© Springer International Publishing Switzerland 2016
Michael Silbermann (ed.)Cancer Care in Countries and Societies in Transition10.1007/978-3-319-22912-6_44. The Magic of Dreams: Conflicts and Quandaries Within Multicultural Societies in Transition
(1)
Department of Psycho-Oncology, Institute of Clinical Oncology, Assuta Medical Center, Habarzel 20, Tel-Aviv, Israel
(2)
Clinical Psychology Track, School of Behavioral Sciences, Academic College of Tel-Aviv-Yaffo, Tel-Aviv, Israel
Keywords
Cultural conflictCultural diversityHealth careIslamIsraelMiddle EastThe Story of Mira and Ramzi
He whose face gives no light, shall never become a star.
—William Blake [1]
Patient: Mira—Jewish female, 36 years old, student
Husband: Ramzi—Muslim male Arab, 37 years old, religious
Background
Mira was in her first year of an M.A. program in English and Arabic Literature. She was an exceptionally bright student, and had worked as a research coordinator on several projects. She came from a middle-class background—her mother worked as a teacher and her father was a computer programmer. Her nuclear family included two teenaged sisters and a younger brother, all living in Jerusalem. Although the family was not strictly religious, a traditional atmosphere was maintained at home.
Ramzi worked as a car mechanic. His extended family, including his two older, unmarried sisters and three brothers with their families, lived together in his grandfather’s house in the north. They owned a restaurant in the center of the village where the family worked. The entire family professed to be religious Muslims and adhered strictly to the Quran .
Mira and Ramzi met more than 8 years earlier in an open forum focusing on equal rights, which was accessible to both Arabs and Jews. They found a common language and a common dream for an integrated Utopian society. At first they lived together. Later, they were married in a Muslim ceremony despite the blunt disapproval and resentment of both families. In keeping with Ramzi’s family tradition, Mira became part of the hamula (Arabic term for extended family). Mira wanted to continue her studies but her wishes met with opposition from Ramzi’s family, who felt she should become pregnant, produce male progeny, and take part in running the large household. Ramzi promised Mira that in just a few years, after children would be born to them, she would be able to resume her studies. Due to geographical distance, Mira seldom saw her own family but regardless of her sense of guilt for abandoning them, she stayed in telephone contact, especially with her mother.
Medical History
In December 2012, after having visited a number of family physicians in the north, Mira went for a consultation at a cancer center in a centrally located hospital, accompanied by Ramzi, her mother and her sisters. She complained of severe pain, excessive tiredness, swelling in her breast, and difficulty breathing. She was 4 months pregnant after countless miscarriages. Owing to her physical condition and the long distance from her home, she was admitted to the oncology department to facilitate a total physical examination for a clearer prognosis. According to her medical history, Mira had felt ill for more than 2 years. Upon admission to the hospital, she was weak, without an appetite and in extreme pain. Ramzi’s family and Mira had assumed that her symptoms were a result of accumulated stress, pressure to become pregnant, and her sense of alienation for not providing what was expected of her. Mira referred to several instances when she had wanted to visit a family physician because of her difficulties in becoming pregnant. Ramzi’s family agreed that she see the imam (Muslim religious leader) and the nurse of the community who had delivered all the babies in the family. Their recommendations included various medicines and herbs for her “confused soul” as well as for her pain. During the past year, Mira had felt a growth in her breast, but dismissed the possibility of a malignancy, thinking and hoping it would disappear.
Diagnosis
Stage IV, metastatic breast cancer with metastasis to spine, liver, and brain.
Medical Recommendations
Radiation therapy as a palliative measure for localized symptomatic metastasis, hormone therapy (Tamoxifen), an immediate abortion, and strong opiates for pain control.
Outcome
Ramzi and his family were fretful about the abortion procedure and distraught about losing the baby. Mira agreed to the abortion as she believed that the baby was already infected by the cancer. Ramzi’s family, however, felt that the baby was their redemption for Ramzi’s disobedience in marrying a non-Muslim. They met with the local kalifa (leader of the Muslim community, who has political and religious authority), until an agreement was reached allowing the operation. Afterwards, it was revealed that the fetus had been a boy. Ramzi was desperate, guilty, and broken in his mourning. He felt that he had killed his only son. Ramzi’s family was reluctant for Mira to take strong pain medication, especially morphine.
Mira died in May in her husband’s home. Her mother and two sisters were with her throughout the final week. Ramzi fasted, prayed, and cried just outside the wall of Mira’s room.
I had several meetings with Mira while she was hospitalized, at which time she seemed to be living inside herself. She communicated in words of self-reflection interwoven with drowsy silences.
Why do I have this punishment? Why did I kill my only son?… because I transgressed the religious boundaries?….I believed in co-existence and mutual understanding…I dreamed that love could surface and endure a dialogue of reconciliation and connection…My dreams have been overturned and become a punishment, my death… Why is death so total, so invincible, so powerful that it strips away every shred of human kindness and human hope?…Dying is like evaporating forever, like a wind that guides the flames of destruction without any compassion…My family and friends could not grasp my radical change of being with Ramzi…Their non-acceptance was reduced to a simple thought: “It will pass.” It is like my illness that has become dormant inside my skin, and if there is no reconciliation it will destroy my body. I love Ramzi. He is a dreamer, he is kind and generous. He believes in our being together, but it was very hard and strange for his family. I remained a stranger, the outsider without an identity. Now, my illness is their premonition of shame and dishonor. My body has been punished by not bearing Ramzi’s children, by not perpetuating their generations of males… Anger and frustration infiltrated his family’s landscape along with their prayers, their moans and their whispers of unspoken words about my death…
Ramzi’s family was obedient to their father and the male elders’ judgments and decisions. To the women of the household, Mira was “different” and had learned to speak Arabic with her tongue, but not with her soul. She was not a devoted Muslim, and her prayers were not accepted by Allah. Her illness was Allah’s demonstration of infinite compassion and wisdom for her mind and body.
Ramzi soothed his anguish of death through his unconditional belief in the afterlife and Paradise. Death was Allah’s gift to purify Mira’s life. But shadows of grief and mourning emerged from this backdrop of tapestries, painted walls, and the scent of incense. Dreading his own death and impending punishment, Ramzi became silent and withdrawn. His silence was the scream of his pain, his despair, and his loss of a thousand dreams. His prayer evolved into a doleful wail of anger, despair, and guilt. Allah had punished him for his disobedient actions, and now his mantra would forever be a credo of unconditional submission to Him, His truth, and His omnipresent wisdom.
In her wail of whispers before death, Mira begged forgiveness for the shame inflicted on Ramzi’s and her own families. She hadn’t fulfilled the norms of behavior according to Ramzi’s family—refusing to convert to Islam, not bearing children, not reading the Quran and had also dismissed the roots of her Jewish tradition.
Mira implored her family and was granted her final wish to be buried in the old Jewish cemetery in Jerusalem, alongside her grandparents. During her childhood Mira had spent hours visiting these tombs, speaking to the souls of her grandparents and discovering the secrets of the trees. To Mira, that eternal garden of silence had belonged to her in her short life, as it did now in the infinitude of her death. She dreamt of the smell of the earth following the cries of the raindrops, the sound of water being consumed by dormant trees. As she glimpsed at an endless sky, Mira died, her face radiating the brightness of her inner life.
Now Mira had become a radiant star.
(Permission was granted by both of Mira’s families to use her story. Names and identities have been completely altered to maintain privacy. Translated from the patient records of L. Baider.)
Intercultural Realities in a Transforming World
Due to globalization, there is an ever-increasing number of countries and societies which can be described as multiethnic or multicultural. Modern societies are characterized as pluralistic, open, and diverse. People from dissimilar origins, cultures, and languages live together or in distinct communities within the same geographic area. A multicultural society poses challenges relevant to every aspect of human life notwithstanding health and health care services, such as overcoming differences in cultural beliefs concerning health, illness, and medication compliance as well as language barriers. Health care practitioners and policy makers face an enormous task in providing effective health care in any multiethnic environment [2].
Given these challenges we propose three fundamental guidelines for health care professionals :
1.
Cultural diversity should be respected.
Respecting cultural diversity implies more than treating individuals as equals, it encourages health care professionals to strive for a fuller understanding of cultural and ethnic differences. Health care providers must understand that the basic values of Western medicine, such as patient autonomy, are not necessarily shared by patient-families of all cultural backgrounds [3]. Health care providers should seek knowledge about the communities they serve (“cultural competence”) while being reflective about their own values and cultural beliefs, and how these shape the care they provide (“cultural humility”) [4]. In the last decade, a substantial number of epidemiological cancer studies have been categorized as Cross-Cultural Collaborative Epidemiological (CCCE) studies [5], in addition to those studies which address epidemiological issues from a cultural perspective [6, 7]. In view of these trends, it is clear that every analysis of data—individual data deriving from a patient interview or epidemiological data resulting from large community surveys—would not be considered complete without allowing for the full cultural context.
2.
Proper balance between respect for diversity and “common ground” (i.e., equivalent treatment for all) should be achieved.
Generally speaking, medical treatment is moving in the direction of individually tailored therapies. This personalized approach takes into account the biological, behavioral, and genetic factors influencing the interindividual variability in drug response. Proponents of this approach point to its potential for maximizing drug efficacy and minimizing toxicity [8]. Nonetheless, there are limitations to this approach in the area of psychosocial interventions. Individual manuals for each problem area and patient may result in difficulties in researching, integrating, and implementing therapy protocols [9]. It is desirable to achieve a proper balance between diversity and “common ground.” Race or ethnicity may no longer serve as a reliable base for common ground and for studying variation in health, as there are more genetic variations within racial groups than between races and many persons undeniably belong to multiple race categories. Then again, the concept of culture may have positive explanatory power for the differences in health behavior and health outcomes than race and ethnicity [10]. In the context of health behavior, Pasick and D’Onofrio (cited Egede, L.E. 2006) [10] define culture as “unique shared values, beliefs and practices that are directly associated with a health-related behavior, indirectly associated with a behavior, or influence acceptance and adoption of the health education message.” This definition may set the scale for balancing individually tailored therapy and respect for diversity with a “common ground” approach. Both practitioners and researchers may then be able to seek the common beliefs and values concerning health, sickness, and disease that influence personal health behavior.
3.
Conflicting cultural backgrounds and beliefs may be used as leverage for achieving better quality of life.
Conflict may carry the potential for positive development [11] and similarly, cultural conflict doesn’t necessarily lead to devastating results. A well-managed conflict resolution may lead to reconciliation, mutual understanding and more pluralistic views and beliefs by conflicting parties [12]. Societies with “built-in” mechanisms (political and religious institutions or rules and norms) for managing conflicts are possibly better able to accommodate cultural conflicts and resolutions. Societies with conflicts between population subgroups, extreme norms of religious behavior, unstable demographic outcomes and conflicts regarding values and family traditions are more likely to live in fragile stability with an ever-present threat of unresolved conflicts (as in the clinical vignette about Mira and Ramzi, where resolution was only possible in the aftermath).
Israel as an Example
Israel can be described as an amalgamation of cultures, religions, and people from different origins spread over an area of 21,643 km2 with a density of 353.1 people per km2 [13]. In fact, Israel can serve as a laboratory for studying cultural conflicts.
At the beginning of 2013, the total population of Israel was 7,984,500 people, with 91.4 % considered “urban,” as almost half the population is concentrated in 14 large cities. The population is relatively young when compared to other Western countries, with a relatively high number of children per family (the 0–14 age group constitutes 28.2 % of the population; the 65+ age group constitutes 10.4 % of the population; while the average number of individuals per family is 3.72). Age at first marriage is relatively low (27.5 for men; 24.7 for women) and the total fertility rate is 3.05, i.e., higher than the world average [14].
The data presented above draws a complex picture of Israeli society. On the one hand, it is similar in many respects to traditional societies (higher rates of children per family, lower age at first marriage, etc.). On the other hand, according to many standard rankings, Israel is more comparable to developed Western countries. The standard of living in Israel is considered relatively high: ranking 19th among 187 nations on the United Nation’s Human Development Index, with high rankings in education and health and low (3.5) infant mortality rates [15].
Looking at population subgroups in Israel, the picture becomes more complex: The Israeli Central Bureau of Statistics [13] reports that Jews (including small percentages of non-Arab Christians and undefined groups) make up 79.4 % of the Israeli population and Arabs total 20.6 %. The Arab population is subdivided into Muslims (84.3 %), Druze (8 %), and Christians (7.7 %). More than three million immigrants of Jewish origin arrived in Israel since its establishment in 1948. Roughly one-third of these immigrants were born in Africa or Asia (approximately half were born in the former USSR), while two-thirds were born in Europe or America [13].
Muslim Arab families are larger than Jewish families (34 % of Arab families number six persons or more in comparison to only 9 % of Jewish families). The majority of the Arab population lives in the northern regions of Israel in Arab villages and cities, in close proximity to extended family.
Among Jews aged 20+, 9.4 % define themselves as Ultra-Orthodox, 9.9 % as Orthodox, 36.2 as traditional, and 43.9 % as secular. Among Muslims and Christians, 8.5 % defined themselves as very religious, 47.3 % as religious, 25.6 % as not so religious, and 18.4 % as not religious at all [16].
Relating the Israeli Demographic Data to Cultural Conflict
The mixture of countries of origin, religions, and levels of religiosity is fertile soil for cultural conflict revolving around diverse aspects of life, from everyday differences and restrictions (regarding food, music, dress code, and literary topics), to lifecycle events (marriage, birth, and death) and traditional practices and customs. For example, formal marriage in Israel can only be performed under the auspices of the religious community to which the couple belongs, as civil marriage does not exist in Israel. The religious authority for Jewish marriage is the Chief Rabbinate of Israel and the rabbinical courts, while Muslim marriages are conducted in accordance with Islamic law and customs. Couples who choose to marry outside of Israel are registered as officially married upon their return to Israel.
Given the tense and unstable situation between Israel and the Palestinian population, the neighboring Arab countries and the threat of terror and war, the Israeli population finds itself constantly exposed to death threats. The Terror Management Theory predicts that under such circumstances individuals will identify more with their cultural worldview which serves as a buffer against the perceived threat [17–19]. Thus, in Israel groups may live within walking distance of each other and even speak the same language, yet maintain very high cultural barriers between themselves. Under these conditions, even a simple physician–patient encounter is a prospective cultural conflict, for example, in the case of an Ultra-Orthodox Jewish male patient, who normally avoids being alone with a woman, who finds himself alone with an Arab female physician in the general practitioner’s room.
Percentagewise, the demographic data may offer insight into the complexity and cultural diversity of the Israeli population, but it is only through the lens of Mira and Ramzi’s story, that the true nature and consequences of cultural conflicts can be discerned. Mira and Ramzi shared a common dream of an idealistic and integrated society. The first crack to appear in their dream was their marriage, which due to the complex religious-legal situation in Israel, was a religious. Muslim ceremony, predictably resented by both families. Mira became physically and culturally separated from her family by crossing the line from traditional Jewish culture into traditional-religious Muslim culture. As part of her new culture she was expected to live with the extended family and bear children. (As mentioned above, many Arab families live in Arab cities and villages in northern Israel, many with an average younger age of first marriage and with more children per family than Jewish families.) Yet when facing a life-threatening illness such as cancer, Mira found herself isolated from any social support, one of the most salient predictors of lower distress rates among cancer patients [20]. Living in constant pain and at-risk for death, she dismissed any strong extra-cultural worldview as a lost dream. Towards the end of her life, Mira seemed ambivalent about Ramzi’s culture and values. On the one hand, she was labeled a “bad wife” for her inability to produce male children; nonetheless she desired the acceptance and recognition of Ramzi’s family. The chasm between these perceptions caused her desperation and total frustration.
Israel: Cancer Epidemiology
Cancer: According to the last update of the Israeli National Cancer Registry [21], the age-standardized incidence per 100,000 for all invasive cancers were higher among Jews (250.9 for men; 255.3 for women) than for Arabs (218.9 for men; 175.8 for women). The rates for Jewish men were lower than the rates for Jewish women, while the rates for Arab men were higher than those for Arab women. The standardized death rates per 100,000 were higher among men (114 for Arab men; 97.9 for Jewish men) than for women (81.8 for Jewish women; 60.2 for Arab women). Among men, higher death rates were found for Arab men and among women, higher rates were found among Jewish women.
Smoking: According to the Secretary of Health’s 2012 Report on Smoking in Israel [22], there are higher standardized smoking rates (for adults 21+) among Israeli Arabs (24.9 %) than among Israeli Jews (19.8 %). The gender specific smoking rates are 23.7 % for Jewish men, 15.9 % for Jewish women, 43.8 % for Arab men and 6.7 % for Arab women.
Breast Cancer: Although the last decade has seen a decrease in incidence of breast cancer among Jewish and Arab women, according to the 2011 Israeli National Cancer Registry [21], breast cancer constitutes 31 % of cancer incidence among women in Israel. Eighty-seven percent of newly diagnosed women were Jewish, while 8 % were Arab. In 2011, age-standardized incidents per 100,000 were 90.1 for Jewish women and 57.1 for Arab women. The risk for very young women (up to age 34) is similar for both Arab and Jewish women, but in all other age categories the risk is lower for Arab women. The 5-year survival rate for Jewish women with breast cancer was 87.2 % and 78.4 % for Arab women.
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