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This section concerns Asian Indians (or East Indians), not Native Americans.


Introduction

Indiaís history is one of many dynasties, religions, and conquering invaders. The invaders exerted power and imposed their own cultural institutions, resulting in cultural blending. Today there are as many as six different racial strains present in India, making attempts to trace origins of people very difficult.

Among the major influences in Indiaís history are Hinduism/Brahmanism, Hellenism, Buddhism, and Islam. Hinduism began about 1500 BC and has been the unifying thread in Indiaís history. Alexander the Great brought Hellenism to India in 326 BC, and although he died three years later, Hellenism continued to influence India for many years. Following the Maura dynasty in 184 BC, Buddhism dominated for over a century. Brahmanism eventually replaced Buddhism, and the Hindu caste system rose. Of the many dynasties that ruled India, the Gupta was one of the most significant. Under the Guptas, Indian culture to new heights and Hinduism peaked. The Islamic Mughal Empire reigned from 1526 to 1707 and exerted considerable influence on Indian culture.

The British entered India in 1608, at first sharing, then dominating a trade organization, the British East India Company. The British replaced the Mughal rule in India in 1858, and remained in control until 1947. Despite some British attempts at reform, hostility grew among Indians, but multiple uprisings against the British government failed. Religious and political conflict also arose between Hindus and Muslims. In 1930, Mahatma K. Gandhi, a Hindu, ordered Satyagraha (passive resistance) and led a revolt against the British government. Britain made a truce with Gandhi, but conditions did not improve. The British remained in India until 1947, when the Indian Independence Act gave independence to India and established Pakistan and India as independent nations. The separation of the countries was largely along religious lines, with the majority of Hindus establishing residency in India and Muslims going to Pakistan. Conflict arose at the partition of India and Pakistan, continues today.

Religions

More than eighty percent of the people in India practice Hinduism. The earliest major Hindu scripture is the Vedas. The other two holy books recognized in the Hindu faith are the Upanishads and the Bhagavad-Gita. These three books are a collection of texts written by seers, or prophets. There is no one author, nor is there one holy book that is used more than another.

The goal of Hinduism is freedom (of the soul or Atman) from endless reincarnation and the suffering inherent in existence and resulting from bad karma. Karma, in the Vedas, comprises the actions the individual commits while in this present life and also an accumulation of actions from past lives.

The caste system is part of Hinduism. Caste divides society into four social classes. The highest class is called the priest class, or the Brahmans. The lowest class is referred to as the laborer class, or Sudras. One inherits class at birth, based on one's karma, or tally of good and bad deeds from previous lives.

Aspects of Hinduism that commonly affect health decisions and communications between patient, family, and provider include:

It must be noted that these religious beliefs are not universal among all Hindu Indians. In the health care setting, it is helpful to have a basic understanding of the individual patientís chosen religion and how the person practices and lives out that faith.

Other religions among Indians are Islam, Christianity, Sikhism, and Zorastrianism (the latter practiced by Parsis, most of whom are from the Bombay area). The 1991 census of India reported 12.12% of the Indian population was Muslim, 2.34% Christian, and most of the rest Hindu.

Language

While there are more than three hundred languages and dialects spoken in India, Hindi, the national language, is predominant, spoken by over forty percent the population. There are two main groups categorizing language in India, including the Indo-Aryans in the north and the Dravidians in the south. Indo-Aryans predominantly speak Hindi, but have numerous dialect variations;. However, in this age, English is becoming a popular second language for many Indians.

In America today, Indians are commonly well educated, English speaking individuals. This is due to the 1965 Immigration Act that granted visas to people in certain professions and to those with high educational backgrounds. This, however, is not exclusive as there are many people with less education who receive visas under conditions of marriage or other family circumstances. Older, first generation Indian immigrants, though well-educated, may not speak English and need a translator for health care transactions.

Family Life

Within Indian society, extended family members usually live together as a single-family unit which includes grandparents, parents, children, as well as the families of parental uncles. With increased mobilization to urban areas, this structure is slowly moving towards that of the nuclear family comprised of parents and their children.

Among Indians in the West, extended families are still prevalent. Often, the husbandís parents move in with the family after they have retired or when the family decides to have children or if there is an illness and help is needed. The grandparentís role in raising the children is highly valued, as they are the link to the Indian culture, religion, and heritage. In families with multiple sons, the parents or grandparents usually choose to live with the youngest son. The financial capability of the son, the need of assistance in child-raising if both parents are working, and the relationship with the daughter-in-law all determine with which son the parents live.

Relationships between siblings tend to be close. Many times brothers live together for both financial and familial reasons. After marriage, if families live apart, siblings and their families continue to meet throughout the year for religious holidays, and special occasions, as well as vacations.

Because of the value placed on independence and privacy in Indian culture and the desire to save face, family issues, including healthcare decisions, are frequently discussed within the immediate family before seeking outside help. Because of the close-knit family structure, a family can expect many visitors when a family member is in the hospital.

Gender Roles

Within Indian society, the roles of men and women are distinct. Women manage the home by keeping all finances, family, and social issues in order. Women are more passive in the Indian culture and men typically are the bread-winners and managers of issues requiring interaction with individuals in the community, e.g., health care. This type of behavior implies that men have a dominant and authoritative role because they are the primary point of contact with society. However these roles are beginning to change among educated Indians in the larger cities of India and among immigrants in progressive or permissive societies such as the United States.

Modesty is highly valued among Indians and patients are decidedly more comfortable and secure with same-sex care providers. Also see womenís health, diet, and other relevant sections.

Marriages

Parents traditionally planned marriages (for males and females) and the children seldom met their spouse until the wedding day. Factors influencing parental choices of a potential spouse include the family values that shaped the person, and the personís educational and financial stability. Family values and education are seen as permanent, but passion in love as transient.

Arranged marriages are still common, but the process has changed, especially among more cosmopolitan Indians. The two to be wed have time to become acquainted (even date) before making a decision to marry. The decision of whether to date is made fairly quickly to prevent a relationship that will not culminate in marriage. It is felt that a close relationship should only be shared with one individual. The fear of a close relationship is tied to concept of premarital sex tainting the women and robbing her of purity, which jeopardizes her potential for finding a suitable spouse.

Currently in America, there are many different marriage practices. Some families send the person who will be married back to India to marry, with the person going through the same process stated above. The person is introduced to several different people and will choose one with whom he (or sometimes she) would like to be further acquainted. Males typically go back to India because they are looking for a passive wife that they can "mold" to their liking. Females are more likely to marry within the United States because they have become more independent, and a man from India may not allow such views. A female may go back to India for marriage because her parents wish for her to marry a man from India.

Many families who have lived in the West for years are becoming open to dating - with some criteria. The family will approve of dating a person that meets the parentsí liking. On the other hand, some youth date without the parentsí approval, so healthcare workers must never assume that the parents are informed about a relationship. The unapproved dating causes much conflict in the home, resulting in high levels of emotional stress for the child and parents. With this increase in dating, interracial marriages are also emerging. Interracial marriages propose the ultimate conflict in the Indian family because the family is concerned with how the family will live with two different cultures, religions, and lifestyles. When a person chooses to marry a person that is not approved by the family, the couple may be thought to be shameful to the family causing the family to sever ties with the couple.

With arranged marriages, couples are more likely to remain in an abusive or violent relationship to save family face. As in any other group, domestic violence is an issue in the Indian community, but often it is hidden to a greater extent. More than many others, Indian women are not willing to bring shame upon the family by talking about family violence. The health care worker may not understand the logic of saving face but must attempt to understand to gain rapport and trust. Most Indian women are willing to suffer, if other family members benefit.

Parenting

In the Indian culture, the whole family is involved in the care of the children. Grandparents play an important role in rearing the children, and if the grandparents do not live with the couple, they will come before the birth and stay to help out for first few months to several years. The children often sleep with the parents from the time of birth to early childhood. If the grandparents are part of care taking, the children may be as attached to the grandparents as to the parents. This may cause some attachment issues with the child and parents. During an invasive procedure, the healthcare worker may want to give the child a choice for support: grandparent or parent Ė or better, both.

Respect is highly valued and children are taught to be respectful of all elders, whether it is grandparents, siblings, teachers, or family friends. Discipline of children is thought to come naturally. The parents will tell the child what is good and bad, but constant reminders are not posed. Understanding is used to help the child determine between good and bad. Children are to help with the chores in the home as a responsibility on a regular basis, not as a punishment issue. An Indian child is likely to mature earlier than some others because of responsibilities beginning at an early age. In many cases, when a family has recently come from India, a child is responsible for many of the adult tasks, such as finance, legal forms, and translation. The healthcare provider should take note when scheduling appointments during school time if the child is needed for translation. The healthcare provider can also assess the effects on the child of having adult responsibilities.

Education

Education is second only to respect. In India, education is based primarily on financial capabilities, so that an intelligent, but poor child will not attend college. Many families migrated from India to America for better education for their children. Parents sometimes encourage their children to excel beyond their capabilities. Some children are pressured to the extent that psychological problems, such as depression and suicide result.

Womenís Health

Background

Many Indian women have come from circumstances in which women have limited access to healthcare. Traditionally, there has been discrimination towards women in decision-making; access to resources such as food, education and health care; job opportunities; and in child-bearing and parenting. This has been influenced largely by the strong preference for male babies over female babies. One of the reasons for this preference is that the youngest son in a family is traditionally given the responsibility of taking care of his own family. If parents do not have a son, then they believe that they will have no one to care for them. As a result of this tradition, parents commonly neglect young girls growing up in India, giving them smaller portions of less nutritional food, witholding medical care, and often removing them from school earlier than boys.

Nutritional Deficiencies

Depending on background and circumstances (with rural background having a high index of suspicion), Indian women may need to evaluated for conditions such as protein malnutrition, beriberi or thiamine deficiency, pellagra or niacin deficiency, iron-deficient anemia, and lathyrism (see following) that may be related to the diet. Lathyrism is a disease caused by eating certain plants of the genus Lathyrus and is characterized by irreversible muscular weakness and paraplegia. Although these and other conditions may be a result of the poor nutrition that many Indian women receive, these conditions may also be related to the vegetarian diet common among Indians.

Dietary evaluation is important, as well as assessment of any physical characteristics that could indicate a nutritional deficiency, such as generalized weakness, fatigue, muscle wasting, edema, smooth tongue, mental confusion, paralysis, diarrhea, and low hemoglobin and hematocrit levels. Teaching nutrition should be focused first on assessing the cultural diet of the woman. Many Asian Indians have chosen to be vegetarians, which, depending on the type of vegetarian they are, limits the choices of foods that are available to them. The foods should then be evaluated to identify which vitamins, minerals and other nutrients each provides. Next, information on making healthy food choices should be made available. This is especially important for the pregnant or lactating woman and for those with illnesses. Finally, allowing the woman to continue eating her cultural or religious foods while teaching her how to make nutritious food choices will be a major key to facilitating health and wellness in Indian women.

Fertility Practices

A common practice of traditional Indian culture that has also influenced the health of the women in this population is the young age at which many girls are married. In the 1991 census report from India, the percentage of married women age 15-19 years is > 35%. Childbearing during the adolescent years poses significant health risks to both the mother and the infant, especially if the mother is poorly nourished.

Closely spaced multiple pregnancies are a major problem among Indian women from rural backgrounds. These place the mother and children at risk because the mother becomes exhausted from child-care demands and stress on her body. Family planning, then is about spacing and limiting pregnancies.

Many Indians do not believe in taking western or modern medications, hence there may be a low acceptance rate of such contraceptive agents as birth control pills and depo-provera among this population. As a result, the teaching may need to focus on intrauterine devices, condoms and the rhythm and withdrawal methods. Sterilization may also be an option. It should be noted that in general, it is considered to be more appropriate and often more comfortable for a client to receive teaching regarding this topic from someone of the same sex, although both husband and wife may want to be present during the teaching session.

Pregnancy

Many Indian women view pregnancy to be a "hot state," or a time of increased body heat. As a result, many feel that one should not become "overheated" because it is believed that this may induce miscarriage. Women who have this belief avoid "hot foods" such as meat, eggs, nuts, herbs and spices; and instead, take foods that have a cooling effect, such as milk products, fruits and vegetables. Overeating is not recommended, as it is believed to result in a very large baby and a subsequently difficult delivery.

Throughout the pregnancy, it is believed that the developing child is vulnerable to evil spirits. It is therefore the tradition of many Hindu families to perform rituals to protect the mother and the unborn baby. During the fifth month of pregnancy, some of the ceremonies preformed include Valakappu, Puchutal and Saddha. These vary according to different regions in India, but they are each performed in the womanís house. During the eighth month of pregnancy, another ritual, called Simantam, takes place in the husbandís house. An additional way that many Indian women protect themselves from evil spirits is by wearing a type of amulet called a valai or valayal, which means, "to surround." It is believed to create an invisible barrier that keeps the pregnant woman safe from the influence of evil spirits.

Some of the physical characteristics that are traditionally attributed to being pregnant are also related to the hot and cold theory of disease. Morning sickness is thought to be caused by an increase in body heat or pitta, an ayurvedic term meaning bile. This term is associated with nausea, dizziness and overheating of the body. Minor swelling of the feet and hands are also seen as increased heat, but are not considered to be of much concern.

Labor and Delivery

The role of the Asian Indian woman in labor is passive. She follows instructions from health care providers or family members. A stoic approach by the mother to the labor and delivery process is desirable, and receives praise. Although there is not a cultural standard that prohibits the father from being present during the delivery, men are usually not in the delivery room at the time of birth. Many times, an older female family member or traditional birth attendant (dais) assists the mother in the birth process. Pain medications are usually not used, as they are believed to complicate the delivery. Staff should be prepared to assist the mother with alternative relaxation or breathing techniques if needed.

After the baby is born, the sex of the child is not told to the mother until after the placenta has been delivered. Because of the high preference for having boys, it is thought that the birth of the girl may cause the mother to become so emotionally upset that the uterine contractions may become inhibited and delay the delivery of the placenta. Once the placenta has been delivered, however, the baby is first shown to the mother, and then to the father and other accompanying family members.

Breast Feeding

Generally, breast-feeding by Indian women is practiced and encouraged. It is usually continued anywhere from six months to three years. It is common for breast milk to be supplemented with cowís milk and diluted with sugar water. The child is given diluted milk because the infantís stomach is believed to be weak initially. Additionally, the working mother may also combine breast-feeding with formula for convenience.

If an Indian woman is having difficulty breast feeding her infant, she may choose to use a traditional feeding cup called a paladai to assist her. The paladai was originally used to burn oil during religious ceremonies in South India. However, because of its long, grooved spout, a baby is able to lick the milk from the groove, thereby mimicking the tongue action that is needed to feed effectively from the breast. Health care providers need to be aware of this practice, as it is beginning to gain popularity in the Western medical community.

Recuperation after Birth

The recuperation time for the mother and baby usually lasts for forty days after birth. During that time, the mother is encouraged to remain at home, where she is to obtain adequate rest and is offered special food along with regular meals. One of the traditional foods is called katlu or panjiri. This dish is prepared by frying whole wheat flour in butter and adding sugar, almonds, pistachios, and a powder made from different herbs. Because this food has a "hot effect," it is believed to restore energy that the mother lost during the birth process. Other hot foods commonly consumed by the postpartum woman include dried fish, brinjals, dhal, drumsticks, and greens. These are all considered to be good for lactation.

Cold foods are believed to produce diarrhea, indigestion and gas and are therefore avoided. External heat as well as internal heat is encouraged for the recuperating mother. The mother should keep herself warm during this time. She will often have back massages with warm oil. She is discouraged from taking more than one bath a week, although she should wash her perineal area with warm water every time she eliminates.

Religious Ceremonies Related to Birth

In many Hindu families, a ritual called "The Sixth" is performed on the sixth day after delivery. It involves placing a religious blanket under the newborn, applying holy red powder that has been mixed with water on to the palms and soles of the infant, and reciting prayers over the child. Afterwards, the baby is to be untouched for a period of time in which it is believed that a Holy Spirit descends onto the child and blesses his or her life. The baby is officially named on the eleventh day after delivery during the "cradle ceremony," and further rituals are performed to protect the baby from evil spirits.

In Muslim families, it is common for the father or the grandfather of the child to recite the Azan in the childís right ear and the Iqama in the childís left ear just after birth to confirm that the child is Muslim. Muslim families may also perform the ceremony of Aqiqah at a party to celebrate the birth. This ceremony involves the shaving of the newbornís head, the sacrifice of one or two goats and the distribution of alms to the poor.

Christian families may wish to pray over the infant for blessings and health. In addition, they may choose to apply holy water or anointing oil to the child's head, hands and/or feet as a symbolic dedication of the childís life to Christ.

Traditional Beliefs and Natural Remedies

The Indian system of medicine is known as Ayruveda, which means "knowledge of life." Indian medicine mixes religion with secular medicine, and involves observation of the patient as well as the patientís natural environment. More than eighty-percent of people in India rely on herbal remedies as the principal means of preventing and curing illnesses.

While modern medicine is preoccupied with the treatment of disease and concerned very little about prevention, Ayruvedic medicine is a holistic system with great emphasis on prevention. Diagnosis according to Ayruveda is based on finding out the root cause of a disease, which is not always inside the body. To give permanent relief, the root cause has to be removed. When curing disease, it is important to not cause new symptoms by suppressing the presenting symptoms. According to Charka, a noted practitioner of Ayurveda in ancient India, "A physician who fails to enter the body of a patient with the lamp of knowledge and understanding cannot treat diseases. He should first study all the factors, including the environment, which influences a patientís disease, and then prescribe treatment. It is more important to prevent the occurrence of disease than to seek a cure."

In the Ayurveda system, the body is comprised of three primary forces, termed dosha. The state of equilibrium between the dosha is perceived as a state of health; the state of imbalance is disease. Upon examination, the Ayurvedic physician finds out the position of the three dosha (Tridosha). Once the aggravated or unbalanced dosha is known, it is brought into balance by using different kinds of therapies. The three dosha are called Vata, Pitta, and Kapha. Each dosha represents characteristics derived from the five elements of space, air, fire, water, and earth.

Space represents the ears and is responsible for hearing, speech, and sound. Air represents skin, which is responsible for touch, pressure, and the feeling of cold to dry sensation. Fire represents the eyes, which are responsible for sight, heat, and light. Water represents the tongue, which is responsible for taste, liquids, and hot or cold. Earth represents the nose, hence is responsible for smelling and odor.

Each dosha represents certain bodily activities. Vata is responsible for breathing, brain activity, circulation, and excretion. People whose constitution is predominantly Vata tend to be thin, quick thinking, with swift action. When in imbalance they become nervous, anxious, constipated, and insomniac. Pitta is responsible for vision, digestion, hunger, thirst, and regulation of body heat and temperature. When in balance, people whose constitution is predominantly Pitta are intelligent, disciplined, sharp, and contented. When in imbalance they are intolerant to heat, become bald, show short temper, anger and lust; and are prone to heartburn and ulcers. Kapha represents solid structure of the body and lubricating mucous. Kapha types have strong, well-developed bodies, with the tendency not to gain weight, and are mentally cool. When in imbalance they are obese, disorganized, and sloppy; and develop allergies with dull activity, speech, and behavior.

India is one of the first countries to focus on medicinal plants. There are approximately 1,400 plants used in Ayurvedic medicine, none of which are synonymous with instant pain relievers or antibiotics. The herbs used in Ayurvedic remedies tend gradually metabolize and have few side effects on the body.

Common Natural Remedies

Botanical Name

Common Name

Use

Andriograohis paniculata

King of Bitters

Hepatoprotective

Boswellia serrata

Olibanum, Farnk incense

Antiarthritic, Antihyperlipid

Cassia angustifilia

Indian senns

Laxative

Coleus forskohlii

Coleus

Antiobesity

Garcinia camogia, Calcium

Garcinia, Kokum

Antiobesity

Garcinia cambogio, Potassium

Garcinia, Kokum

Antidiabetic

Gynema sylvestris

Gymnema

Aphrodisiac, Antioxidant

Shilajit

Asphalt

Potent Aphrodisiac

Tribulus terrestris

Puncture vine

Potent Aphrodisiac

Taxus baccata

Himalayan

Taxol, Ovarian cancer

In Ayruveda medicine common health problems include fever, headache, common cold, stomachache, diarrhea, constipation, arthritis and joint pains. The following section describes the causes, remedies and diet regimen of each illness.

Ayruveda Medicine and Common Health Problems

Fever is a disease with many causes. Anything that disturbs the heat controlling mechanism of the body can cause fever, e.g., infection, injury, or even poisoning. According to Ayurveda, aggravation of one or two of the dosha may cause fever. Common remedies for fever include fasting to remove excess toxins, and mild sweating to digest the toxins. Lying down on a bed covered with a warm blanket for 15-20 min causes sweating. Prior to this, drinking a hot drink is beneficial. A drink made of raisins and crushed, boiled fresh ginger is believed to help reduce the symptoms of fever. Another tradition is to put a paste of sandal wood powder on the forehead of the patient. The paste can be prepared by mixing water and sandal wood powder. The diet regimen advised for the patient suffering from a fever consists of easily digestible foods. Boiled or steamed vegetables, vegetable soup, fruit and fruit juices are recommended.

Headaches also have numerous causes. They can be related to stress, hypertension, overwork, fever, sleeplessness, drinking too much tea or coffee, smoking, and other causes. Common symptomatic remedies for headache include applying a paste of clove powder, cinnamon, and almond in equal quantities to the forehead of the patient. Several drops of ghee (clarified butter) mixed with 3 or 4 pieces of saffron are rubbed together for two minutes. The saffron is taken out and two drops are put in the each nostril of the patient. Taking a wet cloth and wrapping it around the neck of the patient helps to relieve headaches. Oil massage on the head, with the use of sesame oil, almond oil, mustard oil or ghee can be used for massage and relieves tension and headaches. Meditation and relaxing the mind also helps in treating headaches. Diet regimen for headaches includes: light foods, cooked vegetables without oil, vegetable juices and soup, fruits like apples, oranges, and mangos, and hot cow milk.

The common cold is thought to be caused by weak digestion. When food is not digested fully, it changes into mucus (ama) and mixes into the circulation, reaching the respiratory system and causing cold or cough. Common remedies for the common cold and cough include keeping the body warm, especially the feet, chest, throat, and head; fasting; and fresh ginger mixed with honey taken in water three times a day. In case of dry cough, fresh peeled ginger is cut into small pieces with salt applied and then chewed by the patient. This mixture can be kept in the mouth while sleeping. Diet for the common cold and cough includes boiled or steamed vegetables, vegetable soup, fruits, spice teas, herbal teas, and hot drinks. Cold foods, cold drinks, ice cream, sweets, fried foods, milk products like cheese, creams, and yogurt should not be taken.

Toxins can cause stomachaches, according to Ayurveda. Most pains are caused by vata (air), pata (fire), and kappa (water and mucus) aggravation. Remedies for stomachache include one to three ajowan seeds with warm water, two teaspoons of lemon juice with water at least three times a day, one teaspoon of ginger and vegetable oil mixed with warm water, and water in which anise seeds have been soaked. Another remedy is mixing equal weights of dry ginger, black pepper, roasted cumin seeds, and dry mint leaves together with water and drinking the mixture. Local heat at the site of pain also helps to relieve stomach pain. The diet regimen for stomach ache again includes mainly foods that are easily digestible. Little grains, rice yogurt or buttermilk, a little salad with a thin dressing of oil or yogurt on it is recommended. Cooked vegetables like squash, zucchini, pumpkin, and mung dal (green beans or pulses) will also help. Fried and spicy foods that contain too much oil are prohibited.

Diarrhea is thought to be caused by weakening of the digestive force or by weak absorption of the food material in the colon. Remedies for diarrhea include fasting; herbs such as nutmeg, oak bark, raspberry, and marshmallow; sugar and salt solution; pieces of skin from the pomegranate; and if excessive thirst is evident, a drink made from coriander seeds. Diet regimen should include foods that bind the stool, such as yogurt, rice, banana, pomegranate, boiled vegetables, and fruits.

Constipation is defined as when a person does not pass stool at least once in twenty-four hours. Constipation is caused by wrong bowel habits, improper eating habits, and foods not easily digestible; and is related to aggravation of Vata (air). Remedies for constipation include: massaging the whole body with oil once or two a week; applying oil or ghee on the navel every day; taking lemon juice mixed with warm water; or one or two teaspoons of a specific type of gel. Triphala Churna, a powder made of fruits and herbs can be taken with warm water or milk and helps in having a clean bowel movement the next morning. Diet regimen for constipation includes: eating freshly cooked food, spices like cumin seeds, coriander, turmeric powder to make food easier to digest; whole grain breads; papaya; drinking plenty of water; using oil or ghee (clarified butter) in cooking; avoiding vegetables like cauliflower and broccoli.

Arthritis is thought to be caused by of ama and aggravation of Vata. Remedies for arthritis include fasting; camphor, wintergreen and cinnamon oils; guggul, an herb, taken three or four times a day; a paste of red chilies and fresh ginger mixed together and applied to the painful area; two cloves of garlic fried in ghee or oil; and alternate hot and cold baths with camphor powder in kerosene oil which was placed in the sunlight. Diet regimens include foods that are easily digestible and do not make wind or gas. Vegetable juices and soups, juices of carrot, beet root, coconut water or milk, and cucumber mixed together is also beneficial. Fruits like apples, orange, grapes, and papaya can be taken. One should avoid eating hot, spicy and fried foods and avoid too much tea, coffee, and alcohol.

Diet

The essence of good Indian cooking revolves around the use of aromatic spices. Two great influences on Indian cooking and food habits are the Hindu and Muslim religions. Hindus are vegetarians and believe that food was created by a Supreme Being for the benefit of man. Muslims have several food restrictions discussed in the Refugee Health section on religions. Regional variations in diet and cooking also exist.

The skill of cooking Indian cuisine lies in the subtle blending of a variety of spices to enhance the flavor of a dish. Common spice choices include, garlic, ginger, turmeric, cumin, and mustard seed. Besides spices, other ingredients used in Indian cooking are milk products and curd (dahl). Indians have practiced vegetarianism for many years, and non-vegetarian is used to describe anyone who eats meat, poultry, fish, and occasionally cheese.

Rice is standard for every meal. It is usually served with sambhar, rasam (thin soup) and dry curried vegetables. Coconut is an important ingredient in South Indian food. Indian dosa (rice pancakes), idli (steamed rice cakes) and vada, which is made of fermented rice and dal are popular. Seasonal products such as ground nuts, mangoes, and bananas are consumed between meals. Desserts from the south include the Mysore pak and the creamy payasum. Available throughout India is hulfi, the Indian ice cream, rasgullas (cream cheese balls flavored with rose water), gulab jamuns (flour, yogurt and ground almonds), and jalebi (pancakes in syrup). Besides sweets there are a number of tropical fruits such as mangoes, pomegranates, melons, apricots, apples, and strawberries. Traditionally, instead of fruit juices or sodas, water and buttermilk (lasi) are beverages of choice; and are believed to help digestive processes. Tea is India's favorite drink. A meal is rounded off with an after dinner "pann" or "betal leaf", which holds an assortment of digestive spices like aniseed, cloves, areca nut, and cardamon (the areca nut has slight psychoactive effects).

Most Indians eat two to three meals per day, preferring a big meal at lunch and a small meal at supper. Hindus may prefer to use metal utensils such as copper, brass, and iron for cooking and eating on, as these materials are considered sacred. Most Indians eat with their fingers, but only of the right hand. Handwashing before meals is important whether eating with hand or utensils. One must avoid any form of distraction while eating, e.g., watching television, reading, or excessive talking. Overeating is discouraged because it is believed that it decreases one's life span.

Women generally serve the food and may eat separately from men. Food preparation has strict rules. Women are not allowed to cook during their menstrual period. The perception of Hindus is the belief that some foods are "hot" and some are "cold", and therefore, should only be eaten during certain seasons and not in combination. There is a difference in perception of "hot" and "cold" foods depending on the region. These perceptions are based on how foods are thought to affect body functions.

Nutritional deficiencies vary depending on region and other factors, especially socio-economic. Nutritional deficiencies such as thiamine deficiency, pellagra, and lathyrism are common in India. Thiamine deficiency is common among people mostly dependent upon rice. Thiamine is lost through the washing, cooking of rice, and allowing it to remain in water overnight. Pellagra is common in rural areas among the very poor in urban areas. Lathyrism is a crippling disease causing paralysis of leg muscles in adults who consume large quantifies of seeds of the pulse khesari and Lathyrus Sativus over a long period of time. Goiter is prevalent as a result of iodine deficiency in food and water. The concept of the sacred cow has an impact on adequate nutritional management, and osteomalacia is common related to deficient calcium and vitamin D in regions were the cow is sacred.

Death Practices

Many Hindu patients prefer to die at home; and some will go back to India - especially to the sacred city of Varanasi, to die. The idea that suffering is inevitable and the result of karma may result in difficulty with symptom control. Family members are likely to be present in large numbers as death nears. Chanting and prayer, incense, and various rituals are part of the process. After death, healthcare staff should touch the body as little as possible. Ideally, the family should be the only ones to touch the body. A family member should clean the body and this person should be of the same sex as the deceased. After being cleaned, the body is wrapped in a red cloth.

The preference is for cremation and ideally, the ashes are spread over the holy river, The Ganges (or Ganga Ma). The men and boys of the family may shave their hair as a symbol of mourning for the dead. The mourning family may wear all white and wish to have a Brahman at the funeral to perform a prayer and blessing. Photo: Ghats at Varanasi (each fire is a person being cremated). Thanks to Lucy, Martin, & Poli

Diseases and Health Conditions

In India, "the expected number of years to be lived in what might be termed the equivalent of "full health'" is 52.8 years for men and 53.5 years for women. India is thus 134th among 181 nations ranked by the World Health Organization (WHO) (WHO, 2000). Among all Americans, this "disability adjusted life expectancy" or DALE is 67.5 years for men and 72.6 years for women.

Health problems prevalent among Indians include malaria (especially in South India), respiratory infections such as tuberculosis and pneumonia, hypertension and cardiovascular disease, rheumatic heart disease, nutritional deficits, and high risk behavior such as alcoholism and cigarette smoking. Dental caries and periodontal disease affect most of the adult population. Sickle-cell disease is prevalent, with the gene detected in 16.48 percent of selected populations. Prostitution is common and HIV infection is a growing problem. Communicable diseases relatively common in India include the below. Readers are referred to the Communicable Diseases section of the Refugee and Immigrant web site.

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Authors: Sonal Bhungalia, Tara Kelly, Stephanie Van De Keift, Margaret Young

Edited by Charles Kemp

References

Dickson, N. (1998). World: South Asia Indianís battle with population

growth. BBC Online Network. Available online: http://news.bbc.co.uk/hi/english/health/default.html

India. In The Encyclopedia Americana: International Edition (Vol. 14, pp. 865-881). Danbury, CT: Grolier Incorporated.

Knipe, D. M., (1991). Hinduism. New York, N.Y.: Harper Collins.

Lipson, J.G., Dibble, S.L., & Minarik, P.A. (Eds.). (1996). Culture & Nursing Care: A Pocket Guide. San Francisco: UCSF Nursing Press.

Paulanka, B.J., & Purnell, L.D. (Eds.). (1998). Transcultural Healthcare: A Culturally Competent Approach. (CD-ROM). F. A. Davis Company.

World Health Organization (2000). Healthy life expectancy rankings. Accessed on the World Wide Web on October 14, 2000 at http://www-nt.who.int/whosis/statistics/dale/dale.cfm?path=statistics,dale&language=english

Internet Resources (Most self-explanatory)

http://falcon.jmu.edu/~ramseyil/asialit.html

http://india.coolantlanta.com/GreatPages/sudheer/medicine.html

http://www.ayruvedic.org/html

http://www.bbc.co.uk/education/medicine/nonint/prehist/dt/prdtcs4.shtml

http://www.chronicpainsolutions.com/articles/sogalspr.98.html

http://www.censusindia.net

http://www.censusindia.net/cendat/datatable12.html

http://www.encycolpedia.com

http://www.indiagov.org/culture/cuisine.html

http://www.indianherbs.com/herbalist.html

http://www.personal.si.umich.edu/~lija/design/ayurevda.html

http://www.qqq.com/india/cuisine.html

http://www.sikhs.org

http://www.sikhs.org/religion.html

http://www.spindlepub.com/India/profile/htm (handbook for Asian Indians)

http://www.worldbank.org/html/extdr/offrep/sas/rura;brf/medplant.html

http://www.worldbank.org/html/extpb/indiawom/indiasum.html