Cross-cultural Medidine

Culture Shock A Review of Vietnamese Culture

and Its Concepts of Health and Disease
MAJ DUONG NGUYEN, MC, USA, Tacoma, Washington
Misunderstandings of Vietnamese culture and beliefs have led to many unfortunate incidents in the
United States, including court cases for child abuse and even suicide. These can be avoided by an
awareness of the cultural background of the Vietnamese, their philosophy oflife and the influence of
religion and beliefs on their personalities, both as individual persons and as members of extended
family units. The Vietnamese concepts of health and disease are presented, along with brief
descriptions of certain folk medicines that are frequently misconstrued byAmerican physicians.
(Nguyen D: Culture shock-A review of Vietnamese culture and its concepts of health and disease
[Cross-cultural Medicine]. West J Med 1985 Mar; 142:409-412)

om April 1975 through February 1982, about 1.4 mil- The Oriental Heritage
lion Indochinese refugees fled their homelands. Nearly "East is east and west is west. " The Oriental cultures and
580,000 (40%) of these refugees, most of whom were Viet- values differ considerably from those of Americans. For ex-
namese, have settled in the United States.t They have in- ample, American civilization has thrived on overcoming and
curred, in turn, a host of cultural, economic, political, psy- mastering nature, whereas the Indochinese cultures stress har-
chological and social upheavals.2 mony with nature. Instead of towering skyscrapers, the an-
In contrast to the nearly 1 million Cuban refugees that cient Asians constructed their houses not by height but to
have settled in the United States since January 1959, the blend modestly with the environment, creating thereby a sense
Vietnamese refugees have had to confront more immediate of tranquility with life. Even today, Indochinese persons as-
problems: They had no previously settled ethnic group to pire to have the trees, grasses, mountains and rivers provide
offer initial support; their culture was more dissimilar to that warmth and protection for their houses, in the hope that nature
of the Americans, and they have frequently been symbolically will be supportive oftheir lives and their families.4
identified with the unpopular Vietnam war. In brief, their Moreover, the Oriental daily life-style is less stressful.
arrival in the United States marked the beginning of a long and People tend not to rush because their concept of time is much
arduous process of adjustment to a new life in a new country more elastic. In contrast to the almost compulsive punctuality
with an alien culture. of Americans, Oriental persons frequently arrive late for ap-
Inevitably, misunderstandings have occurred. For ex- pointments.
ample, a Vietnamese father took his 3-year-old son to an
American hospital because of possible influenza.3 The child Vietnamese as Individuals
had many ecchymoses on his chest and back, and the father Vietnamese have but a few family names for a population
was suspected of child abuse. Although he explained that the of 56 million persons (1982 figure), with Nguyen being the
ecchymoses represented cao gio-that is, a home treatment of most common. Their names are always written in the fol-
coin rubbing-he was jailed and subsequently committed sui- lowing order: family, middle (sometimes twice) and first
cide. names. This order may create confusion for medical records
In the hope that such misunderstandings can be avoided, I keeping and is frequently a source of misunderstanding. Also,
will briefly review the cultural background of the Vietnamese; they are typically addressed by their first names (even by
describe the Vietnamese both as individual persons and as strangers), a practice that is occasionally denigrated by Amer-
members of extended family units; discuss Vietnamese reli- icans.
gious beliefs and social heritage, and present the traditional A person's age is also a source of confusion. For Viet-
Vietnamese health beliefs. namese, it is calculated roughly from conception. Thus, most

At the time this article was written, Maj Nguyen was at the Madigan Army Medical Center, Fort Lewis, Tacoma, Washington. His current address is
97th General Hospital, Box 37, APO NY 09757. The opinions or assertions contained herein are the private views of the author and are not to be construed as
official or as reflecting the views of the US Department of the Army or US Department of Defense.
Reprints are not available.

MARCH 1985 * 142 * 3 409

 CULTURE SHOCK

children are considered to be a year old at birth and gain separation or divorce-instead of being mediated by compro-
thereafter a year at every lunar New Year-that is, each Tet. mise, resignation or tolerance (as in the past in Vietnam).
For example, a child could be 2 years old by Vietnamese
counting, but less than a month of age by American reck- Religious Beliefs
oning. The Vietnamese are strongly influenced by several sets of
Because of the strong influence of the Confucian code of religious beliefs.7 First, Buddhism was introduced to
ethics, proper form and appearance are very important to Vietnam as early as the second century AD. Its influence is
Vietnamese. For example, the head is considered to be the essentially the creation of a state of mind (rather than compul-
sacred part of the body; therefore, it is most impolite to pat the sory attendance at an established church). Central to this faith
head of a Vietnamese adult. Similarly, the feet are the lowest is a concept of life in which suffering is caused by desire.
part of the body; thus, a Vietnamese person will feel offended Desire can be eliminated by correct behavior-that is, the
if an interlocutor places an imprudent foot on the desk "Eight-Fold Path"-which lessens one's suffering in life. For
pointing towards him or her. Again, to signal for someone to example, some Vietnamese may quote Buddha's teachings
come by using an upturned finger is a provocation (usually about the world as a cycle of ordeals: to be born, grow old,
done to a dog); waving the hand is considered to be more fall ill and die.
proper. Second, Confucianism is more a way of life than a religion
Both Confucian and Buddhist beliefs urge Vietnamese per se. Involving a code of ethics and morals, it emphasizes
persons to be shy and modest. They rarely display strong the hierarchy of the members of society and stresses the wor-
emotions in public. Hugging and kissing are not seen outside ship of ancestors.
the privacy of the home, and the sight of a wife being hugged Third, originating from Lao-tzu (a 6th century BC philoso-
by casual friends in public is a major source of discomfort for pher), Taoism has also had an important role in the develop-
a Vietnamese husband. ment of the Vietnamese cultural personality. Taoism is "natu-
ralism" in the sense that it advocates taking no unnatural
The Vietnamese Family Unit action to achieve conformity to the Tao ("the Way"). This
Because American culture stresses individualism, Ameri- philosophy stresses that, when things are permitted to assume
cans find it difficult to fully understand the power of kinship their natural course, they move toward perfection and har-
for Vietnamese. The family is the fundamental social unit- mony.
that is, the primary source of cohesion and continuity-in Fourth, Catholicism and Protestantism were more re-
traditional Vietnamese society. Differing profoundly from the cently introduced to Vietnam, but they are followed by only a
American nuclear family, the Vietnamese family should be minority of the Vietnamese.
perceived as "a superorganic unit existing across generations Finally, animistic belief is much less frequently invoked
past and future."5 The crux of family loyalty is filial piety, by the Vietnamese than in the past. However, it is still prac-
which commands children to honor their parents. One's be- ticed by the mountain tribes-that is, the "montagnards"-in
havior, for better or for worse, reflects not only on oneself but the highlands ofVietnam.
also on the family itself.
The family may be involved in health care decisions, and The Vietnamese Cultural Personality
they may not leave such a decision solely to the patient. As Such religious concepts and beliefs as mentioned above
Tran, a well-known Vietnamese psychiatrist, noted, "In most have been transmitted through the generations to produce an
cases, the relatives, more than the patients, are the ones to be attitude towards life that may be perceived as passive. For
convinced before the patient can start or continue a thera- example, whenever confronted with a direct but delicate ques-
peutic program."6 tion, many Vietnamese cannot easily give a blunt "No" as an
Most Vietnamese refugees arrived with a large patriarchal answer, because they feel that such an answer would create
household of 5 to 12 members, including the core (nuclear) disharmony. In such a context, "Yes" tends to reflect either
family, the grandparents, some siblings (and their families) an avoidance of confrontation or a desire to please the ad-
and even some in-laws. For those families that stayed to- dressee, rather than an affirmation of truth.
gether, life has not been without problems: Prolonged close- Self-control is another traditional value of the Viet-
ness often creates friction, cumpulsory intimacy may generate namese. Emotions are typically kept to oneself, whereas ex-
personal irritations, exposure of the younger generation to the pressions of disagreement that may irritate or offend are
American culture frequently becomes a source of conflict and avoided. They may be in pain, distraught and unhappy, yet
incessant expectations of mutual dependency may become they rarely complain (except perhaps to friends or relatives).
hateful obligations and a common origin of emotional ill- There are also deep cultural restraints against showing
nesses. "weakness" of the mind. Emotions are considered weak-
When such conflicts arise, the unhappiness will initially be nesses because they interfere with self-control. Superior per-
suffered in silence and in privacy. Such behavior is fostered sons, therefore, should not be swayed by emotions nor, even
by an enduring Buddhist and Confucian pattern of conduct less, permit other persons to see that they are troubled by
that encourages passiveness and personal reserve. But a intimate feelings. Hostility is not usually expressed towards
gradual eroding of these cultural influences, coupled with persons who are considered superior-such as parents, physi-
increasing conflicts within families, may cause the unhappi- cians or teachers. American health services personnel may
ness to evolve rapidly into overt crises. The eventual out- comment that their Vietnamese patients rarely appear des-
comes are more likely to be radical and disruptive-such as perate or depressed, but seem reasonably content, frequently

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 CULTURE SHOCK

smiling and seldom complaining or demanding-that is, they * Giac ("cup suctioning"), with or without prior scarifi-
have "the good patient look."8 cation.
The next step in self-control for nearly all Vietnamese * Xong (herbal steam fumigation).
persons is denial and avoidance. If pain and sorrow inevitably * Balm application (Tiger's balm, Mac Phsu Cula or Nhi
occur, one should try to forget them and hope for the best. Thien Duong oil).
What often sustains this effort against being overwhelmed by * Ingestion of herbal concoctions, an influence of tradi-
desperation is a special form of rationalization: "destiny." It tional Chinese medicine.
was "destiny" when they were saved, when they were able to * Ingestion of organ meats. For instance, consumption of
escape to liberty rather than being detained in a concentration animal liver produces a strong liver, and so forth for brains,
camp. It is also destiny when misery is prolonged for some kidneys and testis. Many Vietnamese also believe that eating
but shorter for others. Accepting one's destiny means resigna- the gelatinous product of tiger bones (produced by prolonged
tion, but it also suggests hope: Things may improve anytime, cooking) will make them strong.
if it is one's destiny for events to change at that particular * Ingestion of hot food to cure cold illness and vice versa
moment. (chicken soup is recommended for the treatment of fever).
The final step is fatalism. When one's life cannot be saved, * Finally, other health practices have obscure origins.
this is accepted stoically. In the older Vietnamese genera- For example, a diet heavy in salt is believed to be good for
tions, it was hardly uncommon to see a house with a coffin pregnant women, and postpartum women should sleep over a
situated beneath the household altar. Knowing that the days charcoal heater to shorten the postdelivery period.
were short, the owner bought his or her future coffin. That is, Besides these examples of folk medicine, Vietnamese
a person must think about impending death, foreseeably pre- readily use Western medicine (often both concurrently). Self-
pare for the final moment and accept the final coming of medication is a popular medical behavior in Vietnam. One
death. The burial site may even have been chosen, because the does not need prescriptions to purchase medicines at drug-
position of the land can have an effect on the children. So, stores in Vietnam, which may partially explain the increasing
during the final days of life, a person will polish the coffin and resistance of bacteria to several readily available antibiotics.
even decorate it for the future eternal trip. Vietnamese also prefer drastic treatments: They believe
In summary, unlike Americans who look to the future and strongly that a shot (intramuscular injection) is superior to a
plan for progress, Vietnamese cherish and uphold their ties common oral preparation, and many ask for the 5 % dextrose
with the past and their historical heritage of "4,000 years of in water solution (called "sea water") to be given intrave-
civilization." While Americans are goal-oriented, Viet- nously for rapid recuperation from illness.
namese prefer activities that develop the human essence, such Because medicine usually deals with invisible and imma-
as philosophy, poetry and meditation. terial elements, Vietnamese rarely feel a need for invasive
techniques or surgical procedures. Surgical operations are
Vietnamese Traditional Health Beliefs perceived as a last resort; they are usually equated with admis-
Vietnamese will frequently use folk treatments either con- sion to hospital, which is, in turn, associated with death (and
currently or before seeking Western medical care.9 Those folk thus to be avoided).
treatments are particularly influenced by the Chinese concepts Because of the previously mentioned religious beliefs and
of yin and yang. That is, the universe-and thus a human because of deep cultural restraints against showing a "weak-
being-is composed of two dynamically opposing forces: the ness of mind," an extremely small percentage of the Viet-
masculine (yang), as represented by light, strength and heat; namese population avail themselves of mental health
the feminine (yin), as represented by darkness, softness and services. Psychiatry and mental health are terra incognita for
cold. An excess in either direction will lead to disequilibrium the vast majority. A psychiatrist is either a "nerve doctor"-
and the production of disease."0 Certain diseases are said to which underscores the biologic label attached to the spe-
result from an excess of the cold element, such as diarrhea cialty-or a "doctor for the insane"-which emphasizes the
which is attributable to a "cold" stomach. Other diseases are bizarre, "out-of-this-world" character of mental diseases. In
ascribed to an excess of the hot element, such as pimples or brief, then, delays in seeking medical care (both mental and
pustules which are attributable to an excess of a hot element physical) due to stoicism are a negative aspect of the Viet-
erupting through the skin. Similarly, foods are divided into namese cultural heritage.
two groups: hot-spices, coffee, beef, wild game-and
cold-tea, most fruits, chicken, duck, seafood. Conclusion
Drugs and medicinal herbs are also carefully classified Misunderstandings will inevitably occur whenever two
according to their properties along a scale of hot and cold cultures coexist. I have reviewed the differing aspects of the
effects. From this concept, a number of techniques for the Vietnamese cultural heritage in the hope that further unfortu-
cure of illnesses have evolved: nate incidences such as the child abuse accusations and subse-
* Cao gio, "coin rubbing" with hot balm oil that pro- quent suicides can be avoided. The Vietnamese in the United
duces ecchymotic marks and petechiae on the chest and States are refugees-and, by definition, are involuntary immi-
back.11 (This has, unfortunately, been a source of many accu- grants. Their expatriation was unexpected, their trip was un-
sations of child abuse leading to court trials and even suicide.) planned and their departure from Vietnam was precipitous.
The Centers for Disease Control have recently been asked to Hence, the absence of any material or psychological prepara-
evaluate the effectiveness of this practice. 12 tion meant that the impact of transplantation could not be
* Be bao ("skin pinching"), a derivative of the above cushioned.
practice. Of course, the Vietnamese will adjust, but the cost of

MARCH 1985 * 142 * 3 411

 CULTURE SHOCK

adjustment will necessarily vary with the situations involved. 4. Toan A: Phong tuc Vietnam (Vietnamese Tradition). Lancaster, Pa, Xuan Thu
Library, n.d.
The most sensitive situations require awareness of the basic 5. Special Report: Physical and emotional health care needs of Indochinese refu-
values, beliefs and traditions that have been imprinted for an gees. Indochina Refugee Action Center 1980 (March 20), pp 30-31
entire lifetime. For American health professionals, a knowl- 6. Tran MT, quoted by Tripp-Reimer T, Theiman K: Traditional health beliefs/
practices of Vietnamese refugees. J Iowa Med Soc 1981; 71:533-535
edge about Vietnamese cultural heritage, even if sketchy, 7. Toan A: Tin nguong Vietnam (Vietnamese Religions and Beliefs). Lancaster, Pa,
should further their capacities for empathy, tolerance and Xuan Thu Library, 1966-1967
compassion so that they will see Vietnamese patients as per- 8. Tran MT: The Indochinese refugees as patients. J Refugee Resettlement 1981;
1:53-60
sons culturally worthy of attention and respect. 9. Rocereto L: Selected health beliefs of Vietnamese refugees. J Sch Health 1981;
51:63-64
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1. Report by the Comptroller General of the United States, GAO/HRD 82-65. Asian refugees. JAMA 1982; 248:710-714
Government Accounting Office, Aug 5, 1982 11. Yeatman GW, Dang VV: Cao Gio (coin rubbing)-Vietnamese attitude toward
2. Masuda M, Lin KM, Tazuma L: Adaptation problems of Vietnamese refu- health care. JAMA 1980; 244:2748-2749
gees-LI. Life changes and perception of life events. Arch Gen Psychiatry 1980; 12. Council minutes: Maryland Refugee Advisory Council, 1982 (December 2)
37:447-450 13. Centers for Disease Control: A clinician's guide to diseases of Indochinese
3. Nong TA: 'Pseudo-battered child' syndrome (Letter). JAMA 1976; 236:2288 refugees. Resident and Staff Physician 1979 (December), pp 76-82

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