How cultural differences can make us understand our flaws in the care sector better

Knowledge Collection Care Stories
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[Curator’s note] Alkasem was a doctor student in Syria, but had to flee the country for obvious reasons. He studied for four years at the university, but on arriving here he couldn’t continue his studies because of his status of refugee in Europe. Still he came to the workshop in Brussels and we are all really thankful for his disruptive thinking and propositions that helped us think out of the box and see our Western society from another perspective.

About alternatives to our healthcare system:

In Syria we have an ‘islamic solidarity’ in society that creates a kind of health system without organization, like you have to give a part of your money to the poor, you have social care system that is organized by the people itself. If you haven’t fastened for one day, you have to give food to 64 people. Every doctor works one day a week for free. That is how we can survive under a dictatorship.  We are already prepared for any kind of chaos, it is made for any kind of situation and is part of our cultural heritage.

I want to see the whole of society as one body, but here everybody lives in his box, I call this “boxpeople”. You live together but you don’t really live together. You are online, but not connected, we have to discuss, to see each other more. This is my new society, so i want to care as much about this now then how I cared about my society in Syria.

For exemple the old people are separated from the rest of the adults, they don’t have a connection. Why do you do that? We don’t talk about generational society, we don’t attach value to the older people here and that makes me worry. I hear a lot about that here we work a lot about societal diversity, but not generational diversity

About people sleeping in the streets:

One of the first things I noticed in Brussels is that a lot of people are living in the streets. Why are they living in the streets, don’t they have families to take care of them? Where are the families of the homeless people? I never saw anyone homeless in Syria, or living on a mattress. How did it happen?

Some of the participants responded later on: 

  • the core family concept has been broken down - after uni and growing up you have to support yourself; so there is no glue which keeps family together
  • in North Africa systems are weak - so there has always been a cultural support; whereas in the West the system is supposed to take care of everything
  • "Free, but alone." vs. "Belonging, but coerced" Comparing systems-based  vs. family-based cultures of care (twitter link)

About trust

Everything moves around friendship. I have the feeling that a lot of people in western society start of with mistrust. If you start with mistrust it is difficult to create trust. And without trust no skill can be shared. How can we create a better health system if we need all kind of difficult systems to create the trust that isn’t there really.

In less then one day, Alkasem showed us that the things we find sometimes really obvious aren’t at all for everybody. He inpacted a lot of the discussions with his point of views and made it obvious that sometimes we are still a bit too etnocentric about the way we want to design solutions. Having completly different cultural heritages at the table makes a discussions so much richer.

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Trust

How can we create a better health system if we need all kind of difficult systems to create the trust that isn’t there really?

Wow, @Alkasem , this is a really interesting take on things. I agree 100% with you on this.

I never lived in the Middle East, so I do not have your experience. But it doesn’t look like the West lacks trust. All our societies run on trust; and normally such trust is rewarded, because we are rule-abiders: we stand in queues, show up for work and at school (resaonably) on time, and do not really cheat. Cheating is quite rare.

So: can you say more about the lack of trust you see? What is it that is done differently in Syria?

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thanks Alberto

…I really don,t know I was born and I raised up like this untill we don,t think about it , belive me when I say : I started to wonder about those things here in Europe

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The intergenerational divide

Having met you in Brussels made me really grateful, @Alkasem

I wanted to say that the intergenerational support has a strong tradition in some places in Europe, and some practices are ongoing - I even wrote about how my grandma and grandgrandma before her come to live with her children at old age. What has changed I feel is that we perceive this to be a burden to some extent - and tend to see less the great potential for mutual support. The response to your question about children moving away to become independent is true, and so living with parents after a while can feel like taking a step back. Especially in cities and urban areas, we seem to have no time to engage in real conversations and see what new things we each have to say to each other or needs we have, even in a family…

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Hi Noemi

me I think the issue is more simple , in the middle east we say we live in a big families because it is more warm , inherited consensus make it so easy , trust me , in Syria I never worried about what I,m gonna eat , who,s I,m gonna spend time with ( because of the agenda of duties for people , neighbours , family ) , I started to wonder about that only in europe :slight_smile:

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Yuck, first world problems…

… is what @Matthias would probably say. Worrying about those things doesnt seem like the best use of our time, I agree.

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First world problems, first world opportunities…

There are heaps of literature how this splintering and individualization of society allows for a reorganization that allows modern industrial society to operate much better. Of course if one sees many of the problems industrial society brings with it, a case could be made that we’ve partially overdone it, perhaps to the detriment of our (and other peoples) health and our environment.

Regarding “What am I going to wear today?” - this is a very old story. It dates back many thousand years, and huge investment into clothes and especially ornament can be found with many hunter & gatherer cultures.

But I am sure the subtle and not so subtle differences will start a lot of thought processes about things you’ve until now taken for granted. In Marseille I see quite different approaches to dressing and style whith street scenes looking quite different depending on day of the week or time of day. I find it quite interesting but don’t spend much time on this myself.

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A quote on wealth, consumerism and the real needs we try to meet

To me what @alkasem23 is saying has more to do with the way we spend our time and attention, the everyday decisions we make, of which many are more artificial than essential. Not to generalize of course, but materiality is definitely what makes today’s West as far as I’m concerned.

“Why, then, if expensive things cannot bring us remarkable joy, are we so powerfully drawn to them? Because of an error similar to that of the migraine sufferer who drills a hole in the side of his skull: because expensive objects can feel like plausible solutions to needs we don’t understand. Objects mimic in a material dimension what we require in a psychological one [] Our weak understanding of our needs is aggravated by what Epicurus termed ‘idle opinions’ of those around us, which do not reflect the natural hierarchy of our needs, emphasizing luxury and riches, seldom friendship, freedom and thought.” - Alain de Botton, Consolations of philosopy.

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It may be generational too

Speaking as an American at the age when living parents are all advanced seniors - and many of those seniors live in homes and facilities, while it can be said without danger of over-generalizing, that to many in my age group, having your late-age senior living with you is seen as an inconvenience.

But I think at least when it comes to that WWII generation in the US, a very large number of them want to keep their independence as long as humanly possible.  They don’t want to live with the family and they don’t want to cede authority over their “space” to any of their kids.  So, it isn’t all neglect and self-interest.  I know a lot of people my age who have parents who don’t want to move in, or they do it as a kind of last resort.

The ones who do, and take on a role in the family that I think is more like the model Alkasem describes, seem pretty happy though.  I admire it.

When I was younger living in San Francisco which has a very high Asian population, it seems like all of my asian friends had an elderly relative, usually a grandparent, living in their house.  Every time I went over to this one friend’s house in Chinatown, granny was always in the kitchen cutting up vegetables or something.  I would see that and think, “that isn’t gonna happen at my house.”  Neither generation wanted it.

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Choice is important

Interesting to read you John, I know a couple of those who want to stick to their freedom, and that sounds understandable. I guess what matters is self determination and individual health, and if that is found separate from coliving in family that’s just how it is. The impossibility seems to be in our inability to provide deeper care when people fall through the cracks - if someone is forced to change their life to adjust to scarcity, whether the ill, old or the caretaker her/himself.  I see people coping at most, because there is no real choice and assessment of the situation outside constraints.

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Elder care and big generations

My 1945-1960 “boomer” generation is now heading into retirement, fixed incomes, scant savings and other common attributes.  This has always been the case with elders as a whole, but with my generation and my kids’ equally large “millenial” generation, the sheer numbers of people needing care are about to go sharply up and remain there for decades.

In the USA, the fabled land of plenty where you are free to succeed and also free to fail, statistics show that the average life savings of my generation are barely enough to sustain them (us) for a year in anything like the standard of living now enjoyed.  And that stadard is lower already than our parents’ WWII generation that was both smaller and wealthier, with a vastly larger middle class.  Then what will become of everyone? American Social Security is robust now but without a lot more care and feeding from a unified nation, it won’t stay that way.  And the cost of urban living is going up fast all over America.  Sending seniors out to the country where the health care is worse and one has to drive everywhere isn’t an answer. At least seniors in the USA have Medicare, but that alone won’t cover the total cost of health care.

I think we are going to see a shift towards the generations recombining inoto households and compounds in the coming years.  The “generation gap” that very much existed for my generation and my parents was, and still is in a way, much greater that what we see with my gernation and my kids.  I have four kids, all well into adulthood.  Two of them let me know regularly that they are open to us combining households in later years.  Getting my own mother to agree to such a thing with me or my brothers is like pulling teeth.

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A third model: “elderly peers”

My mother is now fairly old (she was born in 1937). Women in the family seem to have good genes, though, and she, her two sisters and some female cousins in their late 70s and early 80s are still quite formidable. They are also close to one another. So, my mum does have another option, which is to move in with her sisters. This is not as crazy as it might sound, because by pooling their forces they can hold out much longer than each one of them in isolation. Also, they would probably find this psychologically less disempowering than having to fall back on us, because they would help each other rather than being only on the receiving side.

Like in John’s description, my mother and her sisters and cousins are fiercely independent and would absolutely loathe becoming dependent, even on us.

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Intergenerational divide in our politics and world view

Politically, we can see a large divide in the aspiration and acceptance of ‘outsiders’ between the generations.

My Grandmother (and many thousands her age) have become increasingly conservative in their world view. From what i can gather, their experiences growing up straight after WW2 in a culture that still had lots of echoes of the wartime propaganda left an indelible mark on their attitudes to the outsider.

I grew up in a multi-ethnic society, with children from multiple places around the globe. To me, there is no fear or mistrust in seeing people from other ethnic backgrounds around me. But for my grandparents, there is a lingering Nationalism, a lack of acceptance of ‘otherness’ - socially, sexually, racially. Brought up in the social strictures of oost-war Britain they reject the social liberalisation that they have lived through. One could argue that they didn’t really get to experience the full force of the social liberalisation. Many married young and had children young, many women stayed as full-time child carers and had little interaction outside of the home. Many had large families in the models of their parents before them. Their children have experienced the social liberalisation fully (sexual revolution, oral contraceptives, relaxation of the divorce laws), they grew up with a few non-white faces around them because of Windrush (immigration to UK from newly Independent West Indies) or from Indian sub-continental immigration before and after Partition. Their children (my parent’s generation) were also the first people to truely benefit from the way that membership of the EU opened up travel around Europe and the North African coastline. They experienced the realities of live in other countries and these experiences changed how they think. My grandmother has never been outside the UK in her entire life.

Now, at the point when she is starting to struggle with self care (and here i definitely agree with @johncoate 's view that there is a stubborness and irrational sense of personal independence in their generation) more of the balance of looking after her falls on her kids, whose lives have been so different from hers.

My point then is a difficult one to conceed. Although my grandmother is my family and helped to raise me, i find spending time with her very difficult. Her views are borderline racist at times, her attitude to the world is very negative, her experience is narrow and her opinions old fashioned. I am expected to show respect and deference to her based purely on the fact that she is older than me, yet i know my experience of the world is richer and wider than hers. I wouldn’t want to be forced into living in that straight-jacket in order to reduce care costs.

I do think that there are some positive ideas coming through around intergenerational living though. It’s not that i’m intrinsically against ‘old people’, i think the irony is that i’m not especially fond of MY ‘old people’. I would be more than willing to help look after a number of more liberally minded old people. It comes down the idea first put forward in the Open&Change discussion in HuisVDH

“Free, but alone.” vs. “Belonging, but coerced” 

For me, i’d rather free and alone. But i can also see the attraction of belonging. But not the coersion.

Perhaps this strength of intergenerational bond in Middle Eastern culture is down to having a more cohesive and consistant view of the world than we have in the West. Our horizons have expanded to include views about social and personal freedom that still struggle to gain ground in more conservative cultures.

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Important point!

Excellent point, @Alex_Levene . This could be fundamental to the opencare vision.

We propose that communities are good candidates for being caregivers, because they are fair (they share the burden across individuals), efficient (allocation of who takes care of whom is based on self-selection: low overhead, you give care when and where you are readiest/most motivated to do so, receive it in the time and domain of your greatest need), and retain a human touch that state-and private sector provided care cannot (you care for your own, etc.). This is predicated on the givers and receivers of care recognizing each other as one: everyone is part of the same “we”. When a person is recognized as not part of the “we”, the community’s incentive to care for her fails.

And it would be unwise to put it down to human error or happenstance. Some scientists argue convingly that for humans to divide between “us” and “them” is innate, because in our hunter-gatherer past we evolved under selection pressure at the group level. A full argument is made by E.O. Wilson in The Social Conquest of Earth. Thanks to @WinniePoncelet for recommending the book to me.

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Family in Laos

During my short time in Laos, I couldn’t help noticing analogies to this story. If anyone finds this useful, I can try to condense some other impressions and stories from Laos.

I ever only saw one beggar. He was a physically disabled man, unable to stand, having to crawl through the streets. At different times I saw him receiving food from the small food stalls on the street.

I had befriended a local woman, let’s call her Babs, through a common friend and I asked her about this man. Babs immediately knew who I meant. She said that there were not many beggars and homeless people in Savannakhet, a city of 120,000 people and second largest city in Laos. There used to be many people asking for money on the streets a few years earlier. Most of them came from large, poor families outside the city. One or two family members would go to the city to beg and send some money back home. Recently, the local government chased those people away back to the rural areas.

The reasoning was that the families were able to sustain themselves growing crops on their small piece of land, so they should not come begging in the city. Responsibility to take care of each other rests on the family. This is the situation for most of the Lao: they can sustain themselves but they have almost nothing more and live in poverty. Begging in the city is one of the ways out.

Babs said that now, there only remain a few homeless people who have mental or physical disabilities and no family to rely on. In other words, those who have no other options. The police condones them and they are usually helped by the community, like getting food from food vendors.

Babs mentioned that there were plenty of mentally and physically disabled people due to a poor medical system, pointing out especially the issue of giving birth in rural areas. Most of them are cared for by their family.

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Makes sense…

It’s become clearer that homelessness correlates much more with inequality (especially affordability in housing) than with a country’s wealth, which is what might explain cultural shocks as one moves from east to west… I’m reminded of a friend of mine studying in the US who simply couldn’t get past having seen so many people living in the streets in San Francisco.

I would be definitely interested to read about the specifics of family dynamics in Laos, so if you ever find the time do go for it.