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Cultural Approaches to Pediatric Palliative Care in Central Massachusetts: Pakistani

This subject guide is a collaborative project with the Children's Medical Center Pediatric Palliative Care Team, the Lamar Soutter Library, and Interpreter Services.



General Culture Information: Pakistan is in South Asia and is about twice the size of California. It was created from the northwest side of India in 1947. It is in this northern section where most of the ancient tribes still live and where many ancient tribal cultures and customs still exist. In the north, leading from China, through Jammu and Kashmir, is a famous ancient silk road. The 1,000-mile-long (1,609 km) Indus River and its tributaries flow through the country from the Kashmir region to the Arabian Sea. Pakistan consists of several provinces, including Punjab, Sind, Khyber-Pakhtunkhwa, Baluchistan, and FATA. The separation in 1947 of British India into the Muslim state of Pakistan (with West and East sections) and largely Hindu India was never satisfactorily resolved, and India and Pakistan fought two wars - in 1947-48 and 1965 - over the disputed Kashmir territory. A third war between these countries in 1971 resulted in East Pakistan becoming the separate nation of Bangladesh.Pakistani Culture is very unique in terms of its social values revolving around the religion of Islam. The region has formed a distinct cultural unit within the main cultural complex of South Asia, Middle East and Central Asia with an integration of elements from various invading cultures from the earliest of times. There are differences in culture among the different ethnic groups in matters such as dress, food, and religion, especially where pre-Islamic customs differ from Islamic practices. There is no caste system in Pakistan, but some of the Hindu caste practices are part of Pakistani daily life, particularly amongst the Punjabis and Sindhis. Tribal cultural practices are prevalent in the rural regions of the country.

Population: Estimated at 184,404,791 (July 2010 est.). Pakistanis comprise of numerous diverse cultures and ethnic groups: the Punjabis, Kashmiris, Sindhis and Muhajirs (immigrants from India at the time of partition and their descendants) in the east; the tribal cultures of the Baloch and Pashtun in the west; and the ancient Dardic and Tajik communities in the north.

Language in Pakistan: Although Urdu is the official language of Pakistan, it is spoken as a first language by only 8% of the population; 48% speak Punjabi, 12% Sindhi, 10% Saraiki, 8% Pushtu, 3% Baloch, and 11% other. English is the lingua franca of the Pakistani elite and most of the government ministries. Urdu is closely related to Hindi but is written in an extended Arabic alphabet. Combining the languages of early invaders and settlers, including, Arabic, Persian, and Turkish with native Sanskrit created Urdu.

Religion: Pakistan was formed as an Islamic nation, and Islam continues to be the religion of approximately 97 percent of the population (Sunni 77%, Shi'a 20%). Members of several minority religions also live there, including Hindus, Christians, Parsis, Sikhs, and Buddhists.

Islam governs the personal, political, economic and legal lives of majority of Pakistanis. Prophet Muhammad founded the religion  of Islam in the seventh century when, according to Islamic belief, he received messages from God and recorded them in what became the Qur'an, the Islamic book that instructs Muslims on how to conduct their lives. Among certain obligations for Muslims are to pray five times a day - at dawn, noon, afternoon, sunset, and evening, fast during the month of Ramadan, give Zakat (2% of their wealth) to the needy and perform Hajj, pilgrimage to Mecca, Saudi Arabia. Eid-ul-Fitr is celebrated on the day ending Ramadan. "Greater Eid," or Eid-ul-Adha is an important religious holiday celebrated by Muslims worldwide to commemorate the willingness of Abraham to sacrifice his son Ishmael as an act of obedience to God, before God intervened and switched him with a ram instead. The celebrations start after the Hajj. Muharram, which is the first month of the Muslim Calendar, is a holy month, particularly for Muslims of Shia faith, marking the martyrdom of Imam Husain, the grandson of Muhammad.

Other religions in Pakistan also have special festivals/rituals and holidays, with Christmas and Easter being the special ones of the 750,000 Pakistani Christians.

The main festival of the Buddhist community is Baisakhi Purnima, the day on which Buddha was born and when later in his life he is believed to have attained his great wisdom of enlightenment. Parsi residents of Pakistan celebrate their New Year (Naoroz) on 21 March. Pakistani Hindus also have a number of festivals; the two most special ones are Diwali (Festival of Lights) and Holi (Festival of Colors).

Family Structure: The family has been a dominant institution in the life of the individual. People typically define themselves by the groups to which they belong rather than by their status as individuals. In Pakistan, families adhere to a patriarchal ideology (father as head of the family), follow the patrilineal rule of descent (from fatherfs lineage), are patrilocal (wife and family moves to fatherfs domicile) and endorse traditional gender role preferences. The extended family is the basis of the social structure and individual identity. It includes the nuclear family, immediate relatives, distant relatives, tribe members, friends, and neighbors. These members eat the food cooked at one hearth, share a common income, common property, and are related to one another through kinship ties. The family supports the old; takes care of widows, never-married adults, and the disabled; assists during periods of unemployment; and provides security and a sense of support and togetherness. Loyalty to the family comes before other social relationships, even business. Nepotism is viewed positively, since it guarantees hiring people who can be trusted, which is crucial in a country where working with people one knows and trusts is of primary importance. The family is more private than in many other cultures. Female relatives are protected from outside influences. It is considered inappropriate to ask questions about a Pakistani's wife or other female relatives. The eldest male, whether he is the father, grandfather, or paternal uncle, is the family leader and makes all significant decisions regarding the family and its members. All the male members work together and contribute equally in the family, to minimize the financial burden. All the female members of the family jointly handle the household responsibilities and support each other in work. Most marriages are arranged, seen as uniting the families of both the bride and groom. Consanguineous marriages are common in effort to maintain the ethnic purity and identity. In recent times, the bride and the groom are being given an opportunity to meet briefly before marriage.

Gender roles are very distinct. Traditionally, a womanfs place in society has been secondary to that of men, and she has been restricted to the performance of domestic chores and to fulfilling the role of a dutiful wife and mother. Nowadays, professional women abound, mostly in the field of medicine, banking, engineering and education. Women manage the home by keeping all finances, family, and social issues in order. Men typically are the breadwinners 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.

Pakistanis in US live in westernized nuclear families, without the benefits of extended families. The substitute that support structure, by socializing with extended Muslim communities in their neighborhood, generally tied to the local Islamic center. A high value is placed on independence and privacy in Pakistani American culture, so 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. Modesty is highly valued among Pakistanis and patients are decidedly more comfortable and secure with same-sex care providers. They are very uncomfortable in hospital gowns and can be made comfortable by ensuring that they are completely covered.

Parenting:  Pakistan is an extremely pronatalistic society (encourages having children), and the desire to have a male child is greatly stressed. Families are quite large by western standards, often having up to 6 children. 

Newborn rituals: In Muslim families, it is common for the father or the grandfather of the child to recite the Azan (Call to Prayer) in the childs right ear and the Iqama (Avowal of faith) in the childs left ear just after birth to confirm that the child is Muslim. All boys are circumcised. The child is usually named within forty days after birth and thus is generally known by a nickname until then. A newborn baby's hair is shaved off and food is distributed to the poor in a ritual called Aqiqa. The tradition dictates that shorn hair is weighed and balanced against silver, and that silver is then given to the poor.

Male children are raised to be assertive, less tolerant, independent, self-reliant, demanding, and domineering. Females, in contrast, are socialized from an early age to be self-sacrificing, docile, accommodating, nurturing, altruistic, adaptive, tolerant, and religious and to value family above all.  Childrearing practices in Pakistan tend to be permissive, and children are not encouraged to be independent and self-sufficient. In Pakistani 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. During an invasive procedure, the healthcare worker may want to give the child a choice for support: grandparent or parent – 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. In the traditional family, communication between parents and children tends to be one-sided. Children are expected to listen, respect, and obey their parents. Generally, adolescents do not share their personal concerns with their parents.  Arranged marriages are still the norm, and dating generally is not allowed. Furthermore, sex and sexuality issues are not openly discussed, interrelationships with the opposite sex are discouraged, and premarital sex is frowned upon.

Food:  Because at least 95 percent of the Pakistani population is Muslim, there are two food customs that are followed almost universally. First, Muslims do not eat pork (therefore beef, chicken, lamb, and fish are the basic foods), and second, alcohol is forbidden. The Mughal and Persian styles of cooking, which is rich and extremely spicy heavily, influences Pakistani cuisine. The most prevalent spices include chili powder, turmeric, garlic, paprika, black and red pepper, cumin seed, bay leaf, coriander, cardamom, cloves, ginger, cinnamon, saffron, nutmeg, and poppy seeds. The diet is heavily meat based. Both Wheat and rice are the main stays of the daily diet. Green and black tea is the typical drink served at all meals.  

Communication: Pakistan is a hierarchical society. People are respected because of their age and position. In a social situation, they are introduced first, served first, provided with the choicest cuts of meat, and never interrupted. They make decisions that are in the best interest of the group. 

Titles are very important and denote respect. It is expected that you will use a person's title and their surname until invited to use their first name.

Greetings are often between members of the same sex; Men may shake hands with other men and women may shake hands with other women; however there are seldom handshakes between men and women because of religious beliefs. Women are never physically touched. Men are comfortable expressing affection with hugs.

Pakistani names often include a name that denotes a person's class, tribe, occupation, or other status indicator. They may also include two names that have a specific meaning when used together, and the meaning is lost if the names are separated. It is best to ask a person how they wish to be addressed.

People eat with their right hand, many without using eating utensils.

It may take several visits for Pakistanis to trust. They often ask personal questions as a way to get to know their healthcare worker as a person. Pakistanis do not require as much personal space and will stand close to the person while conversing.

They are generally indirect communicators and speak in a roundabout or circuitous fashion. Direct statements are made only to those with whom they have a long-standing personal relationship. They also use a great deal of hyperbole and similes, and go out of their way to find something to praise.   

Just Can't Say No: Pakistanis prefer to converse in a non-controversial manner, so they will say they "will try" rather than admit that they cannot or will not be able to do something. Therefore, it is important to ask questions in several ways so you can be certain what was meant by a vague response.

Silence is often used as a communication tool.  

Health Care Proxy / End of Life:  The cultural and religious background of Pakistani elders often influence end of life care decisions. Older patients are more likely to subscribe to family centered decision making rather than being autonomous. Sometimes family members may ask the physician not to tell patients, female members of the family their diagnosis or other important information. Suicide is forbidden and families will often view Advance Directives as giving up and will not agree to DNR/DNI status.  

Traditional Beliefs and Alternative Medicine:  Unani medicine or Hikmat is ancient Greek medicine that has evolved within the Muslim world for the past 13 centuries (Unani is an Arabic spelling of Ionian, meaning Greek). It is based on the teachings of Greek physician Hippocrates and Roman physician Galen, that was developed into an elaborate medical System by Arab and Persian physicians, such as Rhazes, Avicenna(Ibn Sena), Al-Zahrawi , Ibn Nafis. Avicennas most important medical work was The Canon of Medicine (Qunun) remained a valued text throughout Europe and the mid-East for several centuries after his death. Hikmat is rooted in the understanding that spiritual peace is essential for good health.  It further defines the state of the body into three different stages: health, disease and neutral. Disease is said to occur when the functions associated with the vital, natural and psychic forces of the body are obstructed or unbalanced. Neutral in the physical body means the state between health and disease when symptoms have not yet manifested. The systems involve four elements: earth, air, water, and fire; four natures: cold, hot, wet, and dry; and four humors: blood, phlegm, yellow bile, and black bile.  According to Unani medicine, management of any disease depends on the cause, aggravating factors, pathogenesis, pathology, and clinical manifestations. The principles of management are determined by: elimination of cause, normalization of humors, and normalization of tissues/organs.  The treatment interventions include dietary therapy, physical therapeutic regimes and pharmacotherapy with single and or compound Unani drugs.

Local Community Information:

Islamic Society of Greater Worcester

57 Laurel street
Worcester, MA 01605-3069
508 752-4377 

Worcester Islamic Center
248 East Mountain Street
Worcester MA, 01606

508 595-0298  



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