Chinese culture and aspects of health care PDF Print E-mail
Written by Lachlan   
Sunday, 22 July 2007

U3A talk
12/6/03
Medical School lecture
24/7/03
Dr James Ng

Introduction

The Chinese have long links with New Zealand. The first shipment of seal skins to China was sent about 1792, when seal skins were New Zealand's first export commodity and China became the best customer for the pelts. In the 1840's, there were Chinese itinerants in Wellington and probably a Chinese man named James Quoy, aged 22, was buried in 1840 in Paihia. The first known Chinese settler, Appo Hocton, came in 1842, and the second, John Jackson, arrived in 1844. Then in 1865, two Otago invitations were sent to Chinese goldminers in Victoria, Australia, to come and rework the Otago goldfields. The Otago Provincial Council promised the Chinese equal justice as others received. So they came, reaching a maximum of around 5,000 residents in nineteenth century New Zealand, chiefly in Otago and the West Coast goldfields. This made them one of the founding peoples of New Zealand, and they are the first and always the largest non-European, non-Polynesian race in this country. That said, they passed through the phases of initial welcome, second thoughts and eventual rejection by the white population and were the main cause and principal victims of the White New Zealand policy which arose at the turn of the twentieth century. Their numbers fell to the low point of 2012. From the 1930s, however, a slow loosening of that policy led to the admission of Chinese war refugees in 1939-41, the restoration of naturalisation to Chinese in 1951, and the apparent establishment of equality of race in immigration permits in 1986. But since then, there were imposed what could be seen as racially discriminatory brakes against Chinese influxes in 1996 and again in 2002-03. To be sure, the brakes were put on all Asians and others, but the Chinese component involved was a prominent factor in the saga. Meanwhile the Chinese population in New Zealand has reached about 100,000, comprising some 20,000 Cantonese with a history going back to the goldfields and about 80,000 Chinese newcomers from various parts of Asia who have arrived especially since 1986. The census in 2001 counted 104,000 Chinese residents but they included students and tourists; nevertheless, immigration since then has possibly made up the 100,000 mentioned.

What is it that makes Chinese immigration so distinctive and recurrently controversial? The irony is that ever since the goldmining days, the Chinese are regarded as 'safe' and intelligent immigrants. They are law-abiding, industrious and family orientated; they do not interfere with the politics or religion of others and they have no bad record for immorality or for chasing after women.

So is it their skin colour which offends? Perhaps, particularly in the earlier nation-building years - but New Zealand now accepts other coloured races. Is it because they are concentrated in Auckland? Possibly, yet the polls suggest that Auckland is not notably a bastion of racial prejudice. Is it because of their chequered history in New Zealand that makes one pause in uncertainty of their value? It is true that the early Chinese were sojourners rather than settlers but history has shown that their descendants can integrate and assimilate well into the wider society. Are they dole bludgers and exploiters of our welfare state, thereby causing resentment against them? The probable truth is that they are no better and no worse than any other New Zealand people, and in fact, many are selected to bring in money and establish new business here. A friend maintains that it was not so much the question of race but the rapid ingress of considerable and initially hard-to-digest numbers per se which offended us in around 1996 and 2002.

Another friend, an Australian, thinks that New Zealand's unfinished issues in biculturalism may have delayed a push into acquiring a fuller understanding of multiculturism - which might help in mollifying attitudes on recent Chinese immigrants. Maybe another reason for the insensitive treatment of Chinese immigration is because the Chinese in New Zealand have barely or just reached the threshold of political strength in Auckland to be seriously heeded by politicians. And a clue may also lie in the old New Zealand saying that the Chinese were persecuted for their virtues. Somehow, Chinese culture produces what New Zealand observers acknowledge to be a confident, self-sufficient, adaptable and diligent people. Therefore they were formidable and often successful competitors in past New Zealand and in so doing, promoted white unease and envy. Can it be that the Chinese newcomers are evoking a degree of these old feelings again?

Our guessing shows that New Zealand needs more knowledge of the Chinese in its midst, and surely this is desirable not only because they are now a numerous minority, but because we now have Chinese tourists approaching 40% of the projected half million tourists from Asia, Chinese students are another 40% of the foreign students who come here, and China is New Zealand's fastest growing trading partner in the region most important to the New Zealand economy. A good way to start is to understand their culture.

Chinese culture

Chinese culture made China a world power for much of its history and is doing so for modern China. What are its features?

The fundamental differences between Chinese and Western cultures is that Chinese culture promotes the group and stability and Western culture promotes the individual and change.

Chinese culture reflects the unique demography of China. The Chinese are said to have common descent from the Yellow Emperor. While this belief is legendary, nearly all Chinese (around 95%) originate from 100 clans. A clan may comprise, or nearly comprise, a whole village or suburb, and counties, provinces and state are conglomerates of a vast number of villages and suburbs with such clan populations. Within each clan population or grouping, in whichever village or place, there are smaller subdivisions or groupings of extended family which subdivide further into linear and nuclear families.

Chinese society thus consists of an aggregate of clan and family groupings, rather than divided into hereditary classes or castes. Put in another way, Chinese society appears as a mass of circles or groupings rather than stratas or levels. Within each circle or grouping the people are related in clan or closer kinship and offer cooperation and succour to each other. Moreover, the smaller groupings can exploit the greater resources of the larger, if of the same clan. The groupings have also been likened to grains of sand which are marvellously adapted against adversity. Whatever the misfortune, a tray of sand will absorb a shock with the certainty that some grains will survive.

Marriage and friendship created links with other clans and groupings, especially since marriage must occur outside one's own clan. Therefore, a district may have all its groupings so associated together, and this forms the basis for common action in an emergency. These associations were further used by Chinese emigrants to extend the clan concept of mutual support and camaraderie to all those overseas from the same area of origin, specifically, according to county origins. I am told that the same kind of helpful extension is happening in the Chinese demographic shift from the villages to the cities today.

As well traditional China gave considerable legal and moral authority to the elders of the groupings, who, therefore, undertook a lot of local governance on their own initiative, even policing, disputes resolution, education, roading, farming projects and so on. As a rule, the central government did not appoint officials below top county positions. These officials had deputies in the larger county towns but not in the villages - where most Chinese lived. Our cluster of Ng villages, for instance, built a primary school in each village, and a secondary school in the nearby market town, and called even overseas kin for finance in such projects as constructing wells and local roading. However, once in a while, a bigger or unresolved matter like banditry or an inter-village spate may require intervention by officials. Apart from this, the latters' routine purpose was to tax the locals on their rice-fields land in an ideally light-handed and paternalistic administrative role in which the ruler was regarded as the father of the nation. Correspondingly, each grouping tried to be a microcosm of the state, with the elders emulating the perfect ruler and his executive within the bounds of their automony.

Because the local groupings had authority and because so many persons were related to each other, the Chinese cultivated compromise, patience, mediation and harmony, and leadership by panels or committees. And you would know that the best atmosphere for fostering harmony is provided by peace, order and stability. The fostered respect of elders and reverence of ancestors cemented the sense of social unity.

Chinese culture thus tends to be communal in nature and has the tendency to minimise confrontation. Consequently, Chinese culture is said to be more pacific and passive than Western civilisation. It does not preclude ambition, but in the narrow village life which encompassed the vast majority of Chinese, the options and opportunities for sudden enrichment and advancement were rare. Perhaps the limited opportunities were a reason why the Chinese people developed an aptness for the long view. The universal yet arduous road to advancement in old China was education which could take a person into the mandarinate and this avenue remains deeply embedded in the Chinese psyche - which means the encouragement of education in the young. But for those who remained in the villages with their limited resources, the norms of life involved hardship, frugality and diligence.

Out of Chinese culture emerged the observable Chinese characteristics, including a family and group orientation, the seeking of consensus, order and stability, hard work, thrift, a commitment to education. The characteristics lead to specific behaviour and mannerisms, such as the avoidance of direct 'no', the walking away from potential argument, conflict or confrontation, a low profile, the hiding of one's strengths, the depreciation of one's success.

Of course I am speaking generally, and other peoples and races possess these features also. For example, the key characteristic of Chinese culture which makes successful families is family orientation - the concentration of interest on family, and hence on the betterment of the children. But when I emphasise how Chinese parents focus very much on advancing their children, I have been told off - that Westerners, too, care for their families. No doubt if I spoke to Maoris or Pacific Islanders, they too would react the same way. Yet it seems to me that Westerners are looser in their family orientation and tend to let their children go into the world earlier than the Chinese, whereas the Chinese run a tighter family for longer, often into the young adulthood and early married years of their children and frequently longer. I use the term 'tight' in the sense of running a 'tight' small business or a 'tight' ship. In my experience as a family doctor, I feel that Western parents let their children choose and go their own paths too soon - in sixteen year olds, 'As long as they are happy', they say, 'they are responsible for their own lives'. In 1998, the Massey University's study of New Zealand values found that over 50% (54%-59%) of parents were most interested in their children acquiring the teaching of independence and responsibility and 37% favoured the teaching of hard work.

The Chinese parents additionally impose obligations, whereas Western parents often try to be friends with their children and thus are less able to make demands. The Chinese parents have a greater idea of family structure in which the children have a definite place, complete with two-way expectations and commitments. The Chinese father and mother are expected to do their best to give the children the best start in life and the children are expected to work hard to achieve and later to reciprocate by taking care of the parents in old age. In support of these assertions, Victoria University has found among young New Zealand-Chinese a persistent respect for older persons and a persistent obligation to look after aged parents. And though Chinese parental vision naturally differs widely as to what occupation their children should do, statistics indicate that they have a two to three times rate of tertiary education over the New Zealand average. In other words, it appears that many Chinese parents highlight education to their children. So we in New Zealand have retained some Chinese cultural characteristics, just like the pakeha New Zealanders who have retained Western cultural characteristics.

Western culture has two signal characteristics. First, there is the emphasis on individuality which tends to encourage a multitude of brilliant ' stars' in many spheres of life; and second, there is the penchant to pursue knowledge and achieve practical results according to current theories, which then leads on to the formulation of more theories.

The combination of both these characteristics means that Western culture encourages more active, experimenting (more restless, open, direct, forthright, aggressive, questioning) individuals than traditional Chinese culture. These characteristics therefore predispose much more to change than their Chinese counterparts. Western culture also have a special ability for evolving social and mechanical machinery, but as said, I think their social relationships tend to be looser than those within Chinese society. Indeed, experimentation and change must largely go together with looseness. In contrast, the Chinese model with its focus on harmony and stability could lead to relative stagnation - as had happened in old China.

What is occuring in modern times is that China and the Chinese are learning Western methods but are reluctant to adopt Western culture wholesale. A present-day Chinese criticism is that Westerners tend to over-emphasise individuality and under-emphasise the individual's obligations to the community. Thus a Taiwanese newspaper comments on excessive individualism as follows, 'Unacceptable levels of crime, over-reliance on adversarial legal procedures and the inability to impose effective norms of taste and decency are some obvious drawbacks to this kind of emphasis'. On the other hand, another major drawback of the Chinese model is that its insistence on family loyalties fosters the tendency to nepotism, and hence to corruption.

Cultures are resistant to change. This being so, numerous examples of distinctions and contrasts still exist between Chinese and Western cultures. Paintings illustrate a contrast. Even now, many Chinese painters look to the past in methodology and subject matter, while many European painters, past and present, experiment in new techniques and themes. You only have to look at the Barr modern collection in the Dunedin Public Art Gallery to confirm this. In gardens, classical Chinese gardens try to reproduce nature whereas European gardens try to control it. Chinese prefer older doctors for their experience and safety, but Europeans tend to like young doctors with their vigorous use of new treatments and technology, and European patients have more of a 'can do' attitude which leads them to think there is a test, drug or operation for every medical condition. The prime Chinese investment is (long term) property, whereas the first preference of European investment advisors is (shorter term) shares. A present-day Chinese scholar contrasts the more direct European exhortation 'Do unto others what you would have others do to you' with the more indirect and less imposing Confucian instruction, 'Do not do to others what you would not have them do to you.'

In China in the 1980s, Chinese guides told me they particularly liked the Americans (followed by Australians and New Zealanders) because they were frank and open, so they (the guides) knew where they stood with them. For all that, European directness may overflow more easily to confrontation or the 'big bang' type of decision and quicker, clear-cut results - whether positive or negative. You can see the 'big bang' phenomenon in the Western concept of war and sport - where a complete victory, winner-take-all attitude applies. John Keegan's book, 'A History of Warfare', attributes this attitude to Western culture, which he reveals is based on Judeo-Grecian foundations. The 'big bang phenomenon' is seen in many other facets of Western life, such as in the recommended economic changes for Russia and Poland following the collapse of the Soviet Union, whereas in this field, China changes step by step. I have been involved with 'big bang' decisions in committees which in effect said, 'lets directly confront the issue, do it all at once, suffer pain if necessary and then move on.' Other instances of directness include direct eye contact. The Chinese have no accent on such a feature and certainly not to the extent of 'fixing one with a stare'.

So despite a smaller world, Chinese culture is still substantially different from its Western counterpart. The great historian Toynbee hoped that the dynamic Western culture with its basic emphasis on change - which leads to growth which leads to expansion and excess consumption - may gainfully merge with Chinese culture, which, he theorized, will impart more stability to the West while the Chinese absorb some Western vigour.

But what does all this mean for our Chinese immigrants now? No doubt settling here is more of a challenge both for them and for New Zealand society than, say, with British immigrants. To feel what they feel, imagine us trying to settle in China. That said, one credible view is that the greater the challenge and cultural difference, the better the ultimate social admixture - if the public will exists to tolerate and make the best of the gift of diversity. The encouraging thing is that New Zealand attitudes are noticeably and positively changing towards Chinese and other Asian immigrants. The modern outcries against such immigration are much more limited than in the past. There is an increasing acceptance of multiculturism and intermarriage, the adoption of different foods and manners, the learning of different languages, and a broadening of outlook gained from overseas travel and other contacts with foreigners. Given also the adaptability of the Chinese and the innate fairness of New Zealanders and I am optimistic that we will see the successful resolution of any perceived problem of Chinese immigration.

As mentioned, the Chinese already resident in New Zealand are about 20% Cantonese, with their roots going back in time to the goldfields. About 80% then, are newcomers who have immigrated especially since the 1980s. The Cantonese have shown that they can make a strongly positive contribution to New Zealand society, become an integrated part of it not least by intermarriage, and anchor their loyalties in New Zealand and in New Zealand values. There can be no doubt that the Chinese newcomers can likewise contribute.

Aspects of health care.

Now, some observations on health. May I mention my paper on physical differences (in Patient Management, October 1994). In this talk I will dwell more on the Chinese approach to health. Remember that they have come from a different culture to New Zealand's. And where a cultural gap exists, even widely available health services will be underutilised. The biggest reason why this is so is language difficulty. According to Ratana Walker's paper for the Health Funding Authority in 1998, language deficiency forms the highest barrier to the utilisation of health services. Language fails many Chinese sick, especially the new immigrants and even the high quality migrants. For though they may be well-educated and/or well-off, still their English may not be fluent in medical terminology. It is said that Hong Kong and Singaporean immigrants are more fluent in English than the Taiwanese and are more versed in British ways. They may have got their tertiary education in Britain and so have a quicker grasp of how the health system works in New Zealand. Even so, the wives of these immigrants may have less English capability and certainly this may be so for the older members of family coming here under the family reunification process. The best advice I can give you is that if in doubt, write down your instructions and explanations so they can translate and understand these in their own time. They are not stupid.

As well, there are the less educated Chinese who have come, say, as South-east Asian refugees, or from the countryside. When they arrive, they may be grossly deficient in English and the older ones may retain a hesitancy in this language throughout their lives. To be sure, some of these people may bring a child or a friend to the doctor's/dentists rooms as interpreter, but not all interpreters are of an uniform high standard. So imagine these people trying to explain their symptoms, or the professional person trying to fully ascertain their story, or trying to secure their understanding and participation in health and dental programmes.

Even our GP and dental system may be strange to them. Where they came from, a patient may go to a number of doctors and dentists and regard a consultation as merely another business contract. For instance, when newcomers called me out after hours when it was convenient to them, and they saw I was displeased, they were astonished, because in their eyes they were paying me and expected to pay for the inconvenience to me. But with explanation, they comprehend our system quickly. Be tolerant if they leave you to seek out a Chinese doctor/dentist. It will largely be the language factor that leads them to this course.

Adding to linguistic difficulty are cultural interpretations of health. For instance, in traditional Chinese culture, having mental disease is a disgrace. Such diseases as tuberculosis and bad asthma and others were also considered a taint on a whole family, thus clouding the marriage prospects of sons and daughters. Considerations of health used to count a lot in the selection of a Chinese spouse. These feelings still have a residual force today, as do old aversions to major surgery, post-mortem and cremation. In olden times, the ideal was to have a whole body for burial, not to mention the fear of operations going wrong. Also, do not forget that Chinese and nearly everyone else are apprehensive of being anaesthetised; it is one of those rare occasions when you are entirely dependent on someone else for life. Other cultural features occur, for example, the Chinese peasant has a low level of cultivated exercise because he or she has no strong leaning to any sport. The same situation is usual among other dominantly rural societies, as it was in Britain until about the 1860s.

As to dental health, I have read that old Chinese in the past expected to lose teeth with aging. Generally the medical and dental health of today's Chinese immigrants seem good - after all they are selected immigrants who have had medical examinations and tests. I have, however, seen a lot of teeth discolourisation in young mainland Chinese immigrants, presumably from the use of tetracyclines. And among the longstanding Chinese families here, I used to see much peridontal disease. It is now proven by Chinese dentists that many Chinese have an enamel defect which predisposes them to peridontitis.

What else? You will find that the great majority of Chinese persons in New Zealand openly or tacitly acknowledge the superiority of Western medicine. In my experience, they use the Chinese medicines, herbalists and acupuncturists for adjunct therapy, if at all. In my childhood, my parents' generation still talked about 'hot and cold' precepts of old Chinese medicine but I haven't heard of these things for years, even from newcomers. Today, if your Chinese patient has returned from places like Singapore, Malaysia and Taiwan (and perhaps from now on, mainland China) one is liable to find that their checkups over there have put the patient through every modern test money can buy, sometimes exceeding what can be obtained in New Zealand. And in your life times, you may well find that New Zealand hospitals might use, say, Chinese radiologists and others in Singapore, Hong Kong or Beijing to interpret xrays or whatever daily.

Nevertheless, despite all the advances, there is a persistent Chinese aversion to blood tests. It is not the needle but the loss of blood which worries; indeed, I am told Chinese patients in the East expect an injection for many ailments. Injections impress them. Old superstitions too may surprise the doctor, akin to such European beliefs as the alleged bad luck arising from a black cat crossing in front, the bad connotations of the number 13, stepping under a ladder and so on. Their Chinese equivalents include No. 4 (which is homophonous with death), the colour white (ditto), lucky and unlucky days. So do not put your sick Chinese patient in room No. 4. Red and yellow are the auspicious colours, so I wear a tie with white dots to a funeral and red or yellow dots to a wedding. I have seen a family shift house because so much ill-health had occurred in it affecting the members; they blamed the house for having bad vibes. Chinese patients will be among your most grateful and prompt paying members of your practice - yes, even with high dental fees - but remember their gifts carry a two-way obligation in their eyes - that you do your best for them.

Finally, I think Chinese are much like Europeans in their attitude to death. Only a minority in either race are accepting and philosophical about their pending demise; by far the majority of both races want 'everything' done to put off the last reckoning. The old Chinese were said to be fatalistic but this may have been an early realisation about the limited options available rather than an inherent lack of optimism and hope.
 
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