1. Johanson, Linda S.

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We removed our shoes, padded gingerly across the cool breezeway, and stepped into wonderland. The Shewdagon Phuya (pagoda, or place of Buddhist worship) in Rangon, Myanmar with its immense golden turrets and gilded altars reminded me of a fairytale castle, except that hundreds of statues of Buddha dominated the landscape. Scores of worshipers reverently poured tiny cups of water from sparkling basins over the statues and offered alms. Intermittently, the silent tranquility was interrupted by the sounding of brass gongs or the monotone chanting of pate-shaven monks.

Figure. No caption a... - Click to enlarge in new windowFigure. No caption available.

The worship stood in stark contrast to my Christian church service in North Carolina. I was in the country of Myanmar (formerly known as Burma) with my physician-husband on a two-week medical mission trip in the spring of 2006. There, I discovered invaluable insights that have increased my sensitivity as a nurse caring for patients of different cultures and backgrounds. Three insights stand out that have had a great impact on my role as a Christian nurse in America.


Insight #1: Although people are superficially very different, many needs are the same.


Myanmar is a very different culture from what I had experienced in America or on previous mission trips. South of China between India and Thailand, Myanmar's main language is Burmese. Ninety-two percent of the population is Buddhist. The climate is tropical, with hot humid summers followed by a warm rainy season.


Agriculture is the main industry in Myanmar. The local pastor in the Mon state region informed us that the people live in a rubber tree forest. They arise at 2:00 A.M. and, armed with a plastic five-gallon bucket, make their way through the dark forest with flashlights to gather a half cup of liquid rubber from each tree. The rubber is then poured into wooden frames to solidify and afterward hung on drying racks. Eventually, a merchant will pass through with a truck to purchase the rubbery rectangles and take them to Thailand for processing.


When we talk about being culturally sensitive, we often think about learning the differences between our culture and another, then trying to figure out how to be considerate of those differences. This can be an effective strategy, but I learned in Myanmar that one also can gain cultural sensitivity by focusing on similarities. Despite the vast differences, people coming to the medical clinic presented with the same needs we have in America: back pain, headaches, arthritis, reflux, asthma, rashes, infections, malnutrition, and depression. When a 50-year-old woman came to the clinic upset because of hot flashes and irregular menstrual periods, I was able to see past her long traditional wraparound skirt and face smeared with powdered white bark. Her anxiety visibly eased as I shared with her through an interpreter that I had been experiencing the same signs of menopause and gave her tips to alleviate her symptoms.


In the past, as a nursing instructor at a Christian college, I assigned students a "culture" to research in order to gain cultural sensitivity. Students would outline the main religious practices of their assigned culture, as well as its health practices, ethnic foods, and cultural ethnocentricities. The assignment, while informative, seemed to emphasize how different others are from us, suggesting that they somehow need to be treated differently. Since visiting Myanmar, I have modified my approach to teaching students cultural sensitivity. Although it is insightful to understand history and trends, it seems more applicable to include a comparison-contrast component. Students need to use critical thinking skills to discern how someone superficially different from them is also similar. It is a wonderful lesson on treating patients as individuals rather than using a standardized plan of care that may or may not be effective.


Insight #2: People of the same religion may not have the same beliefs.


One of the trip highlights was a lecture on the Buddhist faith by Jubilee Phanga, a local Christian pastor. Pastor Jubilee was raised in the Buddhist faith, but converted to Christianity as a young adult. I learned that there are several classes of Buddhism in the world, and that the type practiced in Myanmar is known as "Theravada." Buddhist beliefs vary between countries and classes contingent upon political and societal influences.


The religion practiced in Myanmar digresses from pure Buddhism due to the historical influence of Hindu cults. For example, in the Burmese culture, there is a traditional belief in local "nats" (something like spirits) who guard and rule. Man is obligated to please the nats at all times, so almost every Buddhist household has an altar on which food and drink are offered as pleasing sacrifices. At shrines located throughout communities, people can make sacrifices to nats to keep the village safe from evil. There are, however, evil nats who cause sickness and disaster. Therefore, nat-saya (or spirit-masters) and witchcraft have a significant role in this culture.

Figure. The author w... - Click to enlarge in new windowFigure. The author working through a local translator at one of the mobile medical clinics. (Photo courtesy of Dr. Ron Fair)

As a result of this experience, I learned the importance of avoiding stereotyping. One day a woman came to the clinic dressed in the brown attire I traditionally associated with monks. Her head was shaved, but she wore a pink drape over her robe. I was told she was not a monk, but rather one who had devoted her life to helping the monks in the pagoda. At the clinics, our normal routine was to present the Gospel to each patient. This woman obviously was a devout Buddhist, and we felt uncomfortable about presenting the message of Christianity, assuming she would be offended by the suggestion that she needed Christ. However, the interpreters working with us decided she must have known the clinic was Christian based, so they explained the Gospel message to her despite our concerns. To our astonishment, she made the decision to become a Christian that very day. Had we let our stereotypical perception prevail, she may never have had that opportunity.


Sometimes in our work, we may feel uncomfortable offering spiritual care such as prayer or Scripture because we are worried the recipient may be offended. Although we should always obtain a patient's consent for spiritual care, this experience encouraged me to be bolder regarding my Christian witness in America. Now, I try to avoid presuming what someone's reaction might be based on first impressions.


I also have become more aware of my tendency to stereotype, and I am making an effort toward better control. For example, just because a student's last name is Yang does not mean English is his or her second language and that he or she will have difficulty writing a research paper. I remind myself daily to have an open mind and avoid preconceived notions about students, colleagues, patients, and people I meet.


Insight #3: "Religion is not necessarily synonymous with spiritual support."

Figure. Bill and Lin... - Click to enlarge in new windowFigure. Bill and Linda Johanson take time to appreciate the culture of Myanmar. Shown above is Shwedagon Pagoda in Yangon, Myanmar. (Photo courtesy of Dr. Ron Fair)

Through the lecture on Buddhism I learned fascinating facts about this religious practice in the country of Myanmar. The predominant religious values of Burmese Buddhists are based on the teachings of Buddha, or karma. They believe that life is essentially an illusion, but that the will to exist is a monumental force. Everything that happens to a person is the result of past deeds (in this or a previous life). Bad karma causes bad results, and good karma causes the opposite. To be free from endless reincarnations after death, a person must repay all his debt of bad karma, called wutchui. This is accomplished by kuhtu, or merit earned in five ways:


* 1. Building pagodas: The fastest way to recover wutchui is to donate money, gold, silver, and jewelry to the pagodas-temples of worship to Buddha.


* 2. Shinpyu ceremony or becoming a monk: Between the ages of 5 and 25 years, young male Buddhists are required to become monks for a minimum time of 8 to 9 days (although it may be for life). The life of a monk is a simple existence devoted to Buddha worship.


* 3. Feeding and caring for the monks: The monks are permitted only one meal per day before noon. From dawn to noon daily we saw monks collecting food in large baskets from supporting families. Usually families support at least one monk continually, but we were told that they may give alms to as many as twenty or more monks per day. Most of the people are poor, but because giving to monks is a way to erase bad luck karma from previous lives, the sacrifice is essential.


* 4. "Danapyu" or doing good deeds: Good deeds, acts of compassion, and charitable contributions cancel bad luck karma.


* 5. Participation in festivals: Every month has at least one religious festival during which people gather for fellowship and communal worship, another method for canceling wutchui.



The Burmese Buddhists believe they are responsible for their fortune of karma. If a man dies unsuccessful at canceling the debt of previous bad karma, he may be reincarnated in animal or insect life or lower civil status. The Buddhist is destined to suffer, and his existence is impermanent. This state exists because no one knows the precise amount of wutchui he has to cancel, nor exactly how many good deeds are needed. The best he can hope for is release from the recycling of suffering over and over. If one is successful at canceling wutchui, he or she reaches nibban, which basically is a state of nothingness.


As nurses, we are concerned with holistic care of body, mind, and spirit. It seems logical to consider a person's religious beliefs as a source of spiritual support. However, there is a certain futility associated with the suffering, anxiety, and impermanence of the Buddhists in Myanmar. Even if a Buddhist can successfully cancel all his or her bad debt karma, the best she or he can hope for is "nothingness."


As we learned more about the Burmese faith during our mission trip, I began to see unexpected parallels with Christianity. For example, the Buddhists of Myanmar believe in the existence of suffering that recycles over and over. This is analogous to the Christian doctrine of sin. However, Christians believe the debt of sin cannot be canceled by good deeds or human effort. We believe in Jesus Christ, who paid the penalty for our sins and makes possible the hope of everlasting life. Although it was essential to understand this difference as we cared for the Burmese people, we had to be considerate of the deeply ingrained, disciplined, honorable beliefs of Buddhism. In Myanmar, because Buddhism is so closely associated with Burmese nationalism, any other religion or set of beliefs is very difficult to accept, even one with such a great promise of hope.


I learned to use common ground but not to push it, never challenging the faith of the Buddhists believers, but trying to be a witness of the peace I have as a Christian. The people in Myanmar told us they were amazed that Americans would give their time and money to come to their country to provide free care. They could see that we cared by our mission.


My experience in Myanmar was more than a lesson in history, geography, and sociology. Although I learned interesting facts about the country, the people, and Buddhist practices, more importantly, I gained self-insights. I am now more culturally sensitive. I hope I provide a better Christian witness and more insightful spiritual support. That is worth more than all the gold in the largest pagoda in Myanmar.