• “White” individuals are people whose origins are in any of the original peoples of Europe, the Middle East, or North Africa. This includes individuals who indicated their race or races as “white” or their original nationality as English, Italian, French, Dutch, Scottish-Irish, Scottish, Irish, Swedish, Norwegian, Spanish, German, Italian, Polish, Lebanese, Near Easterner, or Arab.

• “Hispanic/Latino” individuals are from Cuba, Mexico, Puerto Rico, South or Central American, or other Spanish culture or origin regardless of race.

• “Black or African American” refers to a person having origins in any of the black racial groups of Africa. It includes people who indicated their race or races as “black, African American, or Negro” or reported entries such as African American, Kenyan, Nigerian, or Haitian.

• “American Indian or Alaska Native” refers to a person having origins in any of the original peoples of North and South America (including Central America) and maintaining tribal affiliation or community attachment. This category includes people who indicated their race or races as “American Indian or Alaska Native” or reported their enrolled or principal tribe, such as Navajo, Blackfeet, Inupiat, Yup’ik, or Central American Indian groups or South American Indian groups.

• “Asian” refers to a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent, including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. It includes people who indicated their race or races as “Asian” or reported entries such as “Asian Indian,” “Chinese,” “Filipino,” “Korean,” “Japanese,” “Vietnamese,” and “other Asian” or provided other detailed Asian responses.

• “Native Hawaiian or Other Pacific Islander” refers to a person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. It includes people who indicated their race or races as “Pacific Islander” or reported entries such as “Native Hawaiian,” “Guamanian or Chamorro,” “Samoan,” and “other Pacific Islander” or provided other detailed Pacific Islander responses.

Race, Culture, and Ethnicity

Race, as defined by Merriam-Webster‘s Collegiate Dictionary, tenth edition, is a “class or kind of people unified by community of interests, habits, or inherited physical characteristics.” The term culture has a broad meaning; it refers to the unifying beliefs of any group of people of similar religion, values, attitudes, ritual practices, family structure, language, or mode of social organization. Culture provides values that are shared by members of a specific society or a social group within a society. Culture socializes its members on how to perceive the world, how to behave in the world, and how to experience the world emotionally. Elements that represent cultural values and notions include language, social or familial roles, and beliefs about the universe, the nature of good and evil, appropriate dress, eating and hygienic habits, manners, and food. Culture pervades lives and shapes human identity. All personal experiences and norms are perceived through the culture from which they emerge. It shapes human perception of reality and influences societal forms of conduct. Different cultures reinforce different behaviors; what is acceptable in one culture may be considered deviant in another.

Cultural values determine, in part, how a patient should behave. This includes the types of acceptable treatment, type of follow-up permitted, and who will make the decisions. From the medical point of view prevalent in the United States, the clinician and the patient make the decisions, but when a patient’s family exerts great influence, the situation can be very different. In some traditional cultures, the family takes over this role for the patient. Authority figures such as parents or grandparents often predominate. For example, in the case of Romany (“Gypsy”) patients, the primary decision-maker may not even be a relative. Among Orthodox Jewish patients, a medical decision may be made only after consultation with a rabbi. Among the Amish, the entire community may play a role in the decision-making.

Ethnicity is a cultural group’s sense of identification associated with the group’s common social and cultural heritage. The Harvard Encyclopedia of American Ethnic Groups defines ethnicity as “a common geographical origin, language, religious faith, and cultural ties (e.g., shared traditions, values, symbols, literature, music, and food preferences).”

Disease, Illness, and Health

The terms disease and illness are often used interchangeably. Medical sociologists and cultural anthropologists, however, make a distinction. The word disease refers to a disorder in which there is a change from normal in the body’s structure or function, involving one or more organs of the body. Illness is the subjective distress felt by the patient and by those close to the patient, rather than the actual state of ill health. The patient’s culture often determines how the patient interprets, explains, responds to, and deals with a disease. It also influences when a patient will seek health care decisions and from whom. Members of some cultures try to “normalize” their symptoms, maintaining that symptoms in a certain age group are not abnormal. Affected members might say that they have experienced the symptoms before and that therefore the symptoms are normal for them. Other cultures dictate immediate care even if symptoms are minimal. According to some cultures, to be ill is a punishment or curse, whereas according to others, to be ill is to be weak, irresponsible, or unmasculine. For many patients in the United States, the clinician is only one of many health care providers and often not the first. Some patients are likely to consult a healer from their own culture before seeking consultation from a Western-trained clinician. Two patients from different cultures may react differently to the same disease or symptoms. Thus, treating illness, rather than treating disease, requires the health care provider to have not only a broad understanding of medicine but also an understanding of the patient’s cultural background.

Middle Easterners, both Arab and non-Arab, are among the populations most affected by genetic disease. The common cultural practice of consanguinity accounts for as many as 25% to 60% of marriages in some countries and has led to epidemic levels of genetic disease. Beta thalassemia is one of the most common genetic diseases in the Middle East. More than 16 million people are unsuspecting carriers for this serious blood disorder, which causes a lifetime of chronic illness, suffering, and an early death. It is characterized by ineffective erythropoiesis that leads to severe anemia, fever, hyperuricemia, and skeletal deformities. The association of these disorders with Mediterranean background has been long established. The human leukocyte antigen gene complex and the many diseases associated with it continue to receive attention. Table 27-1 summarizes some specific diseases on the basis of geographic distribution and ethnic populations.

Phenylalanine hydroxylase deficiency, or phenylketonuria, is a treatable inherited disease in which the body cannot properly process the amino acid phenylalanine because of a deficient enzyme called phenylalanine hydroxylase. If severe forms of the disease go untreated, the buildup of phenylalanine can be toxic to the brain, causing impaired development and leading to severe and irreversible mental disability. If treated early and consistently, however, people with phenylalanine hydroxylase deficiency can lead completely normal lives.

The frequency of carriers and affected individuals in select populations is listed here.

Another belief about menstruation was studied by Skultans (1970) in two groups of women from a small mining village in South Wales in the United Kingdom. One group of women felt that menstruation was a process by which the body “cleansed” itself; the longer the period or greater the blood loss, the better. These women regarded menstruation as normal and essential to a healthy life. In contrast, another group of women from the same mining town viewed menstruation as damaging to their overall health; they feared that the blood loss was threatening to their health and welcomed the thought of menopause.

Finally, Ngubane (1977) described the beliefs of South African Zulu women about menstruation. They felt that menstruating women had a “contagious pollution” that was deleterious to other living creatures and to the natural world. A man’s virility would be reduced if he had sexual relations with a menstruating woman. Crops would be ruined and cattle would die if menstrual blood came in contact with them. In some of these African communities, menstruating women are isolated from the community because of their “dangerous pollution.”

Although food is a source of nutrition, it plays many roles and is deeply embedded in almost all aspects of everyday life. Some foods eaten in one society are forbidden in others. Each culture has its own rules of food preparation and of how it is served and how it should be eaten. Every culture defines foods that are edible and those that are not. In France, frog legs and snails are delicacies, whereas in the nearby United Kingdom, they are rarely eaten. Some foods are considered sacred and others are prohibited. Food abstentions occur during the Jewish fast of Yom Kippur and the Muslim fast of Ramadan. Orthodox Hindus are forbidden to kill or eat any animal, especially the cow. However, milk or milk products may be consumed because they do not require the death of the animal. Orthodox followers of Islam and Judaism are prohibited from eating pork products. Only the meat from mammals that chew their cud and that have cloven hoofs is edible, provided that the animal was slaughtered ritually: according to halal (Islam) or kosher (Jewish) law. Kosher law dictates that meat and milk products are never eaten together. In Sikhism, pork is allowed, but never beef. Rastafarians are generally vegetarians, and alcohol is strictly forbidden.

Some cultural groups in the Islamic world, the Indian subcontinent, Latin America, and China believe in the “hot-cold theory” of disease. This belief, which is intuitive and common throughout Latin America, states that the body is regulated by hot and cold “humors.” The belief stems from Hippocratic humoral theories brought to this hemisphere in the sixteenth and seventeenth centuries by the Spanish and Portuguese. Health is the balance of these hot and cold body fluids. Illness is defined by a humoral imbalance of these forces. All mental states, illnesses, and natural and supernatural forces are grouped into hot and cold categories. Foods, herbs, and medications are also classified as hot or cold and serve to restore the body to its natural balance. Although it may seem that the system is based on temperature, the thermal state in which the foods or medications are taken is not important. Certain types of herbal tea, served hot, are considered cold, whereas cold beer, because of its alcoholic content, is considered hot. In the hot-cold theory of disease, conditions that are hot, such as ulcer disease, constipation, pregnancy, diarrhea, and rashes, should be balanced and treated with cold foods, such as coconut, avocado, sugar cane, and lima beans. Menstruating or postpartum women who believe in the hot-cold theory may avoid certain “cold” vegetables and fruits because these fruits are liable to clot their “hot” menstrual blood, impeding its flow, making it flow backward into the body and thus causing nervousness or insanity. Cold illnesses, such as arthritis or joint pains, are treated with hot therapy, such as aspirin, iron tablets, penicillin, chili peppers, chocolate, evaporated milk, onions, garlic, or cinnamon.

Consider the following. A patient may be on diuretic therapy and require potassium supplementation. The clinician may advise the patient to eat foods high in potassium, such as oranges or bananas. If the patient acquires an upper respiratory infection, which is a cold disease, he or she may stop eating these fruits, which are classified as cold, because eating them will only worsen the imbalance. This belief should be recognized because it contributes significantly to whether a patient does or does not adhere to therapy. Problems can arise when a clinician prescribes a “hot” medication for a “hot” disease or a “cold” medication for a “cold” disease. The hot-cold theory is even more complex in that the assignment of the “hot” or “cold” qualities varies from culture to culture. It is often difficult for the health care provider to remember the various hot-cold combinations. If a Hispanic/Latino patient has these beliefs, the clinician should ask Hispanic/Latino colleagues on the medical team or the patient and family directly about these combinations. Inquiring respectfully about the patient’s culture can be effective in enhancing doctor-patient relationships. To achieve maximum therapeutic benefits for patients who believe in the hot-cold theory of disease, the health care provider is advised to work within its framework, if possible, in prescribing medicines and diet. He or she should try to consult medical colleagues, nurses, and social workers who share the patient’s background.

Belief in witchcraft as a cause of illness is widespread. In the Hispanic/Latino population, terms such as mal puesto, mal de ojo, mal artificial, brujería, hechicería, and enfermedad endañada are used to describe the “illness of damage”: someone has done something to cause injury, illness, or death. Mal de ojo, or evil eye, is believed to result from excessive respect or love from another person, especially toward newborn children. A recurring theme in witchcraft belief is that animals are present in the body and are introduced by magical means. Almost always, the offending animal is a reptile, insect, or amphibian. These animals have been dried and pulverized, sprinkled onto food, and reconstituted in the body of the victim. Symptoms are often described as animals crawling over the body or wriggling throughout the intestines. The belief is that this is a magical expression of friends, relatives, or strangers wishing bad luck to come to an individual. A hex is an evil spell, a misfortune, or a case of bad luck that one person can impose on another. Magical oils, incenses, religious items, and candles may be used to repel the evil. In the Hispanic/Latino community, a botánica, or religious artifact shop, sells many of these items. The shopkeeper serves as a consultant on health and related issues. Figures E27-1 and E27-2, taken in the Otto Chicas Rendon Botánica on 116th Street in New York City, depict examples of such shops. Often, the entrance to a botánica, as shown in Figure E27-1, shows predominant Roman Catholic imagery. Candles, flowers, plants, and bowls of coconut and molasses frequently surround the Christian statues. The influence of Christianity, as well as of the African and Arabic cultures, is apparent in the idols shown in Figure E27-2. As of mid-2012, there were more than 900 botánicas listed in the business telephone books in the United States, of which there were more than 95 in Manhattan. There are probably many more that are not listed.

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