CULTURAL DIVERSITY
How Tribal Customs Affect Communication
Navajo Indians believe language and thought are powerful: They shape reality. So how do healthcare professionals fulfill their responsibilities, such as discussing health risks, negative information, or advance directives, without offending or frightening a people who believe healing requires them to focus on the positive —
hozhooji nitsihakees (think in the Beauty Way) and
hozhooji saad (talk in the Beauty Way)?
To learn the Navajo perspective on negative health information and to examine the limitations of Western bioethical perspectives, Joseph A. Carrese, MD, and Lorna A. Rhodes, PhD, interviewed 34 Navajo men and women, 8 of whom were biomedical healthcare providers.
Indian Health Service policy states that tribal customs and traditional beliefs should be respected when talking to patients about death and dying. Still, healthcare professionals must uphold the Patient Self-Determination Act, which was put in place to encourage adults to write advance directives, Carrese and Rhodes report in JAMA.
Of the 22 participants in the study who were asked about advance directives, "only three (14%) found the idea somewhat acceptable," write the authors. Ten participants would not even discuss the issue, saying it was too dangerous. However, those interviewees who were Indian Health Service employees and trained in the Western biomedical tradition did point out that issues such as living wills and power of attorney somehow need to be broached "with every patient."
Carrese and Rhodes indicate that the persons they interviewed represent a more traditional yet widely held perspective. Still, they write, some Navajos "may be comfortable with and even expect frank discussion about the risks of medical treatment."
Although "explicit and direct discussion of negative information between health care providers and patients is the current standard of care, . . . a deeper understanding of patients' perspectives . . . should be used to inform clinical interactions, research and educational activities, and institutional policies," the authors conclude.
MENTAL HEALTH
Ecopsychology
Communing with nature — a walk in the woods or organic gardening — will improve your mental health. This is the thinking of ecotherapists, those who "consider their clients' relationship with the natural world in their efforts to pinpoint sources of problems," writes Timothy Aeppel in the Wall Street Journal. Such therapists believe many of our fears, dreams, and griefs are environmental in origin.
Such a perspective is still not widely accepted. "Some psychiatrists worry ecopsychology may be used to push an environmental agenda on patients," reports Aeppel. Indeed, some ecotherapists treat the overconsumption or amassing of material goods as an addiction. Although there are no facts to confirm this theory, "it's a very seductive notion," states Atlanta psychiatrist Randall White.
Despite its detractors, ecotherapy appears to work for some clients. One woman, who reported becoming depressed when she thought about contaminated water or birds covered in oil, says, "I feel better than I have in years." She now walks five miles in the park each day and writes letters to politicians and businesspersons, making them aware of her opinions on environmental issues. "It beats the heck out of taking Prozac," she quips.
Therapists are not the only ones jumping on the ecopsychology bandwagon. Aeppel writes: "Many environmentalists also are embracing ecopsychology as a way to better understand how people think about green issues."
FAMILIES
Growing Old Poor and Alone
Elderly people have traditionally relied on emotional and economic support from their children and grandchildren. But, writes Shannon Dortch in American Demographics, changes in contemporary kinship patterns threaten this tradition. Such changes — especially if combined with a breakdown of the U.S. Social Security system — could leave the elderly of the next century in a bad way.
Dortch cites the work of Kenneth W. Wachter, a demography professor at the University of California at Berkeley who has made projections for the year 2030 based on current trends.
Wachter notes that although adult Americans of the prosperous years 1945-60 tended to have large families, their children — the "baby boomers" — have been less fertile. And the trend toward small families has apparently continued. Twenty percent of family households had three or more children in 1970; only 10 percent of such households were as large in 1993.
In 2030 the oldest boomers will be in their eighties. Wachter predicts that the number who survive into late old age will be larger than in previous generations. But, because they have been less fertile, they will have fewer surviving children and grandchildren to aid and protect them. The boomers' smaller kinship networks will likely leave them more vulnerable than their parents were.
But if boomers have produced relatively few children, they have been parents to more stepchildren than were earlier generations, since boomers have divorced more often. Wachter suggests that these stepchildren may provide support for the aging boomers.
However, notes Frank Furstenberg, a sociology professor at the University of Pennsylvania in Philadelphia, the kinship bonds between stepparents and stepchildren are usually not as strong as those between parents and biological children. And increasing social mobility — the fact that families are so easily scattered — makes it unlikely that either their children or stepchildren will be available to aid the boomers, Furstenberg says.
WORK
Capitalism without Sleep
The Chernobyl, Bhopal, and Exxon Valdez disasters all happened on the night shift. Even so, U.S. businesses are increasingly moving to 24-hour operations, according to Jaclyn Fierman in Fortune. She cites a report from International Data Corporation, a Framingham, MA, research firm, which estimates that more than 40 percent of large companies now conduct at least some of their business at night.
Among round-the-clock employers are:
- L. L. Bean, the Maine-based seller of outdoor goods. A pioneer in 24-hour operations, Bean now does nearly 40 percent of its business after hours.
- Baybanks in Boston, which has an 800 number that offers customers a variety of 24-hour services. The volume of business thus generated equals that of 30 bank branches.
- Heartland Golf Park on Long Island, NY. The course, which is artificially lit and lets customers tee off until 3 am, is popular with workers coming off the midnight shift.
- Toyota's plant in Georgetown, KY, which operates a "night care" center for the children of workers on the 5:15 pm-2 am shift. The center tries to keep the kids awake (except for a two-hour nap at midnight) so that they and their parents can hold to more or less the same schedule.
Around-the-clock business has its critics, including some psychologists and physiologists who argue that new Chernobyls could be the result of upsetting natural sleep habits. But profits are often great for companies willing to operate on a 24-hour basis. That guarantees there will soon be even more of them.
Copyright © 1995 by the Catholic Health Association of the United States
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