Culture and health: reflections from a Rwandan refugee and medical student in Australia
Originally published in as a Feature Article in Issue 17 of Vector magazine. For the full issue, click here.
About the author
Emmanuel Ndayisaba was born in Rwanda. In 1994 during the genocide he became a refugee in different East African countries. In 2011, Emmanuel’s family was resettled to Australia through the offshore humanitarian refugee program. After completing a Bachelor of Health Science at Adelaide University, he was admitted to the post-graduate medical program at the University of Notre Dame Sydney, class of 2018.
Having lived as a refugee all his life, he closely observed the issues related to health inequity and how they affect communities and individuals. Today, as a medical student in Australia, he sees himself as having a duty to give back to marginalised communities, like the ones in which he grew up. He advocates for refugee health and wellbeing through education of the Australian community and believes it is especially important for other medical students to be aware of these issues.
Australia prides itself on being a multicultural country. Multiculturalism continues to gain attention in medical school curricula as it becomes increasingly recognised as an important constituent of good health care delivery. Multiculturalism is used to describe ‘the cultural and ethnic diversity of contemporary Australia’. Understanding how different cultures shape the view of health and acceptance of its delivery is a step towards improving the quality of healthcare in Australia.
In this article I present personal reflections from the perspective of an African refugee in Australia, who is also a current medical student at an Australian university. These reflections aim to shed light on the complexity of cultural influences on the health of African refugees in Australia. In particular, I have focused on sharing reflections which are centred around three broad themes: that culture is identity and identity is everything; the importance of effective communication; and not to shy away from discussing confronting cultural norms. I hope that the piece will provide insight into some of the challenges healthcare providers are faced with when working with patients from a different cultural background and encourage readers to consider ways to address these difficulties in their medical practice.
Culture is identity, and identity is everything
I was born in Rwanda, a small country in East Africa in which I lived peacefully for 9 years. In the year of 1994, my family survived the genocide that claimed more than a million civilian Rwandan lives, which forced us to flee our country. Running with nothing, we ended up in many different countries and refugee camps. The political regime in Rwanda meant my family could no longer live there safely, without constant fear of persecution. We were forced to endure a life of uncertainty for almost two decades. Throughout this time, my parents’ emphasis on culture was clear: they did not want their children to lose any part of their culture, as they constantly reminded us, “culture forms our identity”. In 2011 we were lucky enough to receive Australian offshore humanitarian visas, allowing us to finally have a place to call home; a place where we could live, study and cease to exist as refugees and become Australians.
Not long after we reached the Australian shores, I quickly realised that we had brought our culture with us. However, younger refugees like myself felt these cultural differences less strongly. Since I was nine years old, I had lived amongst other cultures, including those cultures in Burundi, Tanzania, and Kenya. I had friends whose parents were Congolese and Senegalese. When I was in primary school, my Congolese friends would teach me how to dance their Congolese dance, while I taught them how to do the Rwandan dance. At the same time I was part of a drumming group made of refugees from East Africa, the Horn of Africa, as well as the Great Lakes region of Africa. For my generation, multiculturalism has always had a strong presence. Many African countries share similarities and these similarities are amalgamated by Australians to create a so-called ‘African culture’. However, it is difficult to define what this really means, as it is a mixture of so many different beliefs, languages and traditions.
Despite the absence of a well-defined African culture, when we arrived in Australia there were instances which caused me to reflect upon the differences between the Australian and African cultures. For example, I was confronted by the idea of a person putting their parent in a nursing home. My cultural upbringing meant that leaving my parents in a nursing home would cause me to feel significant guilt and to believe that I had failed as a son. Yet, the culture here is one that makes aged care facilities for end of life care almost compulsory and inevitable. It may be naïve to think that I will still take of care my parents when they are older, however this cultural belief is still strong. My parents remind me everyday that when that time comes, my responsibility as a son is to take care of them. Given the career that I have chosen to pursue, I will inevitably lead a very busy life. The culture in Australia accommodates this well, as it allow individuals the freedom to choose their career path and lifestyle. My culture allows this too, but it also expects you to follow the dreams of the whole community and culture. This worries me. Specialty training is incredibly demanding and it is often difficult for trainees to balance studying with having families. For someone in my culture, our sense of obligation to take care of our parents, and in many instances beyond the nuclear family, is strong. I am concerned that employers will not understand my cultural perspective and thus won’t allow me the flexibility to look after my parents – a practice which is foreign to most Australians but is an important part of my culture. This will be an important consideration when I need to decide which specialty to choose. I know that I love intensive care medicine, but cultural obligations might force me to look into something else.
There are significant differences in how ‘family’ is defined in my culture compared with Australian culture. Although there is significant variation between African cultures, they all define family the same way and believe that the responsibility of the younger generation is to take care of their aging parents. The importance of extended family in African culture is worth emphasising, as it has significant impacts in terms of immigration. I have heard of cases where refugee parents are denied the right to be reunited with their adult children who were left behind, because the Australian immigration does not consider them to be ‘immediate relatives’. In my culture your mother’s sister is considered your ‘other mother’, your father’s brother is your ‘other father’ and their children are your brothers and sisters. So for a mother to be denied a family reunion with her biological son is often very distressing for families and I found it very difficult to understand.
These and many other differences serve as a reminder that we have moved to a culture where we were a minority and our ways of seeing life and doing things was no longer the only ‘right way’. Few environments, such as workplaces or education systems, accommodate for our beliefs. I have therefore come to understand what it really meant ‘to adopt’ the Australian culture. While there are some cultural values that can’t be maintained, it is difficult to disregard them without facing inner confrontations and turmoil. For younger generations like myself, this change and adaptation to a new culture is inevitable because it is necessary for survival. The move to Australia was a great opportunity to create a successful future and the chance to start again is one of the main drivers behind the courage to embrace the changes. For my siblings and myself, Australia has rescued us from a life without a future, without a name other than ‘refugees’, to a life with opportunities and hope. This means we are ready to do whatever we can to embrace whatever comes with it, for we have so much to gain, but most importantly, we have the time, resources and support needed to successfully make the transition. But for my parents who came from a different generation, their culture is in many ways, the only thing they have that has not been taken away. It forms their identity, their way of thinking and reasoning. Sometimes, it is all they have to offer to the Australian community itself.
I believe it is important for medical students to remember the magnitude of importance culture and identity has on people. When confronted with patients from different cultural backgrounds, there may be resistance to ideas and other difficulties. It is essential to keep in mind that culture is everything to the identity of a refugee and therefore is linked to our self-worth and understanding of the world, our bodies and our health. For this reason, I urge medical students to open their minds, practice patience in understanding how culture impacts the ways of life and decisions made by your patients, and adjust the biomedical management of your patients to fit their needs. In dealing with people from other cultures, young or old, I ask that there may be a consideration for the adjustments they are making to fit into the Australian culture, and as such, a reciprocated effort to understand our roots so that you may be able to meet us halfway in our cultural journey.
Take the time to communicate and communicate effectively
During our first week in Australia a group of African Australians came to visit to see how we were settling in. As the conversation heated up, the subject of ‘how different the Australian society is’ came up. My ears were attracted to one particular comment by a guest, “They have no respect for the anus, they don’t mind sticking fingers inside.” This was followed by a loud laughter. It was not until a year later, when I was doing my Bachelor of Medical Science that I understood what the conversation was all about – digital rectal exams. My own father was at retirement age, putting him in the high-risk age group for colon and prostate cancer.  I became curious about how he perceived this issue, and whether he understood what digital rectal exams are all about and why they are important. As I expected, he was not comfortable having this conversation with his fifth born son. However, I insisted. It turned out that my father and many other African-Australian men were horrified by the prospect of such a test. “After all, what has my anus got to do with prostate cancer?” My father asked me uncomfortably.
This made me realise that patients with these concerns like my own father’s, need more than just ‘doctor’s orders’ to accept such medical procedures. In the case of my father and his peers, the initiative that I took to explain the anatomy and why the rectal digital examination is related to the prostate helped to alleviate these fears and increase understanding and therefore compliance. It was not easy for me to explain this sensitive issue to these men, nor was it easy for my father to accept such so-called ‘strong words’ from his son. However, it was worth broaching this topic because it helped dispel the fears of my father and his friends and gave them a chance to ask further questions. Doctors in Australia may not have the time to explain such details to uninformed, but at-risk patients. However, recognising the issues surrounding knowledge about health, and acknowledging how this can act as a barrier to accessing health services might reshape the way we, as health care providers, communicate with them and approach them as patients.
Language barriers can present another key obstacle to clear communication. One of the major strategies to distribute better healthcare to minority groups is through facilitating translating services. However, in my experiences, the use of interpreter services can be problematic. When we arrived in Australia, my parents needed to use translating services to access health care. But it did not take long before my mother started complaining. The translators they brought her were all people she had met before in our little Adelaide Rwandan community. These were the same people who would invite her to weddings and other social events. They were the last people to whom she wanted to disclose her medical history. It took me a while to understand the magnitude of this barrier. However, once I observed the close relationship my parents had with the Rwandan community in Adelaide, it became apparent why my mother felt the way she did.
For older people, moving to a new country with a new language and culture is a challenging and frightening journey.  My parents had to do it because they were refugees, which meant they could not plan or choose where to go. They just went to a country that would be safe for our family. My parents quickly formed a community with other refugees of a similar age, which helped them feel connected. To them, this small community is their functional community. Within it cultural beliefs remain strong. One of these beliefs is the importance of never exposing vulnerabilities. My mother therefore felt exposed to her community and was concerned about losing respect every time she knew her translator. She felt reluctant to disclose her whole medical history to her doctors, in fear of telling it to the whole Rwandan community in her area. This limited her ability to get an accurate and complete diagnosis and likely had a negative effect on her mental well-being, as she was limited by what she felt comfortable sharing in front of another person from her community.
The eventual solution for my mother was having a translator from a different community. Refugees and other migrants speak more than one language. This was luckily the case for my mother, who also happened to speak French. After considerable advice and encouragement, she asked her doctor to book a French translator instead. She was fully satisfied and at ease to disclose her whole medical history, without worrying about meeting the translator in her intimate Rwandan community. However, many patients of non-English speaking backgrounds might be too shy to ask for a different translator or may not speak another language. A doctor’s initiative in recognising this potential problem may help patients who are refugees and migrants, especially in the early stages of their resettlement process. In my view, having an opening discussion about which languages they speak, and whether or not they prefer someone from another community or country of origin is one of the most important and simplest steps to providing appropriate health care to these populations.
Don’t shy away from confronting cultural norms
It is important for health care providers to understand possible vulnerabilities that may be disguised in relationships when it comes to new arrivals in Australia. One of the well-hidden issues that I have observed in refugee communities is domestic violence and abuse, whether it is physical, verbal or emotional abuse, with both female and male perpetrators. Surprisingly, these tend to go unreported or undisclosed. When I have conversations about this topic with my parents or other community members, it is often shrugged off as a cultural norm.
The issue of gender roles is one that can be a source of conflicts when comparing cultures.  For example, many African cultures still believe in strict gender roles, in which the man is the breadwinner while the woman stays at home and looks after the children. This is not an issue specific to African people, it has been seen in almost all civilisations across the globe. In Rwanda the mixture of the traditional Christianity and African traditions such as dowry payments, where the man has to give a payment before they take a woman for marriage, means these roles have been further validated. Daily Kinyarwanda language for example still refers to a wife as ‘Umufasha’, which translates to ‘helper’ and husband as ‘Umutware’, which translates to ’boss’ or ‘leader’. In my culture a woman’s merit is based on things like how many children she has (especially the number of sons) and how happy her husband looks. This has cemented strong gender roles that are sometimes incompatible with the mainstream Australian culture. While my culture openly condemns gender violence, it does not necessarily recognise other forms of abuse besides physical abuse or unequitable standards. For example, speaking down to a woman with an aggressive tone is permissible for the husband, but not for the wife. It is important to note however, there are differences between cultures within Africa. For example, Congolese women are known to be vocal and can express themselves towards men. The same norm is seen in the West African countries like Nigeria.
During our move to Australia, one of the stages of the long journey was cultural orientation. This emphasised cultural differences to expect when settling in Australia, such as the fact that both women and men have equal rights and that they are both expected to share household and societal responsibilities. The trainer, an African lady, put it like this, “In Australia, the woman is the boss!” At the time this seemed like a laughing matter for me and my brothers. But as soon as we got in Australia, I realised how much fear that cultural difference had evoked in some men. They feared their wives ‘taking over’ their male role, the role of a ‘boss and a leader’ and abandoning their female role of ‘helper’. As a consequence, these men undertook measures to keep all women at home. This is one of the reasons that some women have babies continuously, even though they may not actually want more children. The same cultural upbringing may influence the woman’s actions, as she might believe that disclosing such a situation will make her lose her husband. Sometimes, this partner abuse occurs in the context of power imbalance, when one partner is dependent on the other for their visa, leaving them vulnerable to hidden forms of abuse. There are numerous cases in the community and further research may be important in providing further insight in the future.
Through my exposure to many cultures and different living situations, I have observed that the cultural norms and customs that create such large gender divides are misguided and that it is in a person’s best interest that these barriers are broken down. For example, a female Rwandan refugee in Kenya could obtain employment when their husbands could not. The husbands then took on the role of looking after young children, allowing these families to survive as a result of looking beyond the cultural expectations. Furthermore, Rwanda currently has the highest number of female parliamentarians in the world.  With globalisation and increasing awareness about the importance of gender equality, more and more cultures are shifting towards this ideal.
It is important for Australian doctors and medical students to realise that cultural norms can be changed, even within the home countries of refugees. While cultures may be different, practices that are not acceptable in the Australian society tend to be universally unacceptable and based on respect for human rights, individual freedoms and dignity. Some of these partner abuses that I have observed, although they stem from long lasting traditions, do cause harm to individual victims, and are therefore not to be tolerated in the name of ‘protecting cultures’. Refugee communities themselves are becoming aware of this and do all they can to intervene where such abuses are noticed. I believe the purpose of cultural pluralism is to take and share what is good, while we learn to reject what is harmful.
As health professionals we need to dig deeper and ask the right questions. I encourage health professionals to have conversations surrounding difficult and sensitive topics like gender-based violence. In having these conversations, we may have a chance to overcome adversities that are justified under the cultural banner. Culture is malleable and ever evolving, as are norms and values. Desired change in culture starts with discussions and open dialogue between members of different cultural backgrounds. I believe that doctors are ideally positioned to be active participants in this dialogue.
Moving to a foreign country is not easy and it is especially difficult for refugees, as they do not choose their destination or have time to prepare themselves for the culture shocks they will encounter. These significant changes in their lives often translate to challenges that can be seen in the healthcare sector. As medical professionals it is important to consider the cultural background of patients because, as the problems described in this article exemplify, access to health care on many levels can be difficult for these groups of patients.
These shared reflections are based on my own observations and may therefore vary from person-to-person and patient-to-patient. Being aware that these problems exist and having an open and respectful approach to them will assist in resolving many of these issues. People from diverse cultural backgrounds, refugees in particular, are vulnerable and it is our duty as doctors and healers to help them access health care which is matched with their cultural understanding, needs and values.
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