This chapter takes an explicitly critical perspective to exploring the interplays between culture, health, spirituality, and religion in relation to nursing care. It considers the connections between health, ethics, and morality in Aymara, American Indian/Dakota, and Aboriginal traditions. The three case studies used are from different countries (Bolivia, United States of America, and Australia) and are told in the voices of the three co-authors (Calestani, Scemons, and White and Hendricks, respectively), yet they show many common themes and provide a point of departure for further discussions on the importance of knowing the local context of patients’ lives. The three traditions described in this chapter are considered from Orsi’s concept of lived religion, which means being “situated amid the ordinary concerns of life at the junctures of self and culture, family and social world.”1
These case studies encourage nurses to think about patients’ selfidentity and to explore how religion should not be separated from social life, being embedded in the many relationships in which patients are involved (families, communities, natural world, and spirits). Professional nursing practice has to take into consideration how patients’ moralities may shape ideas of health and illness. This realization may involve a redefinition of nurses’ role in health services delivery and requires reflexivity on the part of nurses about the assumptions and values they carry.
Medical anthropologists usually distinguish between three “bodies” the personal, the social, and the political as socially constructed notions of the self, identity, and the social sphere.2 It is therefore impossible not to take into consideration the historical and ongoing effects of colonization in our three case studies. Harris’ model indicates the presence of two or more mutually exclusive knowledge systems, the model of the colonizers, and that of the colonized.3 Harris explains that often this implies a juxtaposition or alternation of the systems, where both are accepted without a direct attempt to integration. In our three case studies, it emerged that this alternation of systems has an important impact on social justice and health disparities, implying ethical issues for the provision of health care and the role of health care professionals.
The concept of cultural safety, defined by Stout and Downey,4 shows that nurses and indigenous people have been embedded in historically determined colonial power relations. Indigenous people often experienced these as a lack of trust and consequently as an emotional inability to access health services. Cultural safety tries to overcome this limit and finds expression in caring spaces that seek equality and are rights-oriented. The overarching goal is the health of indigenous people, but this cannot be achieved without an in-depth analysis of how spiritual and indigenous religious beliefs about health and illness may affect the role of health care providers.
Our three examples show that concepts such as health, spirituality, or ethics are seen as integrated into all aspects of life within indigenous traditions. Garvey, Towney, McPhee, Little, and Kerridge comment that:
The terms “ethics” and “bioethics” are not evident within Aboriginal cultures because the ethical convictions that form these cultures cannot be dissociated from them and values are woven through the very fabric of Aboriginal cultures. In general terms, Aboriginal societies do not differentiate bioethics or the process of healthcare decision making from the values, narratives, and contexts that define and structure all dimensions of living.5
Diener and Suh define subjective well-being as “values people seek,” emphasizing the importance of including people’s ethical and evaluative judgments about their lives, about why it is worth living and what it means to be a person.6 Taylor writes,
People may see their identity as defined partly by some moral or spiritual commitment, as Catholic, or an anarchist. Or they may define it in part by the nation or tradition they belong to, as an American, say, or a Quebecois. What they are saying by this is not just that they are strongly attached to the spiritual view or background; rather it is that this provides the frame within which they can determine where they stand on questions of what is good, or worthwhile, or admirable or of value. Put counterfactually, they are saying that were they to lose their commitment or identification, they would be at sea, as it were; they wouldn’t know any more, for an important range of questions, what the significance of things was for them.7
Taylor continues “to know who you are is to be oriented in moral space.”8 This space is where there is a sense of what is good and what is bad, and what is worth doing or achieving. Well-being has to be about the way an individual exists and functions in relation to the world and to himself or herself.9 Diener and Suh write about the importance of self-actualization and autonomy for the majority of individuals in North America.10 They describe a highly independent adult as someone who is able to transcend the influences of others and society. This contrasts with our findings about Aymara, American Indian/Dakota, and Aboriginal people, where a person exists and functions in relation to others (humans and spirits). The community is responsible for the well-being of all its members and is the center of spiritual activity. Moralities include harmonious social relations with other human beings, and also with the natural world (land and sea), which is recognized as being alive; respect for and responsibility to the land is an important belief and a moral tie. Connectedness to people and connectedness to places are two important factors in the nurturing of the spirit within and maintaining the wellness of physical, mental, emotional, and spiritual spheres. The concepts of being healthy or unwell are understood within a system of harmony and balance; to be well, a person and his or her community must observe cultural and spiritual obligations. Illness is believed to be caused by spiritual forces such as grief, anger, conflicts with other human beings, or other unknown causes.
The case studies invite health care practitioners to consider the differences within the same ethnic group; assuming that all members of a tribe or an indigenous group share the same opinions and perceptions about the role of tradition or spirituality, or the same concepts of health and illness, would be wrong. Based on different community experiences, Dakota, Aboriginal, or Aymara individuals may be members of one of several Christian denominations. This does not preclude adherence to the practice of more traditional spirituality, but may in some cases involve a rejection of some practices. Members of a specific ethnic group find themselves participating at rituals and activities at times, withdrawing at other times, and carefully selecting which ones to embrace or avoid. The circumstances of different informants to our data varied even within the same ethnic group.
It is important that nurses are prepared to practice in a pluralistic society where perceptions of the self, illness, and social attitudes toward illness and disease can differ radically from their own. Moralities and spiritual orientations have also to be taken into account and cannot be separated from patients’ everyday life and self-identity. When providing health care for people from native, aboriginal, or indigenous traditions, nurses have to take into consideration that beliefs about disease and its causes may be attributed to soul loss, spirit intrusion, sorcery, and natural and supernatural factors. In addition, patients may embrace an organized, usually Christian, religion together with tribal beliefs and practices, implying hybridism.
This hybridism can lead to religious and medical pluralism, which becomes very important for understanding individual and collective ethics and moralities, as well as what it means to be “a good person” and therefore to have “a good life.” The decision-making process of nurses has to include a wider perspective on beliefs and values, becoming culturally and religiously sensitive and competent. These may lead to different views of and by health practitioners/nurses, redefining their role according to patients’ needs. The role and perception of the local community of the patient also raise important reflections on the level of engagement that the community should or should not have in supporting its members when they are ill and sick. Holden and Littlewood argue that nurses could be seen like ethnographic fieldworkers.11 The nurse must be immersed in understanding the patients’ world and their religious beliefs to create a wider awareness of different patients’ spiritual needs, showing awareness of their cosmological order and system of beliefs.
M. Calestani
The first case study comes from ethnographic research carried out in the Bolivian highlands, focusing on two neighborhoods (urban Senkata and semiurban Amachuma) of one of the most indigenous cities of Latin America, El Alto, populated largely by Aymara migrants from the countryside. There are 34 ethnic groups officially recognized in Bolivia. Quechua and Aymara are the larger language groups, although it is questionable how far linguistic markers in themselves represent distinctive and identifiable ethnic affiliations.
El Alto, at 4,000 m of altitude, is a place of medical and religious pluralism. Patients may experience difficulties of access to primary care centers and hospitals in the countryside, but in El Alto, Aymara migrants have the option to choose between Western medicine and traditional healing processes practiced by local shamans, known as yatiri. The people are mainly Roman Catholic, with an increasing number converting to Pentecostal and Evangelical Protestantism. Inhabitants in El Alto also believe in the spiritual forces of the surrounding environment, entorno. They believe that each element of the dry plateau is alive; the snow-covered Andean peaks are Achach-ilas (God Mountains) and the earth itself is Pachamama (Mother Earth).
Well-being in El Alto and in the surrounding countryside is attributed to harmonious social relations, both with people and spirits. If a member of the household or of the community is ill, this affects the entire household and community, indicating many connections with the spiritual and religious spheres. The causes of various pathologies are unsolved tensions or conflicts among household or community members. Difficult relationships with spiritual forces can cause someone to be unwell. Those who have offended the God Mountains may experience illness of animals or household members as punishment.
The spirituality of El Alto’s inhabitants has to be inclusive of all the multiple religious elements they are in contact with, because only in this way can they be fully protected, assuring their own, their household’s, and the community’s well-being; and avoiding the evil eye, often connected with jealousy both from humans and supernatural forces. Suerte (luck) guides health, including the different human spheres that are not limited to the body or the psyche.12 It can be acquired through effort and work by asking for protection from supernatural forces. The process is extremely complex, requiring the full moral commitment of people who have to appease the spirits. Relations have to be continuously fed by the circulation of money and special offerings. Faith is another important ingredient. Money and offerings on their own are ineffective. It does not matter how ill someone is or how much someone lacks; what matters is the capacity to overcome a critical situation and to believe that the spiritual forces will help one to do so.
Supernatural forces are there to help people to overcome their difficulties, but they cannot do it for free. One has to pay respect by making material offerings. “The offerings made by people are going to be symbolically ‘eaten’ by supernatural forces through the burning of the objects offered. This allows one to enter into an empathic relationship with the objects as well as with the rest of one’s community.”13 Hence, the process of consumption of sacred practices and objects is fundamental. This is considered as a kind of “culinary” pact based on “commensality” between people and gods. Individual and collective rituals and offerings are essential to promote and assure individual and collective health and well-being. These rituals often take place in sacred places and are a moral responsibility for the entire community.
During my fieldwork in the Bolivian highlands, I visited many sacred places. In particular, I spent much of my time in the Apachita de Warakho Achachila, which is on the main road that goes to Oruro. This site belongs to the community of Amachuma and it becomes very busy during the month of August. This is the month of the Pachamama, the Mother Earth, and it is a time when beautiful as well as terrible things can happen, depending on how much respect one pays. At that time, the Pachamama “tiene más hambre” (is hungrier than usual) and the earth opens. This opening is neither completely positive nor completely negative; the offerings can enter more easily, but at the same time the evil can come out.14 The outcome is always in the hands of people themselves. Some people believe that they might influence their suerte (luck) through their actions, and thus have an impact on their well-being.15 This is the time when the culinary pact or commensality with the Pachamama is reconstituted.16 For example, during the Wilancha (in Aymara, the literal translation of this word is “hacer sangre” [make blood]) ceremony a white llama is killed and offered to the Pachamama. This is followed by heavy social drinking of beer.
The opening of “a hole” in the earth is a powerful metaphor, which has been explained by Fernández Juárez as “a crossing of borders and limits” between opposites, such as health and illness, that can influence the conceptual stability of the Aymara world, affecting and upsetting the order attached to authority.17 Suerte must be produced by putting a lot of effort into it and this process represents the only possible way of protecting the individual, the household, or the entire community from any sort of disturbance, disorder, distress, or illness.
Nevertheless, this practice and strategy to produce suerte is not shared by everyone. Some people, especially those who are Evangelical Christians, do not approve of these rituals and offerings to the Pachamama. One day in August 2004, while I was at the Apachita, a man approached me. He understood that I was not Bolivian and asked me where I came from. We started to talk about the rituals and the offerings that were taking place. He was against them and added:
In this place there is something . . . a malevolent supernatural force belonging to the Devil . . . It is against God’s Law . . . People visit this place with hopes . . . and their desires become true, but then they have to pay for what they have received. The Devil gives, but then he also takes everything away. Only God gives you forever . . . and stays forever. I don’t do these kinds of rituals because I’m Protestant and we are different. It’s not like the Catholic Church, which is like a prostitute. The Catholic Church accepts everything, even bad traditions.
Another time I went to visit two people who had recently opened a repair shop for electrical equipment in Senkata. While we were chatting about a personal experience I had with a yatiri (a local shaman), a woman with a broken black and white television entered the shop. She started to listen to us and looked as though she wanted to join in, therefore, I decided to include her in our conversation. “Madam, what do you think about yatiri?” She looked very happy about the question and replied that she did not believe in them and that she only believed in God. God was her protector and was giving her strength to overcome all the difficulties. “A yatiri is able to take away your partner. . . . They are all bad people. I don’t trust them.” She too belonged to a Protestant Church.
Evangelical conversions are fundamentally linked with a different conception of health and “the good life,” which only happens post-conversion. Senkata residents often mentioned how their life had improved after they decided to become Evangelical Christian, especially with regard to their health; avoidance of alcohol has been a blessing for most of them, including the positive effects that non-participation in social drinking can have on economic stability.18 This may have the effect of making more cash available to invest in children’s education and in creating work opportunities. The people interviewed also expressed the benefits of conversion from a spiritual and moral perspective, saying that “they feel closer to the Lord.”
There are some differences between the many urban and semi-urban contexts of El Alto, often related to the effects of membership of different religious congregations and their different rules and views regarding community rituals and celebrations. For example, in the case of the Wara-kho Apachita (Amachuma sacred place), I saw some of the members of the Baptist Church from Amachuma visiting it (Warakho Apachita) during the month of August. The main community authority—the general secretary of the Trade Union, who belongs to the Baptist Church—also participated in some of the rituals in honor of the Pachamama. As mentioned in the previous section, this is not accepted by some Evangelical members. He was present at the closure ceremony (which is also a very important political and community event) of the festivities of the month of the Pachamama. Although he is very active in his church, he did not interpret his participation in the ceremony as disrespectful of his religious beliefs. He said that he had to participate for the sake of his community, which for him is the most important aspect of leading a good life. However, other evangelicals, especially from Senkata and those who belong to the Seventh Day Adventist congregation, see this as disrespectful, believing that it is the Devil that acts in the Apachita.
Roman Catholics generally believe that it is the Pachamama in conjunction with the Achachilas that offer protection and listen to people’s desires for health, prosperity, and luck. They easily identify the Pachamama with the Virgin Mary and the Achachilas with the Saints. Therefore, they do not see their worship as something negative or malevolent, but as compatible with Catholic practice. Religious identities shift easily between different spiritual spheres. In Amachuma, conversions to evangelicalism have increased in recent years, especially among local administrative authorities (e.g., the general secretary of the Trade Union) who had a huge impact on other citizens’ conversions. Amachuma is a good example of embracing different beliefs at different times, and of the existence of a certain degree of hybridism.
When I first arrived in Amachuma, it was a Sunday morning in the middle of December. The minibus left me in the unfinished main square, where the Town Hall and the Catholic Church were located. It was strangely silent and the church was closed. Then I heard some singing coming from a house; I discovered that this was the place where the Baptist Congregation of Amachuma was meeting.
The Catholic Church was always closed because there was no longer a priest in Amachuma. The priest lived in Senkata. Although Senkata and Ventilla were regularly attended by the priest, there was no time to reach Amachuma. By contrast, the Unión Bautista (Baptist Congregation) was open every Sunday and sometimes also in the middle of the week, offering religious courses to women and children. The pastor was a middle-aged woman from the United States of America. Her new house was being built at the entrance of the neighborhood. She had recently bought the land around her house from the Amachuma community with the idea of building a modern hospital where American doctors could work. “Why American doctors and not Bolivian?” I asked, and was told: “Well, she is American, and in the end, what is important is that we are going to have a hospital.” On the other hand, Catholics had a different opinion. For instance, a Catholic Amachuma woman told me: “Yo no soy una mujer de hospital” (I am not a woman who goes to the hospital). In times of illness, she would only visit the local shaman, the yatiri.
This situation shows different orientations even within the same ethnic group and how people often negotiate their beliefs in order to achieve their well-being. Even in the case of health, there is a fundamental relation with faith and morality. Pentecostalism seems to stand to hospitals as Catholicism stands to local shamans. However, even in this case, people seem to shift their identities according to the different circumstances, trying to assure their personal as well as communal well-being by oscillating between different religious identities. Despite their religious affiliation to the Baptist Church, they proudly attend the rituals of the Apachita. It is important to participate in rituals to assure a reciprocal connection with the Pachamama and assure health and well-being for the entire community. Yet, it is also fundamental to become part of the Pentecostal congregation, so that the village can have a hospital. This religious pluralism is in accordance with a medical pluralism and shows how people have different orientations according to time and space.19 It is impossible to outline a unique model for all Aymara people, as everybody aspires to different things and may have different values, as well. Well-being is socially and morally contextualized. There is a constant tension between different practices of sustained pluralism between rural and urban values, but also religious and medical practice. Values are never fixed and general formulations concerning well-being do not sufficiently take into account fluid social situations.20,21
Donna Scemons
The following case provides particular information concerning some American Indian traditional, spiritual, or ethical concepts and time-honored Dakota tribal beliefs. Oral history, oral tradition, connectedness, and respect, including community and family, are presented from a traditional American Indian worldview with specific applications from the perspective of Dakota American Indians living in the United States of America. For American Indians, presenting such information may be criticized as intrinsically controversial because the “possession of knowledge does not confer the right to communicate that knowledge to outsiders.”22 The reference to outsiders herein is not intended as disrespectful; however, it includes those who are not American Indian, and thus it includes many individuals in professional nursing. The sum of what is offered here is presented with significant, careful deliberation, thought, and respect to and for all that American Indians and the Dakota People hold as sacred and true.
American Indian, Native American, Native, Injun, Indian, Indigenous, or Indigenous people are all expressions that represent the legacy of European contact with many of the original inhabitants of the United States of America. American Indian, according to the Health Resources and Services Administration, “refers to people descended from any of the original peoples of North and South America (including Central America) and who maintain tribal affiliation or community attachment.”23 The term has become the accepted delineation in the majority of health care records for every Native American receiving nursing care in any of the 50 states or U.S. territories. The inherent fallacy of these linguistic designations is the grouping together of diverse human beings under one label that obliterates more than 500 years of history,24 disregards the complex cultural and spiritual identities of more than 564 sovereign nations,25,26 fails to account for nearly half of American diversity,27 and “implies a uniform culture and healing system.”28 Some share certain beliefs, mores, and values; however, every American Indian tribe and every person who identifies as a traditional American Indian or Native American requires individual assessment of spirituality, ethics, religion, culture, and values. The terms traditional American Indian, traditional Dakota, traditional Indian, or traditionalist are defined thusly:
. . . traditional, in an Indian sense is considered to mean multiple interconnections of emotional, physical, [mental], intellectual, and spiritual identity that combine to define expectations for the Indian way.29
Yet, for all who deal with American Indians in a health care setting, “it is inaccurate to assume all members of one tribe-share opinions about matters such as the role of tradition [and] spirituality.”30 The terms American Indian, Native American, Dakota People, First People, the People, or Peoples in the following are interchangeably used in reference to American Indian People as a general referent and Dakota People as a more specific linguistic reference. Understanding these various terms and their use in language must acknowledge the fact that before the coming of Europeans to the Americas there were no such people as Indian, Injun, Indigenous, or any of the multitudes of expressions meant to convey reference to the First Peoples. American Indian is currently the federally accepted term and will be used throughout the following as official designation for members of the Oceti Sakowin, or Seven Fireplaces.31
Within the Oceti Sakowin are three linguistic groups or dialects: Dakota, Nakota, and Lakota, who in the U.S. tribal system are federally referred to as the “Sioux.”32 Historically, each band inhabited adjoining lands and members from each group moved freely among the various bands. The Dakota were primarily a woodland tribe living in what was to become known as Minnesota, whereas the Lakota inhabited areas along the Missouri river and the Great Plains. Those People who spoke Nakota lived between the Dakota and Lakota tribes along what is now the eastern border of South Dakota.33
Historical geography has significant importance to American Indians because a connection to the land is “intimately intertwined with native religion, values, culture, and lifestyle.”34 Deloria, a Standing Rock Sioux, explained “. . . the sacred lands remain as permanent fixtures in their [Indian] cultural or religious understanding.”35 For many of European descent, a sacred place has historical significance but rarely does the place “provide a sense of permanency and rootedness that the Indian places represent.”36 The land is not seen through Euro American lenses implying ownership, rather as Laguna Pueblo author Paula Gunn Allen writes,
The land is not really a place, separate from ourselves, where we act out the drama of our isolate destinies—the earth is not a mere source of survival, distant from the creatures it nurtures and from the spirit that breathes in us—the earth is being, as all creatures are also being; aware, palpable, intelligent, alive.37
To the First People, the land is seen as alive and connection to the land is at once one of respect but also one of responsibility; a recognition of “. . . sharing of a defined space.”38
For professional nursing, an understanding of the self-identity of each patient coupled with at least a modicum of knowledge about the patient’s culture and spirituality has become a necessary educational and self-reflective journey. During an encounter with a patient who chooses “American Indian” when asked about national origin or heritage, the nurse must acknowledge 500 years of historical oppression, subjugation, and attempted forced assimilation. Further query concerning what tribal group or groups the patient chooses to recognize for inclusion in the medical record is a final requirement. Inquiring about the patient’s tribe or nation is a sign of respect.39 Knowledge of how a patient self-identifies by tribal affiliation is the beginning of a patient–nurse relationship, as within tribal connections are embedded the concepts that include the patient’s spiritual beliefs and ethical values.
From tribal affiliation and self-acknowledgment of belonging to the Dakota Nation, the nurse could reliably discern that the individual patient comes from a people who have a long and rich history of oral tradition.40 This oral tradition is relied upon by most American Indians, including the Dakota to “convey ideas, feelings, culture, attitudes, and ways of life.”41 Spoken words are greatly appreciated in this tradition, representing a “sharing from the heart”42 and a strong belief that, “If I do not speak with care, my words are wasted. If I do not listen with care, words are lost.”43
Oral tradition does not simply mean that American Indian people talk and do not have written history or the ability to write. Ruoff explains this tradition, as “American Indians hold thought and word in great reverence. Breath, speech, and verbal art are so closely linked to each other that in many oral cultures they are often signified by the same word.”44
This tradition reflects how information is gathered, then understood, and dispersed. Traditionally “old knowledge is valued,”45 which is not to say that new knowledge is not sought. Oral tradition includes specific ceremonies, rituals, principles, and activities that are passed down through tribal elders. For an American Indian person, oral tradition is “a whole way of being.”46 One aspect of this tradition is storytelling, explained by Leslie Marmon Silko:
I don’t mean just sitting down and telling a once upon a time kind of story. I mean a whole way of seeing yourself, the people around you, your life, the place of your life in the bigger context, not just in terms of nature and location, but in terms of what has gone on before, what’s happened to other people.47
The historical experience of “other people” is demonstrated through the art of storytelling as one of the mechanisms through which American Indians remember the history of the People, respect ancestors, and pass on spiritual, religious, and ethical values. The use of oral history is not the only method of communication employed by American Indians; however, to many traditional Indians orality is preferred over written methods. There may be distrust and suspicion of written words, as explained by Harjo and Bird:
It is through writing in the colonizer’s languages that our lands have been stolen, children taken away. We have been betrayed by those who first learned to write and speak the language of the occupier of our lands. Yet to speak well in our communities in whatever form is still respected.48
Voss, Douville, Soldier, and Twiss speak of the People being:
. . . wary of the written word, for often the written word objectifies understandings and can be manipulated outside the relationship in which the understanding was shared. The written word can be exploited in ways that were not intended.49
As evidenced by these statements from American Indian authors, oral tradition and orality are the preferred mode of communication when presenting moral and ethical values, including spirituality and religion, for many traditionals.
Religion for an American Indian is “not separated out from the rest of social life . . . [its]beliefs and rituals-permeated everyday life.”50 Traditionalists do not build houses of worship, require a certain day or time to be spent in worship, nor do they evangelize. Rather than “have a religion,” the Indian has a rich spiritual life devoted in part to finding and maintaining a balance through harmonious actions meant to demonstrate respect for all that Creator has fashioned. As Echo-Hawk and Foreward affirmed, spirituality has been and remains “a mystery to most Americans.”51 Perhaps one of the most important facts to acknowledge in any discussion of American Indian religion or spirituality is that there is no one religion or spiritual path acknowledged by this diverse cultural people. Each tribe and often the individuals in that tribe have personal beliefs that may be significantly different from other tribes or individuals.
Acknowledging the Dakota Indian person’s spirituality and religion requires knowledge of what for a number of American Indians is a duality. Based on different community experiences, the Dakota person may be a member of one of several Christian religions. This does not preclude adherence to the practice of more traditional spirituality. Depending on the geographic region “historically subjected to Church rule or control,”52 American Indians may consider themselves committed Catholics, Presbyterians, Methodists, Episcopalians,53 or other Christian denominations while concomitantly maintaining belief in traditional practices, customs, ceremonies, and rituals. Having one foot in one tradition and the other foot in a moccasin creates this duality. Therefore, to ask an Indian “What is your religious affiliation?” is not as readily answered, as it might be for a person of Euro American descent. American Indian belief is that all is connected: the physical, the mental, the emotional, and the spiritual. “Some American Indians have converted to Christianity, some retain their American Indian spirituality, and some practice a mixture of both Christianity and American Indian spirituality.”54
Dakota religion and spirituality are considered deep personal matters, about which one does not speak as long as one believes.55 Eastman ascertains that the theology, religion, or spirituality of the Dakota are the last thing that any non-Indian person will be able to comprehend.56 This latter statement may seem somewhat harsh, but Indian beliefs “cannot be compared to the religions brought [to the North American continent] from other nations.”57 In Dakota tradition, spirituality cannot be dissected away from the land or the relatedness of all things; life itself in all its forms is sacred. One example of this is the sense of community, where everyone is owed respect as imbued with life. An individual existing without the community is at once foreign and not well-understood by Dakota. This sense of community transcends the individual, the worldview of the Dakota is spirit filled and human beings are not considered superior to other life forms. A deep sense of unity with one’s tribe through respecting kinship and family ties is a powerful force among American Indians and Dakota People.
Traditionally, there are no privileged groups among Dakota, rather respect is given to all. Those in the community deemed elders are revered for their spirituality, wisdom, life experience, and willingness to share with other community members.58 The concept of sharing comes from a long tradition of generosity within the community and is an absolute value. Those who had the most are those who gave the most and “receiving was not stigmatized, needy people were seldom divided into the categories of deserving and non-deserving.”59 Sharing with all and caring for the less fortunate without stigma as a community value was at odds with the Protestant separatists who initially upheld that the poor required moral guidance and were generally indolent.60 Interestingly, a perception of American Indians as “. . .helpless, hopeless, and doomed to inevitable destinies of drunkenness and poverty” has been a majority view since initial contact.61
This latter statement does not explain that “. . . most tribes maintain the view . . . the community is responsible for the well-being of its members.”62 During an illness, the community comes forward to make the sick individual feel nurtured and loved by all.63 The importance and role of extended family for traditionalists is central in times of health as well as illness. Family members are central players during acute as well as chronic illnesses. In one study of chronically ill children, extended family caregivers were represented by “mothers, fathers, siblings, grandparents, aunts, uncles, and cousins.”64
For the Dakota, the group is more important than the individual: “. . . interdependence is valued.”65 “Connections and close relationships between people are highly prized.”66 Cooperation among community members is thought to lead to and maintain group harmony. Balance and harmony are reflections of connectedness and a sense of relatedness; for many this is significant contrast to the Western concept of individualism. Although American Indians value each individual, the value comes as a member of the community. Based on this connectedness and sense of community, Dakota most often rely on consensus if decisions or solutions are required. Consensus may “. . . extend beyond the sphere of the traditional nuclear family,”67 reflecting the community and connectedness.
At times, the community is seen as confusing to individuals outside of the group, for example, when Dakota refer to aunts and uncles as mother or father.68 Traditionally, individual aunts and uncles participated in much the same manner as a mother or father would in a traditional Euro American family. An Indian family may be related to individuals from other clans, groups, or tribes from the community’s perspective. This relatedness may not be through legal channels or actual birth into a family, although the community may refer to the individual, clan, or group as family. In a busy health care environment, referring to a mother, brother, aunt, or grandfather may be erroneously perceived as designating an associated biological or legal status. Consequently, the portrayal of a family member may lead to uncertainty on the part of health care providers.
The significance of community and family may lead to other inaccurate perceptions or actions by health care providers. A health care provider may solicit group members to participate in changing the health behaviors of a tribal or community member, yet Dakota have a strong aversion to interfering in another person’s life or behavior.69 This societal more emanates from a strong belief in the voluntary cooperation of each member of the tribe, group, or clan. Such belief is in part due to the consideration that each human being has a right to choose self-behavior at any particular point and relative to the situation. This is not to imply that behavior is never questioned by Dakota, rather it is reflective of respecting every individual’s choice if it does not interfere with the overall goals or needs of the group. Consequently, many American Indians firmly believe that it is not any individual’s right to interfere with the actions or activities of others. Such behavior is often not understood by those who believe in the doctrine of being one’s brother’s keeper. Good Tracks explains: “. . . when an Anglo is moved to be his brother’s keeper and that brother is an Indian, then almost everything he says or does seems rude, ill-mannered, or hostile.”70 American Indians tend to view interference with another human being as at once authoritarian and also not the Indian way. The rights of every human being are respected and to interfere in another’s behaviors or actions, even if the behaviors seem foolish, is to be disrespectful.
Dakota children are taught from earliest age to behave in a manner that is both modest and humble. A young Indian child learns that some behaviors are considered inappropriate, disrespectful, and likely to bring shame or loss of honor on themselves, family, clan, or community. For example, traditional American Indians consider talking about or bragging about one’s accomplishments as disrespectful, ill-mannered, and lacking in sensitivity to those around them.71 Dakota believe relationships with all things must be based on equality and respect.72 In Dakota tradition, unlike many Western societal traditions, “. . . a great man must act like a servant, but live like a chief, looking up to the sun rather than the earth, content to have his feet touch the dirt, if his head was in the sky.”73
While the idea of having one’s feet in the dirt may be met with dismay among some cultures, to American Indians this reflects “the community view is inherent in the culture—the spirit of community neutralizes individual power—[and how] Native American people prefer to look at the community as a source of power and leadership.”74 For those of Euro American heritage, the concept of community as the source of power and leadership is an American Indian traditional belief that may be challenging to integrate. American Indians do not necessarily perceive the attainment of credentials and degrees as “signify[ing] power and status.”75 This does not preclude American Indian understanding of formal education or the effort required to attain credentials or degrees. Advanced formal education is viewed by many traditionalists as a journey undertaken by an individual as part of self-determination.76 Values that are perceived as more important to American Indians are respect, generosity, sense of community, and connectedness. Finally, the information provided within this case study is intended to provide assistance to those professional nurses who provide care to members of the People in various health care settings. Remember to think and speak from your heart. Mitakuye pidamaya De yuonihan Yuhapi c’anet was’te Wopida unkenic’eyapi, or in the dominant language: All my relatives. For this honor with a good heart, thank you.
Nereda White and Joan Hendricks
For Aboriginal and Torres Strait people, health does not just entail the freedom of the individual from sickness but requires support for health and interdependent relationships between families, communities, land, sea and spirit. The focus must be on spiritual, cultural, emotional and social well-being as well as physical health.77
Australia’s population includes two Indigenous groups. The first group consists of the Aboriginal people who mainly inhabit the Australian mainland, Tasmania, and some islands off the coast of the Northern Territory and the state of Queensland. The second group includes the Torres Strait Islanders who live on the islands of the Torres Straits between Australia and Papua New Guinea, and in more recent years due to employment and education opportunities, reside in coastal towns and cities. From 2009 population figures, it is estimated there were a total number of 550,818 Indigenous Australians included in the total Australian population of approximately 21 million people (representing nearly 3% of the total population). The largest number (161,910) live in the state of New South Wales and 156,454 live in Queensland.78
This case study focuses on Aboriginal people’s health and details the Aboriginal Health Centre on Stradbroke Island, located off the coast of Queensland near Brisbane. The use of Indigenous in this case study will include both Aboriginal people and Torres Strait Islanders.
Aboriginal people’s current life chances are intrinsically linked to their past and present socioeconomic and cultural status in Australian society.79 Australian Indigenous people continue to endure poor general health and for every key measure Indigenous Australians suffer greater health burdens. These disadvantages begin at birth and continue throughout the lifespan. Mortality rates for Indigenous infants and children are two to three times higher than for the rest of the population, and 13% of Indigenous babies are of lower birth weight. Indigenous people are more likely to be hospitalized. There is a greater prevalence of cardiovascular disease (leading cause of death), respiratory diseases (asthma), renal disease, and diabetes (especially Type 2). Life expectancy for both men and women is 17 years less than for other Australians, with Indigenous males 59 years compared with 77 years for non-Indigenous men and Indigenous females 65 years compared with 82 years for non-Indigenous women.80
The Indigenous age structure has implications for the health care of greater numbers of younger Indigenous people, but also highlights the reduced life expectancy of Indigenous Australians who may present end of lifespan conditions at a much earlier age. The median age at death in 2008 for Indigenous males was reported as being 49.0 years (South Australia) to 59.9 years (New South Wales).81 Disparities also exist for Indigenous people’s participation in the areas of education, employment, and access to adequate housing. Additionally, they suffer greater rates of incarceration. These disadvantages combine to be powerful determinants of contemporary health and well-being.
Dispossession and years of oppression have had long-term effects on Aboriginal people’s physical, social, and emotional well-being, particularly for those people who were removed from their families. Their grief and loss are encapsulated in the following quote:
We may go home, and we may reunite with our . . . (families), communities but we cannot relive the 20, 30, 40 years that we spent without their love and care, and they cannot undo the grief and mourning they felt when we were taken from them. We can go home for ourselves as Aboriginals, but this does not erase the attacks inflicted on our heart, minds, bodies and souls, by caretakers who thought their mission was to eliminate us as Aboriginals.82
This colonial legacy calls for a holistic approach to the health care of Indigenous Australians that addresses the current inequities that are faced in all areas of life.
Although the majority live in cities, Indigenous people are “ten times more likely than non-Indigenous Australians to live in remote areas” where medical facilities and access to allied health care services are severely limited.83 Service in some remote communities may be restricted to doctors and specialists flying in and out, and patients may be required to travel to major cities far from their communities for treatment. This, in turn, creates problems with the culture shock of being in an alien environment without the support of family. Eckerman et al. emphasize the impact on the individual and the “associated tension and anxiety of entering a new culture combined with the feelings of isolation, sensations of loss, confusion and powerlessness.”84 Being hospitalized can be a traumatic experience for anyone, but for Aboriginal people it may “cause them to withdraw from communicating and interacting with the health systems.”85
In addition, families who are left behind suffer from the absence of significant members. For example, when women are required to travel to a city hospital to give birth, the family is often without the primary carer and unable to visit and bond with the new baby. There are many stories about Aboriginal people “pining for country” to the point that this has been believed to have contributed to their death (Authors’ personal knowledge).
Available mainstream health services are not always utilized by Indigenous clients due to:
lack of knowledge about the service and what it provides;
lack of knowledge about health matters generally including understanding of their own health condition;
distrust of health services due to a long history of poor relationships with government providers;
feeling “shame” or embarrassment about speaking about health matters to a “white” person;
issues such as preferring to speak to (or being treated by) same gender practitioner due to “women’s business” or “men’s business;”
lack of culturally trained health care professionals; and
language and communication difficulties (medical jargon; Standard Australian English [SAE]).
Language and communication are particular concerns for Aboriginal people for whom SAE may be a third or fourth language. Traditionally, there were over 250 languages, all with a number of dialects. The map of Aboriginal Australia published by the Australian Institute of Aboriginal and Torres Strait Islander Studies shows a division into nearly 700 language groups. Although colonization has resulted in significant language loss through the death of language speakers and forbidding people to speak their languages, there are still communities where traditional languages are spoken, as well as kriol/creole and Aboriginal English. This creates difficulties for Aboriginal and Torres Strait Islander people communicating with the outside world where SAE is the dominant language. The inability to be understood and communicate creates personal distress for patients in cross-cultural health care situations, thus impeding their treatment and recovery. Furthermore, the specific language of the medical world provides a significant obstacle to understanding and addressing health issues.
The appropriate training of health professionals is critical to enable the treatment of Aboriginal clients in culturally affirming ways and to enable practitioners to work together on health goals with Aboriginal communities. Aboriginal people are more likely to access health services where they feel welcomed by staff whom are not judgmental and who acknowledge the history of oppression that has led to many of the barriers currently faced by Aboriginal people. Eckerman et al. argue that
. . . if we empathise, we try to understand—understand such factors as poverty, bad housing and unemployment, which create an unhealthy environment. We try to understand the effects of racism, what it does to a powerless minority, and we have a close look at the service we deliver and consider whether or not they suit the people’s needs.86
Furthermore, it is vital for nurses to develop an understanding of the interplay between white race privilege and Indigenous disadvantage.87 The growing body of writing about “whiteness” will help nurses to understand that by normalizing “whiteness,” the privileges that one experiences as a member of a white group in Australian society perpetuates institutional racism.88
Aboriginal spirituality is derived from The Dreaming, a spiritual concept, which is embedded in all aspects of daily life and is traditionally passed down the generations through the process of storytelling and enacted through law, kinship structures, and custodial obligations to the land and sea. The Dreaming tells of the journeys of Ancestral Beings who created the natural world and provides links with the past, present, and future. It is the natural world, especially the land or county to which a person belongs, which provides their links to their Dreaming.
Dreaming relies on profoundly spiritual insights into the interrelations of land—the living spring of God’s creation—family kinship and community. This interrelation of land, kinship and community is integral to human identity . . . This culture taught from early age that all living things matter. Land is the first teacher and its teachings are manifest in our deepest thinking.89
The Aboriginal concept of health is holistic, encompassing mental health and physical, cultural, and spiritual health. This holistic concept does not merely refer to the “whole body,” but in fact is steeped in the harmonized interrelations that constitute cultural well-being. When the harmony of these interrelations is disrupted, Aboriginal ill health will persist.90
Connectedness to people and places of birth (referred to as “country”) are two important factors in the nurturing of the spirit within and maintaining wellness. Rituals, celebrations, and ceremonies from birth to death are fine tuned to nature. The songs of the birds, the voice of the wind, the stillness of the billabongs, the landforms, and Dreaming tracks are constant reminders to respect and be still—to experience the fullness of the Dreaming and the presence of the sacred.91
There are significant cultural and community protocols relating to death, dying, and grieving. Aboriginal people believe life is a journey and that there is a time to come and a time to go. The pain of death of a loved one is quelled by the togetherness of community support for the immediate family and is regarded as “Sorry business” that affects not just the immediate family, but the whole community. It is common in many communities for all business to cease, to allow time for appropriate mourning practices. This practice can be challenging for outsiders wanting to provide services or conduct business. It is also the practice in some communities to refrain from speaking the name of the deceased person until the appropriate period of time has passed. Another belief associated with death is the warning to families through the appearance of an animal or bird.
North Stradbroke Island, known by its Aboriginal name Minjerriba, is located in Moreton Bay, 30 km south east of Brisbane, Queensland and belongs to the group of islands known collectively as Quandamooka (Moreton Bay). According to the 2001 census, North Stradbroke Island has a population of 2413, of whom 13.9% are Indigenous. It was first sighted by Captain James Cook in 1770 and permanent settlement of the island by Europeans began in 1825 when Amity Point was set up as Moreton Bay’s first Pilot Station. At first, the local Aboriginal groups were welcoming to explorers and shipwrecked sailors but later, as the island received convicts and free settlers, there were often violent clashes between the locals and the newcomers. Today, Quandamooka (Moreton Bay) is the homeland of the three clan groups: the Nunukul, the Ngugi, and the Gorenpil, who are recognized as the people of the sand and waters Yulu-Burri-Ba (YBB). These three groups have descendants who have continued to maintain their identity on Minjerriba and a close affiliation with their traditional country of belonging.
The YBB Aboriginal Corporation for Community Health was established in 1990 under the auspice of North Stradbroke Island Aboriginal and Islander Housing Co-op. The Corporation is governed by a Board comprised of local community members. YBB provides a range of health services to the Indigenous population of North Stradbroke Island including: a general clinic, a massage therapy clinic, an optometry service for retinal screening and general eye testing, weekly diabetic clinics offering check on blood pressure, a methodone clinic, counseling service, and a Dental and Hearing Health Clinic. Professional staff includes doctors, registered nurses, and Aboriginal health workers, Counselors, a drug and alcohol worker, a dietician/nutritionist, optometrists, a maternal and child health nurse, and a hearing health team. YBB also provides home visit services for regular patients of the practice whose condition prevents them from physically attending the surgery and also provides transport as needed. The center’s services are well-attended by the local Aboriginal population and also by some of the non-Aboriginal Stradbroke Island people. While the community is well-serviced during the day, there is concern about the lack of after hour services. This concern is compounded as access to mainland emergency services is by ferry, which does not operate a service from 8 p.m. until 6 a.m. Air sea emergency remains as the only alternative during these hours.
Through its services, YBB is an excellent example of the Aboriginal community taking control of their own health needs. This in its true sense is capacity building in community. Further information about the service can be found on its Web site: Web site: http://www.ybb.com.au
The chapter aims to encourage nurses toward a critical analysis of their own practice. All the contributions to the chapter bridge the disciplines of nursing/health studies, anthropology, and religious studies, and emphasize the importance of viewing the patient in the context of his/her family, community, culture, and religious affiliation. To enable appropriate care for Aymara, American Indian/Dakota, and Aboriginal people, there is an urgent need for nurses to have knowledge of the historical, colonial, and social processes that have resulted in social and health inequities for these groups. Also, understanding their spiritual dimensions and appreciating cultural difference may provide better health care services delivery. Hopefully, the experience of being hospitalized may be transformed from a traumatic one to a positive one, promoting the interaction of indigenous, American Indian, and Aboriginal people with their national health services. Importantly, the community of clients has to be involved in planning and evaluating health care services, interventions, and programs if they are to be effective.
All the case studies look at how members of different ethnic groups conceptualize health and illness, ethics and morality, sometimes in a panorama of everyday medical and religious pluralism. Their commitment to shared values and respect for the cosmological order is fundamental to achieve “the good life’ and ‘to be healthy.” These definitions are morally constructed. Religious beliefs and practices also provide an important idiom for the expression of aspirations and the pursuit of ideals. Moreover, they also have a positive effect on emotional states, promoting solidarity, feelings of confidence, and a sense of full personhood and empowerment as various anthropologists have argued.92 The case studies shed light on the role of beliefs and faith in therapy, providing an account of culturally “traditional” health treatments that are informed by religious beliefs.
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