Well Around The World

inspiring healthcare innovation through medical anthropology and ethnographic research

Health Insights Asia - a summary from our travels through China, Vietnam, Cambodia, Laos and Thailand

March, 2011:

We are on the plane leaving Asia for Europe. The past three months have been an incredible experience rich in stories and anecdotes, pictures of artifacts and personal health experiences. While there are still so many stories to be written down and shared with you, here are a couple of themes that have bubbled up and sit at a higher level. It's probably not quite accurate to lump China and Indochina together, as there are major differences between each country and region, but given the similarities, I'll attempt it anyways.

 

1) Maintain the health balance through daily action
One thing that strikes me as major difference between Asian and Western notions of health, is the perception of the default state of health. Growing up in Germany and the UK, I get the sense that being healthy is perceived as normal. If you become ill, something is wrong with you. In China, and it also seems to be the case in Vietnam and Thailand, health is a matter of balance. Everyone seems to be taking something for one ailment or the other. While it is normal to constantly do something for one's health by eating the right foods and taking natural medicine, I wonder how people perceive sickness.

A while ago, I came across an academic paper published by a medical anthropologist that examined how people felt about the common cold versus the flu in Europe. There seems to be an intriguing difference: while people felt that coming down with a cold was their fault, for example they hadn't dried their hair properly after a shower (a Celtic belief) or didn't wear a scarf in cold weather (also a Celtic belief), the flu was perceived as something beyond their control.

Do people feel guilty when they get out of balance, i.e. sick, because they haven't done the right things to prevent it?


2) Fine-tune well-being
Western medicine is known and admired for it is fast acting and solves a big problem quickly. It excels at fixing life threatening emergencies. However, its strength isn't to create sustained well-being . Traditional Chinese Medicine (TCM), herbs and other remedies take longer but enhance one's well-being as they bring the body back into a balanced state. In China, severe and chronic conditions, such as diabetes or hypertension, are not only treated with Western medicine, but also with TCM. In Vietnam and Thailand, it seems that people also complement their treatments with additional herbal medicine from pharmacies that cater both, Western and herbal medicines.

3) Strengthen cultural health identity by practicing local health rituals
Strong presence of Western development organizations seem to push local practices of healing to the periphery, it seems. Cambodia and Laos, the two least developed countries in the region, seemed to have the highest numbers of development organizations, and a correlation with lowest number of herbal pharmacy shops visible and accessible from the street. Are there any development organizations that includes local health practices?

So, when people are poor and cannot afford western medicine, they perceive their local health practices as poor man's solution. It's cheaper and more accessible than western medicine. Health organizations often lump local practices together with superstitions and so practices get pushed to the periphery. Until they are stopped being practiced, maybe.

On the flip side, as people become more well-off, when is Western medicine THE cure versus A cure? What difference does it make for people in their journeys from sickness to wellbeing when local health practices are included by the western medicine healthcare provider vs sought out by themselves? In China, it seems that cultural health practices bring a cultural pride and identity to people. What happens, when people loose this notion of cultural health-self?

Story:
Southern Medicine - Vietnam's medical identity?

 

4) Including the spiritual world for a complete health stakeholder map
Accidents, disease or disability are commonly linked to people's superstitions and beliefs in ghosts and spirits of the ancestors. While in the West, scientific explanations are sought, it seems that the Asian approach looks into both worlds: the spiritual and the scientific. It's easy to claim that the more educated and developed people are, the more they focus on the scientific explanations. The stories that I've come across suggest something else: both worlds exist in parallel – just to play safe? Or, are there important socio-cultural needs that aren't addressed by the rational scientific approach? The spiritual aspects deal both with the emotions of the individual as well as the family and larger community.

Stories:
Laos - Angry spirit causes accident
Vietnam - Ancestor's spirits top doctor's orders

 

5) ...?

This is by no means a complete list, and I am curious to hear from you. What patterns have you observed? What is missing? 

 

Vietnam - Bloody Hanoi traffic

Warning: this blog post contains disturbing images.

Walking to a restaurant in Hanoi, we pass by a display that is rather disturbing: close-ups of injuries, people with bloody limbs or missing limbs. We are quite confused and disturbed seeing these awful images, especially right before lunch. Later, we find out that this is an emergency hospital for accident casualties. In order to raise awareness of the results of risk-taking in traffic, they display these images. Traffic in Hanoi is fast paced and there seem to be no rules at first sight. Cars and motorbikes come from multiple directions. As pedestrians, we are at the bottom of the food chain and quickly learn different techniques to cross the street:
(1) Wait until someone else crosses the street and follow in their 'shadow'. A group of other pedestrians with the same goal makes it even easier as critical mass allows you like a school of fish to look bigger and even the fiercest drivers slow down.
(2) Move slowly into the traffic and walk across at a steady speed so the traffic can flow around you without halt.
(3) Hop into a cab and let them do the U-turn. This had crossed our minds but we refrained from doing it – intrepid travelers' honor.

From a pedestrian perspective, Hanoi's traffic is intimidating and the scare tactics seem to be not needed. However, a French expat tells us that traffic becomes a very different game the moment you sit on your motorbike and weave between cars, pedestrians and street peddlers.

My guess is that displaying bloody images as scare tactics don't work very well, though. It's often not the fear of our own lives that make us change our unhealthy behaviors, but the fear of negative social impact. “Others will think badly of me if I do X' seems to be a more powerful formula. People in Russia started using deodorant when they feared social exclusion, as folks with smelly armpits failed to get jobs they were qualified for. And, Listerine mouthwash became successful as halitosis was invented as a condition that would interfere with one's dating success. More on Wikipedia: Listerine's new ads featured forlorn young women and men, eager for marriage but turned off by their mate's rotten breath. "Can I be happy with him in spite of that?"

So what could this hospital do to make irresponsible driving and traffic accidents socially unacceptable? Stories of families who ended up spending all family savings to restore their loved one's health, sacrificing family business opportunities (key Vietnamese value) and educational opportunities for the children (another key Vietnamese value). It'd be interesting to prototype a couple of stories that touch upon key cultural values and allow people to engage deeply instead of showing bloody images that make you want to look away and not think about the possibility of an accident at all.

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Vietnam - One stop barber shop

On Cat Ba island, Vietnam, we observe a barber cleaning his client's ears on the street. The headlamp adds a sense of drama to the situation. How deep will he stick his little metal tools into his customer's ears? In the West, the following phrase is commonly cited: “Don't stick anything into your ears that's smaller than your elbow.” But in Asia, getting one's ears cleaned is part of a hygiene ritual. I've heard people in China claiming that it is important to have one's ears cleaned regularly otherwise they clog up. A barber offering the service told me that his clients find it quite pleasurable, like a massage.

Vietnamese barbers seem to also offer other services such as nose hair trimming and chiropractic neck adjustments. Watch out what you are getting into!

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China|Laos|Vietnam - Mouth mask: a multi-purpose tool

In China, riding on busses with chain smokers and in polluted cities, our mouth masks have become our best friends.

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In Vietnam, the mouth mask is part of the motorbike outfit together with the helmet and gloves during chilly weather.

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It also protects you from 'cold winds' entering through the mouth and nose which are commonly believed to be causing sickness. In China, it's utilized to protect others from one's own sickness.

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But there is more to the mouth mask than health. Mouth masks are also utilized in the quest for white skin. What a tan is in the West, white skin is in Asia. And probably even a little more desired, as white skin speaks of higher social class, especially for women. So for this social engineering purpose, women of lower social standing do everything to protect their skin from the sun. 

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For those of dark pigmentation, there are a range of products to whiten your skin (Pakse, Laos). Alas, it's impossible to find a skin moisturizer that doesn't offer to whiten your skin. And just to be on the safe side, this Nivea deodorant also does the job under your armpits (Bangkok, Thailand).

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Vietnam - Helmets for hairdos

In Danang, Vietnam, we saw motorbike helmets that had a little opening at the back and wondered whether there was a little clip-on of some sort. It all became obvious when we see a woman on her motorbike zooming passed us: her helmet fit perfectly around her hair bun.

How many times have I had to redo my hair bun to fit with my bicycle helmet? As European I must admit that the thought of not wearing a helmet once in a while crosses my mind - even in the California where biking helmets are a social norm. When I lived in Munich, my vanity many times jeopardized my safety. The Danang helmets elegantly solve this issue, making it so much easier to comply with safety regulations. I wonder about the impact this considerate design has made?

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The pictures below were quite tricky to capture as we were in a taxi rushing to the bus terminal. It took me a dozen attempts or more to get these shots. Fortunately, hairdo helmets are popular in Danang.

 

China|Laos|Vietnam - Medicinal souvenirs

When Chinese travel, their souvenirs include the usual knickknacks as well as local produce such as fruit, honey, meats and also natural medicinal products. Unfortunately, the US and many other countries disagree with such practices and many Chinese travelers have to give up their often pricy purchases. Next time you are at an international airport and a flight from China arrives, watch how the customs activities increase and the dogs sniff around to detect any last bits and pieces of produce.

In Vietnam and Laos, it also seems to be a common practice to purchase medicinal souvenirs. Shops selling local natural remedies are right next to the touristy souvenir stores. In Sapa, Vietnam, close to the Chinese boarder, many natural medicinal products are sold as imports from China. Our Vietnamese friend Yen tells us how her brother bought some of these maggots soaked in alcohol and is crazy about this medicine. Whenever he feels under the weather, it's his first choice to get better.

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This one below are herbs crushed to make a powder for medicinal baths. The Red Dzao tribe use these herbal baths to stay healthy and energetic in the mountains. More on their herbal baths here.

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In Laos at a famous waterfall sightseeing spot, local natural medicinal products are sold next to souvenirs: dried roots, dried frogs on sticks and palm sugar wrapped in bamboo fibre.

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Are Chinese and SE Asian tourists more open to conversations around health at sightseeing spots? Could this behavior of purchasing remedies at tourist sights be leveraged for public health campaigns? What if pharmaceutical companies would get out of their medical setting and allow let say their new diabetes treatment to be discovered right next to local remedies?

 

Vietnam - Southern Medicine: Vietnam's medical identity?

Vietnam seems to have one additional medical framework: Southern Medicine. Our Vietnamese friend Van explains, “while Western Medicine comes mostly in white tablets, Chinese Medicine consists mostly roots and animal parts, Southern Medicine, unique to Vietnam, is herbal leaves.”

It's fascinating to me, how Vietnam's three medical mindsets reflect the geopolitical forces the country has been exposed to throughout history: 1000 years under Chinese rule, French colonial rule and of course US military activity during the American War as the Vietnamese refer to the Vietnam war.  

A people that has been pushed and pulled in so many directions throughout history makes me wonder whether there is such a thing as a 'medicinal identity'. When is it of importance to have a set of remedies that is a true product of one's own culture and people, and not imported or introduced by outside rulers? Are there any studies that have shown a treatment to be more effective when cultural pride is involved, such as developed by culture X for culture X? I China, I've seen this design aspect being played out in consumer electronics and the claim that Chinese understand much better what Chinese need. How about in the health space?

In Sapa and Hanoi, we come across many shops selling Southern Medicine. It seems like they come in clusters occupying entire streets or certain areas of town. Van tells us that each herbal store in Hanoi is owned by a family and that the knowledge is passed down from father to son for multiple generations. We browse through them and they are a mixture of Chinese and Southern Medicine: dried roots, alcohol tinctures, various animal parts and dried leaves. We walk into a couple of them to try and find someone to talk with, but as it turns out the herbalists are busy during Tet (Vietnamese New Year), and the women and teenagers tending to the stores weren't able to answer any of my questions. They only pointed us to the self-explanatory drugs and supplements, such as weight-loss enhancers which are mostly imports from China. It seems that the younger generation isn't that interested in learning the family knowledge. But since the entire country isn't in its representative state, I don't want to draw any conclusions.

Have you had any experiences with Southern Medicine and would like to share your story? I would love to talk with you, please get in touch.

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Vietnam - Eat your fruit, says Uncle Ho

Visiting the Ho Chi Minh Museum, we learned how he kept in shape while he was hiding out. What neat little fitness devices. The best part in this bizarre place was this installation of Uncle Ho's favorite fruits. In today's context of growing fast food, is this a reminder to choose the healthier options?

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Vietnam - Ancestor's spirit tops doctor's orders

For the past couple of years, Van has been carrying a map of northern Vietnam with her, "to find my uncle and bring him back home," she explains. At first, the way she talks about her uncle makes me think that he's still alive. Only as our conversation progresses, I finally understand that he passed away in the "American War", as the Vietnamese call the Vietnam War, and his remains have yet to be found. Running a small silk shop with regional handicrafts, Van is the one in her family who travels the most and while she is looking for local weavers for beautiful fabrics, she also carries out the family search for her uncle's remains.

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Thousands of families are searching for their relatives who died in the war and since official information is rare and hard to obtain, they seek help from psychics and spiritual mediums of the exact locations (read more from the BBC). Van's family has attended a session where a psychic channeled her uncle's spirit into her cousin. But the spirit was of the dumb kind and couldn't answer any questions so the family continues to seek help through professional mediums. “We know of the right place, once three mediums have given us the same information, then we can be sure.”

Medium centers from the outside looks like homes or offices but inside the living communicate with the dead – many to seek answers to their decade-long searchers for the remains, but some to just talk with the deceased because they miss them, are concerned of their well-being or need their advice.

When the remains of a family member are home, mediums aren't needed as the ancestor's spirits are readily accessible in prayers and dreams. Every Vietnamese home seems to actively care for the family altar as the ancestors are perceived as extremely important for the physical, emotional and financial well-being of the family. “It's the duty of the living to care for the spirits of the deceased and send them whatever they might need,” Van explains. This is done by burning paper money in all currencies, paper clothes, and even paper motorbikes, airconditions, TVs, cell phones and laptops. The idea is that happy spirits can better protect the family.

“The ancestors give us advice and help us with important decisions. It's common that an ancestor has an opinion and helps us make the right decisions, for example when we buy a house or a family member is sick and requires medical treatment. Then, the ancestors might tell us which hospital to go to, whether to trust that doctor, or when to stop or change a treatment plan.”

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