Cultural Diversity and Spiritual/Religious Health Care of Patients with Cancer at the Dominican Republic.

OBJECTIVE: Noncommunicable diseases have become a global pandemic with disproportionately higher rates in low-and middle-income countries. Dominican Republic (DR) as a Latin Americans and Spanish-speaking Caribbean developing country shares a socioculturally distinctive spiritual and religious pattern. It underlines their attitudes, values, and belief systems, socioeconomic reality, and racial attitudes. Social sciences and religious studies suggest that a relationship between spirituality, religion, health-care services (Sp/Re-HCS), and cultural diversity exists. This article argues in favor of a descriptive historical analysis of that relationship.
METHODS: Systematic search of academic articles, abstracts, and conclusions published in Medline, EBSCO, PsycINFO (OVID), ATLA Religion Database, and Google Scholar was undertaken using a combination of English and Spanish relevant terms. The analysis of articles was examined through a historical background approach, a systematic review, and a content analysis.
RESULTS: A Roman Catholic organization, Voluntariado Jesús con los Niños Foundation, serves to cancer patients that have almost no financial protection. The Dominican Evangelical Church (DEC) founded in 1932 a medical service base at the International Hospital in Santo Domingo (IHSD). When the DR government developed medical services, the DEC closed the IHSD. Since then, there is no any DR Evangelical or Protestant organization that offers Sp/Re-HCS to cancer patients (S/R-HCSCP).
CONCLUSIONS: This analysis suggests that a relationship between S/R-HCS and cultural diversity exists. In this sociohistorical analysis, the nonhomogeneous cultural distinctiveness of the Sp/Re-HCS has been demonstrated through the analytical description of the only one organization of S/R-HCSCP at DR.

Introduction

As López-Sierra and Rodríguez-Sánchez[1] pointed out, that behavioral, cognitive, and psychosocial science literature strongly suggest that a relationship exists between spirituality/religion and health-care services of cancer patients (S/R-HCSCP) and cultural diversity. That relationship is not uniform and manifests culturally heterogeneous.

In spite of common values shared by many Latin Americans (LAns) and Spanish-speaking Caribbean (SSCn) from diverse regions and countries are not a homogeneous culture and thus, a uniform style of communication does not exist in their cultural spectrum. They often differ across social, political, economic and cultural, religious, spiritual, and symbolic dimensions.[23]

As a country, DR is suffering from the double burden of infectious diseases as well as an increase in noncommunicable diseases, which together paint a grave picture of health in the DR. For instance, mortality due to noncommunicable causes already accounts for a considerably higher proportion of deaths than communicable causes. Epidemiological data from developing countries such as DR suggest that Sp/Re evokes in health-care receivers the sources to find the necessary inner strengths, which include perspective thinking, rituals for transcending immediate physical condition, and modalities of coping with their illnesses.[14]

However, Sp/Re is not a homogeneous because it always manifests itself in diverse cultural and political settings. As such, Sp/Re provides the individual and their families with a practical context and social memory, which includes traditions and social/family practices for maintaining meaning and well-being.[3]

DR represents a cultural diverse case of S/R-HCS in the context of LAn and the SSCn.[56] Hence, a descriptive-historical approach could be a valuable illustrative and analytical tool to understand these health-care dynamics.

Sociohistorical background

DR is an economically developing country which makes up the Greater Antilles islands located in the Caribbean Sea. This nation occupies the eastern end of Hispaniola Island. The island was a Spanish colony until it gained its independence in 1844 and was officially named DR.[78]

In December 1492, Christopher Columbus disembarked on the Samaná peninsula, at the North Coast. At that time, the island was inhabited by the Taino people and called Quisqueya. The Spanish occupation of the overseas territories discovered after 1492 required the development of a system of health care as an indispensable part of governmental services. This was to ensure the safe colonization of the newly acquired territories.[9]

To that end, one of the earliest measures Spain undertook was building hospitals. Bartolome de las Casas, referring to the foundation in Hispaniola, the first known European settlement in the New World, reports that in January 1494, Columbus constructed a building to keep supplies and the ammunition for the soldiers, a church, and a hospital. Afterward, the capital of Hispaniola was founded August 1496, on the eastern bank of the mouth of the Ozama River. The location for the capital was chosen because it was believed that winds that came to the island from the north produced diseases. The capital was originally called Villanueva Isabela. This name in turn was later changed to Santo Domingo de Guzman.[910]

In 1503, Friar Nicolás de Ovando, second governor of Española built what would be considered a hospital and named it Hospital San Nicolás de Bari (Saint Nicholas Hospital). The hospital was a hut situated in the same place as the Chapel of Our Lady of the High Grace. It is believed that the hospital belonged to a pious woman of African origin who gathered all the poor people she could and treated them according to her skill.

Nicolas de Ovando provided the hospital with incomes from the capital city's best-rented houses. He followed the instructions received from King Ferdinand and Queen Isabella in a letter dated March 20, to build it hospitals in towns where he saw greater need, and where the Christian poor and the indigenous people, the Tainos, could receive care. In 1590, brothers and officials of the Brotherhood of the Conception laid the first stone of what was at that time known as the “old hospital.” The aim of the old hospital was to treat the poor and care for no more than six patients at a time. The established medical model in San Nicolas de Bari, as in Spain and its colonial possessions during the XVI century, was the so call Hippocratic and Galenic humoral theory. The four humors were considered to be the basic units and fundamental building blocks of all nature. Good health was believed to be the result of the harmonious balance of those four humors throughout the body. Illness was thought to be the manifestation of the “disturbance of that balance.” As such, a malignant tumor treated from this medical perspective was the direct result of the aforementioned “disturbed balance.”[911]

In Spain, as in many Western Europeans countries, experimental medicine model started to develop at the beginning of the 17th century. Cancer began to be understood as a local or regional disease related to the tumor nodes. Medical doctors advocated for breast cancer surgery which included the removal of the tumor, nodes, and pectoralis major. During the 19th century, pathology and cancer surgery advanced. Through the 18th century, the San Nicolás de Bari adopted the experimental medical model and mainly cared for ill soldiers. As a result, its name was changed to Hospital Militar (Military Hospital). In the second half of the 20th century, the main therapies used for the treatment of cancer were surgery and radiotherapy. The hospital operated for over 350 years.[91012]

Noncommunicable diseases, including cancer, are overtaking infectious disease as the leading health-care threat in middle- and low-income countries. LAn and Caribbean countries are struggling to respond to increasing morbidity and death from advanced disease. Health ministries and health-care systems in these countries face many challenges caring for patients with advanced cancer: inadequate funding; inequitable distribution of resources and services; inadequate numbers, training, and distribution of health-care personnel and equipment; lack of adequate care for many populations based on socioeconomic, geographic, ethnic, and other factors; and current systems geared toward the needs of wealthy, urban minorities at a cost to the entire population.[13]

This burgeoning cancer problem threatens to cause widespread suffering and economic peril to the countries of Latin America. At present day, DR is organized politically and administratively into 31 provinces and a National District, with a total of 117 municipalities and 56 municipal districts.[14]

From 1994 to 2000, the country occupied the top places in leadership in economic growth in Latin America and the Caribbean. It is a country that has maintained sustained economic growth. Public health research shows that DR's persistent economic growth has not corresponded with a sustainable strengthening of development on a human and social scale. That is, the rise in the production of wealth has not been met by a similar rise in the promotion of an environment that provides viability for the exercise of the full right of human capabilities.[15]

As of 2012, DR has an estimated total population of 10, 135, and 105. Its residents can expect an average of 12.3 years of schooling a Gross National Income per Capita of US$ 5,762. The estimated life expectancy at birth in 2012 was 72.04.[1617]

The age-standardized adult mortality rate by cancer at ages 30–70 per 100,000 people in 2008 was 270. In 2010, they were 8433 estimated cancer reported deaths. In 2012, the density of physicians per 10,000 people was 8.1. Based on official estimated data, as of 2012, the five most common cancers in DR are (1) urological (bladder, kidney, prostate, and testis), (2) gynecological (cervix uteri, corpus uteri, and ovary), (3) breast, (4) lung, and (5) head and neck (lip and oral cavity, nasopharynx, other pharynx larynx, and thyroid).[1819]

The Dominican League against Cancer (DLAC) is a pioneer in the management of cancer in the DR. It was founded on September 13, 1942, and incorporated in 1947, by Decree No. 4134 of the Executive.

At its inception, the institution was named Miracle of Charity Voluntary Institute of Oncology. The institution second name was after Dr. Heriberto Pieter, a Dominican hospital benefactor. One of the institution's main objectives was to engage in social and health issues such as education, detection, prevention, treatment, and cure of cancer. The institution also provides assistance to low-income patients who need medical services such as hospitalization, chemotherapy, radiation therapy, diagnostic studies, among others. DLAC has 70 years of work experience in the prevention, detection, and treatment of cancer attending an estimated of 1,200–1,600 patients daily, which represents around 327,000 cases a year.[6]

Founded in 1982, the Dominican Society of Hematology and Oncology (DSHO) is a group of Dominican medical doctors specialized in diverse branches of oncology. Originally, DSHO was organized under the name of the DSHO attached to the Dominican Association, Medical College. It is a nonprofit organization which aims to promote the development of oncology in the DR through communication and integration of all its stakeholders whose objective is also to improve the life quality of cancer patients.[620]

Methods

A systematic search of academic literature published in standard databases Medline, EBSCO, PsycINFO (OVID), ATLA Religion Database, and Google Scholar was undertaken using a combination of relevant terms. The search was limited to articles and books published in English and Spanish. The academic literature was selected after applied recognition of significant terms approach to academic literature abstracts and conclusions. The analysis was performed through a historical background approach, a systematic review and a content analysis.

First, the aim of a historical background approach is to provide the reader with critical information about the topic being studied, such as highlighting and expanding on foundational studies conducted in the past, important historical events in which something takes place or was created and how that influences how we can interpret it. In the study of S/R-HCSPC, the purpose is to analytically describe how and where it started, how it developed during time, and where it stands today.[9]

Second, academic secondary literature was systematic review and summarize. The revision involved a search process to critically appraise research studies.[10]

Finally, a content analysis is a technique used for analyzing different types of texts by coding the texts according to explicit rules. It is a technique for making inferences by objectively and systematically identifying specified characteristics of messages. This technique allows researchers to find and explain the focal point of the study.[1221] The main conceptual definitions are as follows:

Cultural diversity is the embodiment of uniqueness and plurality of identities and worldviews of groups and societies making up humankind[3]

S/R is an idiosyncratic and culturally diverse concept. A fundamental human potential as well as need for meaning and value and the disposition for relationship with a transcendent power and values, that may or may not expressed in terms of a specific religious traditions, belief, and rituals[1819]

S/R-HCS is an extensive, in-depth, ongoing care process of actively professional listening, counseling and summarizing a client's story, spiritual strengths, needs, hopes, coping strategies, and liberation processes as they emerge over time. It occurs in the context of an interfaith organizational and intercultural community life, in which an ongoing assessment and interprofessional liberating interventions happen to help meet a holistic liberation process, wellness needs, and goals of the client[1322]

Roman Catholics in LAn and the SSCn refers to the religious believers which affirm that they connect to God through intermediaries (the clergy and the saints). The saints play an important role in popular devotion and the connection to well-being. Roman Catholics’ homes have small shrines with images of Catholic saints and the Virgin Mary. The altars are usually surrounded by flowers and lighted candles. Although the most popular figures are the Virgin of Altagracia (the patron Saint of the country), the altars represent a wide range of religious images[5]

Evangelicals (in LAn and the SSCn, evangélicos or, less frequently, protestantes, both terms in Spanish) serves to identify non-Roman Catholics at the SSCn basin. At DR evangelicals do not include churches affiliated with the Church of Jesus Christ of Latter-day Saints or with Jehovah's Witnesses, for they do not subscribe to the Ecumenical Catholic Nicene's Christian Creed of AD 381 – the statement of faith upon which all evangelicals religious denominations agrees.[232425]

Results

The DR has a cancer registry as well as procedural policies to combat cancer. In 2007, the DR began to implement an extensive financial reform of its health system. Before the reform, cancer patients had almost no financial protection. There is a public health system, yet with severe limitations. Any extra treatment such as chemotherapy or access to morphine (often used in palliative care) causes poorer patients to suffer greatly. Most S/R-HCSCP services were (and still are) provided by two not-for-profit oncological hospitals (with the most comprehensive cancer care that exists in the country) as well as the private facilities serving mainly high-income groups.[262728]

The public hospitals offered only basic services to low-income patients in early stages of the disease. Most insurance plans had little coverage for cancer, and patients had to rely on out-of-pocket expenditures, minor support from civil society organizations, and subsidized care from not-for-profit hospitals.[29]

In 2012, the density of physicians per 10,000 population was 8.1. Based on official estimated data, as of 2012, the five most common cancers in Dominican Republic are: (1) urological (bladder, kidney, prostate and testis), (2) gynecological (cervix uteri, corpus uteri and ovary), (3) breast, (4) lung and (5) head and neck (lip and oral cavity, nasopharynx, other pharynx larynx and thyroid). The number of oncologists needed is based on the number of patients requiring pathology, surgery, chemotherapy, and radiation therapy. This number is estimated from the percentage of patients requiring surgery, chemotherapy, and/or radiation therapy for the top ten cancers in both men and women. The number of oncologists needed for the DR's two most populous cities based on 2013 population estimates.[6222330]

Dominican Republic approved an extensive health financial reform in 2001 which began full implementation at the end of 2007. Prior to the reform, cancer lacked financial protection. Most specialized services were provided by two non-profit oncological hospitals, as well as private facilities primarily serving high-income groups. The public hospitals offered only basic services to low income patients in early stages of their disease. Most insurance plans provided limited coverage for cancer; further; only minor support and subsidized care were available from civil society organizations and not-for-profit hospitals, respectively. Thus, patients were forced to finance treatments out-of-pocket.[6222330]

There is one main civil society, not-for-profit, and voluntary Sp/Re-HSCP provider religious organizations in DR. The Roman Catholic's Voluntariado Jesús con los Niños Foundation serves to cancer patients that have almost no financial protection.[31] In Table 1 the main characteristics of this organization is described.

Table 1

Characteristics of Roman Catholic's civil society faith organization of S/R-HSCP Voluntariado Jesús con Los Niños Foundation

Geographical area serve	Santiágo de los cabelleros, DR
Population served	Pediatric cancer care
Type of organization	Civil society/nongovernmental/nonprofit
Founded	1997
Faith religious tradition	Roman Catholic's Carmelite Sisters Order
Type of oncologic disease treated	Pediatric hematology-oncology
Objectives	1. Support families of children suffering from cancer
	2. Supports the training of medical and paramedical personnel
	3. Provides expandable material and medication for chemotherapies
	4. Provides conditioning of the pediatric and recreational areas to create a more favorable health environment
	5. Follows post hospitalization patients for their complete recovery and reintegration into their social environment
	6. Psycho-oncological support to patients and their relatives, medical staff, and volunteer corps
	7. Develop new models for pediatric cancer care at a national level in the Dominican Republic
Partnership	Dana Faber/Boston Children's Cancer and Blood Disorders Center and Pediatric Hematology-oncology Unit (UHOP) at Hospital Infantil Regional Universitario Dr. Arturo Grullon (HIRUAG)

In terms of the Evangelical or Protestant church, the Dominican Evangelical Church (DEC) is a religious institution which founded in 1932 a medical service base at the IHSD. For 25 years, this institution served as one of the most prestigious centers of health-care and nursing training school. When the government developed medical services at Santo Domingo to such extent, the DEC felt that the IHSD should be closed. Since that decision, there is no any Evangelical civil society and not-for-profit organization that offers S/R-HCSCP at the DR.[1532]

Discussion

As many religious studies and social scientists of religions suggest, the religious landscape of the DR should be understood as a dialectical relationship between the material world and spiritual world, in which one world can affect and shape the other, especially the spiritual dimension of religion and its connection to the causation of illness and healing practices from Roman Catholic and Evangelical religious organizations’ understanding of the S/R-HCS in DR.[5172030]

Roman Catholicism in Dominican Republic

Catholicism has been at the center of the DR's political, social, and culture history from the beginning of colonization. It is very much a part of national identity, and the Catholic Church continues to be a powerful political force within the country at all levels of government. While fundamentally Christian (historically Roman Catholic), Dominican religiosity is also broadly characterized by the influence of African-derived beliefs and institutions as well as those from neighboring Haiti.[33] The influence of West African spirituality can be seen in widespread spiritual beliefs and religious orientations toward possession, magical healing, divination, polyrhythmic drumming/music, and a pantheon of African-derived spirits.[34]

In that sociohistorical reality, DR S/R is rooted in a dynamic amalgamation of Roman Catholicism with religious practice of the indigenous habitants of the Caribbean and the enslaved population of the 16th-century slave trade of Africans brought to the Americas and the Caribbean Islands. As a result of this sociohistorical process, religious rites, praying and keeping religious artifacts, and erecting small home altars are some common religious practices.[16]

Evangelicals (evangélicos/protestantes) in Dominican Republic

An emergent Evangelical faith and spirituality (manifest in Pentecostals movements and denominations) has become a growing manifestation of a popular form of evangelical religious and spiritual practice. In an effective combination of austere religiosity, critical rhetoric, egalitarian worship practices, open membership policies, and cathartic emotional rituals, these churches have been embraced in every corner of the country (predominantly by the poor and popular classes) to fulfill the desires and to meet the material, emotional, and intellectual needs of Dominicans. This understanding provides an alternative style of human-divine relationship, primarily in confrontation with the dominant culture, but flexible enough to appropriate from that culture the customs and practices, which contribute to the nature of healing of diseases and well-being of the community, and create a different force for struggle.[172030]

The growth of Pentecostal religion in LAn and the SSCn over the past 50 years has been particularly acute. The DR is a case in point, as it has long been considered a staunch supporter of Catholic supremacy. However, despite having inhabited the margins of popular culture for years, today Pentecostal Christianity constitutes a common and in some cases inseparable feature of everyday culture and society in the country.[20]

Conclusion

This descriptive-historical analysis suggests that a relationship between S/R-HCS and cultural diversity exists. That relationship is not a cultural homogeneous experience. In this sociohistorical analysis, the nonhomogeneous cultural distinctiveness of the Sp/Re-HCS has been demonstrated through the distinctive description of the only one of the faith's civil society and not-for-profit organization that offers S/R-HCSCP at DR.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.