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Common medical issues and cultural concerns of Liberian patients
Unlike most African immigrants in the U.S., Liberians speak English, a reflection of their ancestors’ history as slaves in the American South. Although English is the official language of Liberia, over 30 indigenous languages also are spoken. The social customs and culture of the Americo-Liberians were modeled after Southern slaveowners, including holiday celebrations, weddings, funerals, and the establishment of the Masonic Order of Liberia.
A custom unique to Liberians is the “snap shake,” a handshake greeting, which originated in the 1800s as a sign of freedom among former slaves. The custom was derived from the practice of slave owners who would break the middle finger of a slave’s hand to indicate bondage. When shaking hands, you grasp the middle finger of the other person’s right hand between your thumb and ring (third) finger, and bring it up quickly with a snap.
In Liberia, both Americo-Liberians and indigenous peoples are highly patriarchal, with women serving as homemakers, agricultural workers, and childbearers. A traditional marriage practice involves grooms making a bridewealth payment to the bride’s family. Because marriage is viewed as an ongoing process, bridewealth payments can be made over many years. In Liberia, formal education originated with mission schools whose primary aim was conversion to Christianity. In the 1960s, many children received foreign scholarships to attend school in Europe and the U.S. In Minnesota, nearly 40 percent of Liberians are employed in nursing homes, as registered nurses, licensed practical nurses, and certified nursing assistants.
Liberia has a rich history in quilting and textile arts and is known for its classical carved wooden masks and the artistic ability of its wood carvers. The ceremonial masks often are commissioned by secret men’s societies for use in initiation rituals. Liberians are also known for making large wooden spoons with features of humans, animals, and spirits of the forest, as well as musical instruments and drums made from wood, animal skins, raffia, and gourds.4,5
Traditionally, Liberians eat a healthy diet consisting mainly of rice, fish or meat, greens, and other vegetables. Rather than being the main part of the meal, meat or fish is usually a supplement to the meal. Rice is often served with breakfast, lunch, and dinner.
Typical Liberian dishes include a variety of vegetables and fruits, such as eggplant, okra, cassava, and plantains, as well as coconut, peanuts, bananas, mangoes, citrus fruits, and sugarcane. Stews and soups are spiced with cayenne and other hot peppers. Goat soup is considered the national soup. Meals are often accompanied by fufu, a thick paste made with fermented cassava. Cassava leaves or potato greens are mashed or chopped to the consistency of cooked spinach with pepper and onion. This mixture is then boiled with beef or chicken and served with rice.
Favorite meals may include pigs’ feet with bacon and cabbage, fish with sweet potato leaves, shrimp and palm nuts, and a combination of rice and platto leaves or okra called check rice. Favorite desserts include coconut, peanut cookies, and sweet potato or pumpkin pie, and a sweet bread made from rice and bananas. Preferred drinks are homemade ginger beer, palm wine, and Liberian coffee.4,5
Roughly 85 percent of Liberians are Christians. Others in Liberia practice Islam or one of several traditional animist religions. Some people combine elements from Christianity, Islam, and indigenous religions in their spiritual practices. Indigenous religions often recognize the practices of polygamy and witchcraft.
In Liberia, many believe that illness and death are caused by the evil intentions of other people. This belief has lead to many court hearings of witchcraft cases. In the U.S., Liberian often combine both Western and indigenous health care practices and treatments.
Major health concerns for Liberian Americans who have lived in this country for 10 or 20 years are related to hypertension, Type 2 diabetes, high cholesterol levels, stroke, and heart disease. Physicians suggest the increased risk is due to Liberian Americans eating a less healthy diet, with less fiber and more fat, and exercising less in America than they did in Liberia.
Also of great concern for thousands of Liberians living in the U.S. and in Liberia is undiagnosed post-traumatic stress disorder (PTSD). Civil war victims and aggressors both suffer from PTSD. War experiences have created ongoing mental health issues for victims who still come into daily contact with some of the same people who tortured and raped them or tortured and killed their family members in Liberia.
A secondary health concern for this population is the increased risk of infections for Liberians who travel regularly to and from Liberia. According to the World Health Organization, infectious diseases in Liberia, including yellow fever, lassa fever, malaria, typhoid, polio, tuberculosis, and diarrhea, are widespread.
In 2009, life expectancy in Liberia was estimated at 58 years and the maternal mortality rate was reported to be nearly one out of 100 births. In 2007, 20.4 percent of children under the age of five were malnourished. In addition to these health issues, civil war has destroyed the nation’s electrical and sanitation facilities, as well as nearly 95 percent of its health care facilities and medical infrastructure. In 2008, Liberia had only one doctor and 27 nurses per 100,000 people.3,4,5
End of life
At end of life, individuals may be visited by clergy and prayed for by members of a religious congregation. Funerals are very important, are often elaborate, and may go on for days or weeks. A Liberian funeral is a time for both grief, since the departed will be missed by loved ones, and a time for joy, since it is believed the deceased has gone on to a better life among his or her ancestors. On the night before the funeral, a wake is held in the family home where the extended family and friends of the deceased gather for a feast, with drinking, singing of spiritual songs, and often a Liberian drummer. The purpose of the wake is to be jovial, to console the immediate family, and to wipe away the grief.
Liberians in Minnesota
Although there is no accurate or official record of the number of Liberians living in Minnesota today, according to the Minnesota-based Liberian Journal, Minnesota has one of the largest Liberian populations in the country, with the highest concentration living in the Brooklyn Park area. In a March 2, 2009, Star Tribune article, Kerper Dwanyen, then president of the Organization of Liberians in Minnesota, said more than 250,000 Liberians live in the U.S., with an estimated 35,000 residing in Minnesota. People of Liberian ancestry make up the third largest group of African immigrants to Minnesota. Large populations of Liberians also reside in Philadelphia, Pennsylvania, and Providence, Rhode Island.1,2,3
As a result of 14 years of civil war in Liberia that began in 1989 and ended in 2003, the U.S. granted temporary protective status to thousands of Liberians and has extended that status several times. Although peace was declared with democratic elections first held in 2005, Liberians say the political and economic situation in Liberia continues to be fragile, and those who have put down roots in Minnesota do not want to return to a difficult life in Liberia. Liberia has a unique historical relationship with the U.S., initially connected through the slave trade. In 1820, the American Colonization Society, a private organization that included U.S. President James Monroe, sent nearly 300 freed American slaves to Liberia to colonize the country. In 1847, the colonists, identified as Americo-Liberians, established the Republic of Liberia based on the U.S. government model. In 1980, the Americo-Liberians were overthrown, initiating two civil wars that devastated the national economy and left nearly 250,000 people dead. Agricultural production was completely disrupted and the entire population was dependent on donated food.2,3,4,5
Culture in context
Culture is essential in assessing a person’s health and well-being. Understanding a patient’s practice of cultural norms can allow providers to quickly build rapport and ensure effective patient-provider communication. Efforts to reduce health disparities must be holistic, addressing the physical, emotional, and spiritual health of individuals and families. Also important is making connections with community members and recognizing conditions in the community.
Get to know your patients on an individual level. Not all patients from diverse populations conform to commonly known culture-specific behaviors, beliefs, and actions. Generalizations in this material may not apply to your patients.
In order to provide equitable and effective health care, clinicians need to be able to function effectively within the context of the cultural beliefs, behaviors, and needs of consumers and their communities. According to the 2002 Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, racial and ethnic minorities tend to receive lower quality health care than nonminorities even when access to insurance and income is accounted for. Failing to support and foster culturally competent health care for racial and ethnic minorities can increase costs for individuals and society through increased hospitalizations and complications.
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