A brief clinical scenario:

62-year-old Sri Lankan male, who moved from northern Sri Lanka two months ago to Staten Island, presents to your clinic to establish care. Upon discussing the patient’s medical history, the clinician discovers that the patient has a history of feeling thirsty and excessive urination for several years due to Neerilivu (diabetes term in Siddha medicine). He states he used to take an herbal medicine for this condition in Sri Lanka. He reports no concerns or adverse effects while on the medication. The patient requests more of his medication since he ran out recently.  

Why it requires cultural awareness/humility:

This patient has a probable history of type 2 diabetes mellitus and was taking herbal medicine to treat his diabetes while in Sri Lanka. This scenario requires cultural awareness as the patient is requesting an herbal medication that is unlikely to be available in the United States. The clinician will need to discuss other options, including but not limited to traditional diabetic medications available in the United States for him to start.

The cultural factors that need to be considered:

• This patient is from the northern region of Sri Lanka, making it likely that he is a Tamil Sri Lankan, which is confirmed upon further discussion with the patient.
• He believes in Siddha medicine, which is one of the four traditional medicinal systems practiced in Sri Lanka. This type of medicine is less known to the western world because a lot of the literature have not been translated from Tamil. However, there are over 150 plant species used for anti-diabetic medications in Siddha medicine in addition to animal parts and inorganic substances. Understanding that this patient has differing beliefs in how to treat his diabetes needs to be considered when approaching treatment plans.
• Siddha medicine links diabetes to a variety of issues including consumption of diets rich in animal fat and certain social behaviors such as excessively walking in the sun or excessive sexual intercourse and not to biomedical changes in the human body.
• While pills are the most common formulation used for treatment of diabetes in Siddha medicine, other preparations such as powders, oils and topical creams do exist. The patient may have not taken pills in the past for his diabetes. Additionally, the patient may not know the exact preparation/ingredients in his medication.
• Of course, if the patient does not speak fluent English, an interpreter is required for the entire visit to ensure proper communication and understanding.

Any beliefs that might be different from western medicine beliefs or unique considerations that care of this patient might require:

• The patient may have never had bloodwork done for diagnosis of his diabetes, especially if he was seen by a local Siddha healer in a rural area, as the diagnosis and treatment would have been based on his symptoms, his pulse, and the odor of his urine.
• It is important to understand that this patient may have differing beliefs as to why he has this illness.
• The patient may not believe in using western medicine to treat his diabetes or he may feel uncomfortable in this new setting. He may request that he speak to a Siddha healer instead and deny further treatment, especially if the clinician does not respect his background and previous treatment.

Areas where conflict might develop:

• Conflict might develop if the patient has strong beliefs about the traditional Siddha medicine he was using for his diabetes and does not want to use anything other than what he was previously using in Sri Lanka.
• Assuming that the patient wants to be started on medications available in the United States for his diabetes.
• If the patient had previous encounters in the United States, or elsewhere, where the clinician was insensitive to his use of herbal medicine, he may be reluctant to share his treatment methods. He may be reluctant to try other methods, especially if the clinician immediately rejects his previous treatment methods.

What would be expected of the student in demonstrating Cultural Competence/Humility – what things would the student be expected to say/do/avoid/suggest/consider in this scenario:  

• The student should be respectful to the patient’s beliefs in his illness and his previous treatment. Use open-ended questions and do not judge his culture or medicinal beliefs.
• The student should explain to the patient that the remedy he was using is likely not available in the United States, but there are other options available (of course, this is after consent to do a fingerstick and workup including hemoglobin A1c to confirm his diabetes diagnosis).
• Staten Island is home to the one of the largest populations of Sri Lankans outside of Sri Lanka itself. It is possible that there are others in his community who have continued to use their own traditional medicine or have transitioned to western medicine. The student can encourage the patient to discuss the treatment plan options with members in his community.
• Do not say “traditional medicine does not work” or “your healers or Siddha doctors were not helping you.”
• The student should consider asking the patient what he believes caused this condition, as his beliefs may differ. Do not dismiss these beliefs.

Any patient counseling or education that would be required in the situation:

• Counseling on available options of medication for diabetes in the United States.
• Explaining the physical exam and subsequent laboratory testing that is needed to diagnose diabetes and obtaining proper consent from the patient to continue with the evaluation.
• Educate the patient on possible changes he can incorporate into his daily life now, such as exercise and diet. Additionally, by exploring the reasons why the patient believes he has this illness, the patient may be able to make lifestyle changes that he believes will help treat his diabetes (i.e., not excessively walking in the sun or decreasing his consumption of certain types of food)
• Clearly explain that regardless of what treatment he decides, managing diabetes is important and discuss the risks of poorly controlled diabetes.

Sources:

• https://www.sciencedirect.com/science/article/abs/pii/S0378874116304779
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6192459/
• https://www.nhp.gov.in/Neerizhivu-(Diabetes-Mellitus)1_mtl