe. My nose was so stuffed with boogers and snot that the only way I could breathe was to keep my mouth open and pant like a dog. The hairs on my seven-year-old arms stood up, forming small goosebumps all over.

“Amma,” I wheezily tried to shout. No response. “Ammaaaaa!”

I lay shivering under my pink flower-printed blankie for what felt like hours, hoping that someone would come to my rescue. At long last, I heard the thump of footsteps and the jingle of Amma’s bangles as she walked toward my room.

“Vaana lo thadavaddhani cheppana? Didn’t I warn you about playing in the rain?” Amma chided me. “Now the rain got you wet and gave you jalubu (common cold).”

I nodded, my teeth chattering from the cold.

“Undu, vedi vedi ga miriyala paalu theeskostha. I will bring some warm pepper milk for you.” She left the room toward the kitchen to make the miriyala paalu.

After some minutes, Amma returned with a small steel glass in her hands and sat next to me on my twin-sized bed. I peered into the glass and found a pale brown-colored liquid with small black specks floating in it.

My nose scrunched up in disgust. “Naaku odhu! I don’t want it!” I wailed.

“If you want to feel better, you have to drink it,” Amma said.

According to Amma, miriyala paalu, like ripe mango and dried coconut and rasam (a spicy watery tomato soup popular in South India), was a “hot” food that would increase my body heat and cure my cold. Bananas and fennel seeds and perugu (plain curd), on the other hand, were “cold” foods that would reduce body heat and cure a fever or sore throat. I didn’t know much about the Ayurvedic principles behind these practices. All I knew was that I would never play in the rain again if it meant I would have to drink miriyala paalu.

I sat silently next to Amma, considering my options. I could either brave the miriyala paalu concoction, or I could stay here shivering under my blankets. After some deliberation, I conceded.

“Only if I get to watch Hanuman after,” I countered. I had seen this cartoon movie at least fifty times already, yet it remained my favorite. I stretched out my tiny hand and held the small steel glass. The warmth of the glass in my hands felt amazing. I put it to my lips and took a sip. It tasted exactly as I imagined it would. It was spicy and warm and burned my throat as I swallowed it. A small piece of black pepper ball got caught in my throat and I started gagging.

“Amma!” I wailed. “I don’t want to drink it anymore!”

“Please, thalli. Naa kosam. For me.”

​

I pinched my nose and gulped down the rest.

***

My family’s medicine cabinet was never stocked with Tylenol or Dayquil like in other homes. Instead, jars of turmeric, dried basil leaves, black pepper balls, ginger powder, kasturi pills, and other kitchen ingredients lined the shelves of our bathroom. This is the approach to health that my family has preserved for generations. In my family where tradition and culture are kept alive through a myriad of ways, Ayurveda had also worked itself into our daily practices. My family trusts our turmeric more than any Tylenol to keep us healthy because it is what we know best. It is our familiar.

Consequently, my brother and I grew up with an unfamiliarity of most over-the-counter medications. I had only taken Tylenol around ten times my entire life, the majority of those times having taken place in the last couple of years after I moved out of the house.

According to a 2014 study by pharmacologist Martins Ekor, it has been estimated that up to 80 percent of the world’s population in the Global South relies on herbal remedies as their primary source of healthcare and views traditional healing practices as an important part of their culture. When these families emigrate from the Global South to other countries, they carry their culture with them, herbal remedies and all. In my family, our healing traditions were very much a part of our culture and practices. My family didn’t see value in using medication for something we could heal using ingredients we already had at home. They had been passed down to us across generations through the experiences and wisdom of our ancestors. If our methods worked for our grandparents and great-grandparents and great-great-grandparents, why wouldn’t they work for us?

Not to mention, our traditional methods of healing were much more affordable and easier to obtain compared to medications from the pharmacy. We didn’t have to drive to the nearest CVS in search of Neosporin or Tums that would expire in a year or two anyway. We had our own medicines right here in our kitchen: a mixture of pasupu (turmeric) and kobbari noona (coconut oil) in place of Neosporin, and kasturi pills (small black balls made of a concoction of dried spices and herbs) in place of Tums.

When the time came for me to leave for college, Amma packed my suitcases with many small glass jars and Ziplocs filled with turmeric, ginger powder, kasturi pills, basil leaves, and all the other ingredients that would help protect me against the dreaded dorm room germs. For the first two years of college, I somehow managed to escape the need for these items, but my luck ran short in my third year.

I came down with the flu in mid-March, the day before my a cappella group’s biggest concert of the year. How wonderful. Not only did I have chills and a sore throat, but I also lost my voice. I had never experienced this before, so I was particularly horrified when I opened my mouth to speak and nothing but a small croak escaped. How in the world would I recover in time to sing my solo tomorrow?

For the first time, I opened the jar of ginger powder that Amma had packed in my suitcase. It was tightly sealed shut from the years of being left unopened in the back of my dorm room dresser. I made myself a concoction of ginger tea with honey to drink at bedtime with the hope that I would feel better in the morning.

I woke up the next morning feeling just as crappy as I did the day before. The good news was that my voice had returned. The bad news was that I had a 101-degree fever and was too fatigued to even sit up, let alone perform on stage for three hours. Not to mention, I didn’t think I would be able to hit any of the high notes in my “Hallelujah” solo. I made myself some more ginger tea as I deliberated. Should I call the musical director and let her know I couldn’t make it? Or should I just suck it up and do my best, even if I end up sounding like a dying hyena on stage for my last concert ever? I was frozen with indecision.

Taylor, my roommate, saw me sitting in my bed with my cup of tea, clutching my head.

“Isn’t your concert tonight?” she asked.

“Yeah,” I groaned. “I don’t want to miss it, but I may not have a choice.”

“You look terrible. Did you take Tylenol?”

I shook my head no.

“Girl. How are you gonna be a doctor and prescribe medications to others if you won’t even take them yourself?”

Taylor had a point. I wasn’t comfortable with taking over-the-counter medicines because it was something I never grew up doing, but I had already tried my home remedies the night before and they were unsuccessful. Besides the return of my voice, I wasn’t feeling much better. I was in a race against time to get well before my concert that evening.

She handed me a Tylenol and told me to get some sleep. The least I could do was try. If it worked, great. Otherwise, I’d be in the same boat as I was now. I gingerly took it, swallowed it down forcefully with some water, and got back under my blanket.

Several hours later, my alarm rang. I woke up from my nap, and to my surprise, my head was no longer pounding. I was able to stand up without keeling over, and my fever had mostly subsided. I wondered how it was possible that a single pill was enough to do the job. Maybe it was just some really strong Tylenol. Or maybe it was that my body had no tolerance to Tylenol because I never grew up taking it. Or maybe, just maybe, my ginger tea and extra hours of sleep were starting to kick in.

I rushed to get ready and headed to the concert hall in my heels and black gown. Though I still wasn’t feeling my best, I was able to sing my “Hallelujah” solo and hit all the high notes, which was much more than I could have hoped for that morning.

To this day, I can’t quite articulate why I hesitate to use medication. Logically, I know that these medications have passed many checkpoints in clinical trials, but for some reason I still instinctively reach for the ginger powder before the Tylenol. Even though I was born and raised here in the United States, my cultural upbringing has pulled me toward the health attitudes and beliefs I hold today.

This episode was an important step for me in realizing that unless I made peace with my own conflicting views of medicine and healing, I could not expect my future patients to do so either. Yet at the same time, I realized that this process of learning to balance my own cultural beliefs with my health needs has equipped me to be a more effective advocate to those patients who face similar dilemmas.

***

​

The United States is a country of ever-increasing diversity. According to the 2000 US Census Bureau, there were around seventy million people from nineteen non-European ethnic and cultural groups living in the US. With each of these groups comes a unique set of cultural beliefs about health and illness. Some swear by using antibiotics for every condition, while others won’t even touch a medication unless it is all natural. Some believe that illness is due to an imbalance of good and bad energies, while others believe that illness is caused by evil-eye or dark spirits. Some prefer that family members or elders take care of the individual’s health-related matters, while others forbid disclosing anything about one’s personal health to even the closest of family.

As you can imagine, it is close to impossible for people from every one of these diverse cultural groups to find a physician that knows and understands the cultural beliefs they hold about health and illness. Similarly, it is close to impossible that a physician is competent and knowledgeable about the cultural beliefs of every single patient they see.

At the end of the day, what patients want is to be listened to and understood by their physicians. Likewise, what physicians want is to help empower their patients toward taking ownership of their health in the way that best fits their needs and goals. But when there exists a discrepancy in language and literacy, distrust of the medical system, unfamiliarity with Western medical practices, differences in health beliefs, varying emotional states of mind, and many other barriers to communication, it can be extremely difficult for the patient to open up with their doctor. To top it off, our physicians work in a healthcare system that burns them out, that prioritizes quantity over quality, that gives them ten to fifteen minutes per patient max (Linzer, 2015). With all of this on the plate, the patient’s hope of being understood threatens to become just that...a lost hope.

A very special group of people ensures that patients can receive the culturally concordant care they need: cultural brokers. According to the Jezewski model, cultural brokering is defined as “the act of bridging, linking, or mediating between groups or persons of different cultural backgrounds for the purpose of reducing conflict or producing change.” The practice of cultural brokering is actually quite ancient, dating back thousands of years to the first recorded encounters between groups of different cultures. From encounters between ancient Macedonians and Persians in the third century BCE, to those between Anglo-Europeans and Native Americans in the eighteenth century, cultural brokers were crucial to bridging divides across these cultures in order to enact change and mediate conflict.

The term “broker” is used in many industries and contexts to refer to the middleman who facilitates the flow of information between two parties. For example, brokers are an important part of the financial and real estate industries because their knowledge of both buyers and sellers allows them to serve as an effective means of communication. The buyer may not understand all the jargon and technical terms that a seller uses, or perhaps the buyer is unable to make a financial negotiation because he lacks the necessary knowledge. In such cases, the broker steps in to help the buyer make sense of the various industry rules and regulations, explaining them in layman’s terms. By helping ease communication and build trust between the buyer and seller, the broker helps to establish a meaningful relationship between the two parties.

In a similar vein, cultural brokers facilitate between the culture of the (often) foreign-born patient, the culture of the host country where the patient seeks care, and the culture of the healthcare system itself. Sometimes the patient may not agree with what the doctor suggests because it is at odds with their cultural beliefs. Other times, the patient may be overwhelmed by the many moving parts of a foreign healthcare system and needs help with navigating it. In such situations, the cultural broker steps in to ease these interactions between patient and provider, mitigating any misunderstandings that may arise in the process. This process of cultural brokering in the healthcare system can be carried out by anyone who has an understanding of both cultures. This might be an interpreter, a priest, a patient advocate, a family member, and sometimes even the doctor themselves.

As every child of immigrants knows (myself included), playing broker becomes second nature as we help our families navigate the challenges of living two cultures at once. But it wasn’t until I entered my current professional role as a patient advocate that I came to realize exactly how irreplaceable our cultural upbringing and experiences are in the healthcare setting. I understood diabetic Mr. M’s cultural attachment to rice. I encouraged turmeric-reliant Ms. B to get vaccinated against COVID-19. I saw first-hand the amalgamation of cultural, linguistic, and spiritual barriers that exacerbated the health conditions of our immigrant patients, and I realized how my dual-identity upbringing had equipped me to help our patients overcome these barriers.

Some people believe that having a cultural broker, having this extra third wheel, gets in the way of the sacred patient-doctor relationship, but I disagree. I believe that having a cultural broker enhances the patient-doctor relationship. The cultural broker encourages the patient to be more open and communicative with their doctor, assuring them that their doctor can and will help them achieve their health goals. Likewise, the cultural broker educates the doctor about the cultural beliefs of the patient that might conflict with the care being provided. Cultural brokers are important for helping both patients and doctors navigate their care accordingly. Just as the doctor’s goal is to treat their patient so well that the doctor is no longer needed, the broker’s goal is to facilitate such a trusting and open patient-doctor relationship that the broker is no longer needed.

There is an ever-increasing plethora of data and research on the importance of culture and diversity in providing healthcare, but it is the stories of these middlemen that get lost in the fray. So, I wrote this book about us, the oft-forgotten cultural brokers. I wrote this anthology of personal narratives, positive experiences, and cautionary tales with the hope of bringing to light the countless efforts of cultural brokers in healthcare. Whether it’s the son who encourages his Italian father to open up to his doctor about his medication noncompliance, the Mongolian interpreter who assures her patient that HIPAA would protect her personal health information (unlike in her home country), the Internal Medicine intern who encourages his patient to open up about her heavy period (a culturally stigmatized topic) with her doctor, or the ICU hospitalist who calls her patient “Aunty” to help her feel more at home in this strange environment and new country, each of the stories in this book shares the importance of the cultural broker in building, facilitating, and enhancing the patient-doctor relationship.