People of Russian Heritage. People of Polish Heritage. People of Thai Heritage. 800 words minimum

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Chapter 36

People of Thai Heritage Ratchneewan Ross and Jeffrey Ross

Overview, Inhabited Localities, and Topography Overview Siam, the land of the musical The King and I, is the former name of Thailand, a country in Southeast Asia well known for its cuisine and exotic culture. Thailand today is composed of a unique blend of traditions reaching back to its origins as a mixture of Southeast Asian peoples, its background in Buddhism, and its profound influences inherited from the cultures of both India and China. For providers of health care to Thai patients, the beliefs and practices that stem from these combined traditions can present both opportu- nities and challenges.

Thailand began a tradition of emulating Western political, economic, and cultural ideas in the late 19th century. In the closing decades of the 20th century, Thailand—like several other Asian “economic tigers”— began a period of explosive economic growth. Thailand’s growth continues today, but it has also been inter- rupted by periods of political conflict and economic instability: Since the Asian financial crisis of 1997 to 1999, Thailand has endured a weakening of its currency and investor confidence as well as outbreaks of severe acute respiratory syndrome (SARS), the tsunami of 2004, and the continuation of violent insurrections in its predominantly Muslim southern provinces (Warr, 2009). Also, regarding Thailand’s central government, the bloodless coup of 2006 was followed in 2010 by alarming clashes of violence between “yellow shirt” and “red shirt” competing political factions, and these con- flicts have further strained Thailand’s economic and cul- tural stability (Kane, 2010). Indeed, the political opposition of these two factions can be said to reflect a deeper and broader cultural divide in Thailand between the urban elite of the city and the poor of the country, thus challenging Thailand’s “national capacity for creative compromise” and—at least in some sense— contributing to a kind of “collective anxiety” among the Thai population (McCargo, 2008).

Yet, most visitors to Thailand continue to be impressed by the unique ways with which the Thai people manage a precarious balance between the con- trasts of the old and the new, between the rich tradi- tions of their past and the frenetic influences of modern economic competition, all amid a continually shifting global culture.

Concerning health care, this balance can often play out as a tension between older cultural beliefs (and sometimes superstitions) and more modern concepts of medicine grounded in empirical research. These tensions need to be understood in general by health- care providers for their positive and negative poten- tials for care and, in particular, for how these may vary from individual to individual.

Thailand is located north of Malaysia, west of Cambodia, south and west of Laos, and east of Myanmar (formerly Burma). Further to the north lies the once-sleeping giant of China, now dramatically influencing Thailand’s political and economic spheres. Thailand’s land mass (513,115 km2, 198,115 mi2) and population of 67 million people are roughly equiva- lent to those of France (U.S. Department of State, 2011). Over 10 million people live in the regions of greater Bangkok, the capital of Thailand. Once called the “Venice of the East” because of its historic canal system, Bangkok today is the vast and vibrantly pul- sating hub of the country. More than anywhere else, it embodies the contrasts between the old and the new in the country.

Thailand has several important rivers. The main river, the Chao Praya, irrigates the fertile soil of the central plains. The Mekong River in the north and northeast marks the boundary between Thailand and Laos before flowing further southeast to Vietnam. The Ping, Wang, Yom, and Nan rivers are located in the north (Hoare, 2004).

Thailand is divided into 77 provinces within four different regions: north, northeast, central, and south- ern. Each region is unique in its geographic and cul- tural characteristics. Northern Thailand is the most

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2 Aggregate Data for Cultural-Specific Groups

beautiful region geographically with high mountains, deep valleys, rivers, forests, and waterfalls. The “Golden Triangle” in the north, where drug and opium smugglers have sought asylum, lies at the junc- tion of three countries: Thailand, Laos, and Myanmar (Hoare, 2004).

In general, Thailand has a tropical climate with three seasons. The summer, or hot season, runs from March to June. The rainy season lasts from July to November, and the cool season from December to February. Many Thais, with their good sense of humor, will tell you that the country’s three seasons are called “hot, hotter, and hottest” (Hoare, 2004, p. 12). For visitors from a tem- perate climate, the weather throughout most of the year in Thailand will seem very humid and hot, with some relief from the heat only during the weeks of late December and early January. Thais love the beauty of their land and are adjusted to the weather, yet many who see snow for the first time in another country experience great joy at such a moment.

Heritage and Residence In terms of its history, Thailand is the only Southeast Asian country that has never been colonized by West- erners. The earliest knowledge of what today is Thailand is shrouded in lost histories of the ancient peoples of Southeast Asia. New cultures arose as kingdoms shifted through the centuries. The Dvaravati (1st century BC to the 11th century AD) were strongly influenced by Indian culture so that even today the Rama legends of Indian mythology form an integral part of Thailand’s belief system (Hoare, 2004). The present king of Thailand is the ninth of the Rama kings, and the Thais’ perception of their king’s divinity can also probably be traced to Indian origins.

The first people culturally considered as “Thais” probably migrated from the south of China. Sukhothai, founded in the 13th century AD, is considered the first kingdom of Siam (or Thailand). Its most famous king was Ramkhamhaeng, who is credited with developing the first Thai alphabet. Sukhothai had a profound influ- ence on the development of Buddhist theology and clas- sical art in Thai culture (Hoare, 2004). The Sukhothai period was eclipsed in 1350 by the extremely powerful kingdom of Ayutthaya on the Chao Praya River. The kings of Ayutthaya further embodied the essence of divine kingship as an inheritance from Indian philoso- phy. Although Ayutthaya eventually met its tragic demise when the Burmese sacked the city in 1767, it still represents a magnificent blossoming of artistic and cul- tural expression in the history of Siam (Hoare, 2004).

After an interval known as the Thonburi period, the present Rattanakosin period of Rama kings began in 1782 with its seat in Bangkok. Rama I undertook building Bangkok from a sleepy little village into what eventually became the great city of the Grand Palace (Hoare, 2004).

Especially in the 18th, 19th, and 20th centuries, policy makers of Thailand remained independent of European colonial powers by steering a political course as a strategic buffer zone between British Burma (today Myanmar) to the west and French Indochina (Cambodia, Laos, and Vietnam) to the east (Hoare, 2004).

Thais are very proud of their independence. In 1939, the name of the country was changed from Siam to Thailand, which literally means “The land of the free.” This name change reflected a fundamental shift from supreme monarchy to constitutional monarchy as a governing system (Hoare, 2004).

In 1932, Thailand appointed its first prime minister. Thereafter, the king no longer served in any critical decision-making capacities (Hoare, 2004). Still, the lineage of Thai kingships continues, and the Thai people continue to love and deeply revere their king. This intimate relationship between royalty and the peo- ple is intertwined with Thai Buddhism and the Thai peoples’ perception of their king as divinely ordained. The king is usually not directly involved in Thai politics, but if a strong moral issue arises, he generally helps in addressing the problem guided by his peace and wis- dom (Hoare, 2004). In 2006, the Thais celebrated their beloved King Rama IX’s 60th anniversary. His monar- chy is now the oldest in the world. Any criticism of the king and his family is not at all acceptable to Thais and is even forbidden by law. Yet, Thailand’s present con- stitutional monarchy is a democratic form of govern- ment built around the actual governing authority of the prime minister and the parliament.

Reasons for Migration and Associated Economic Factors Approximately 70 percent of all Thais (120,000 Thais) in the United States live in Los Angeles (Wikipedia, 2011a). Los Angeles is thus often referred to as Thailand’s most recent province and “home to the world’s first and only ‘Thai Town’” (Wikipedia, 2011a). Coincidentally, both Bangkok’s and Los Angeles’s names mean the “City of Angels.” How- ever, Thai communities are spread throughout the United States. Other cities with sizable Thai popula- tions include New York City, Houston, and Chicago.

The first two Thai immigrants in the United States were Eng and Chang, the famous Siamese twins who captured the world’s attention because of their con- joined chests and whose career was a public exhibition. They settled in North Carolina in 1839, later changed their Thai last name to Bunker, and got married to American women (Wikipedia, 2011b). The first Thai student in the United States came with an American missionary in 1871. His name was Mr. He Thien, and he graduated from a medical college in New York. He later became the father of the former prime minister of Thailand, Pote Sarasin (Wikipedia, 2006).

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People of Thai Heritage 3

During the Vietnam War, many Thai women mar- ried American GIs and immigrated to the United States (Bao, 2005). Immediate family members of these American Thais often followed them and settled in the new country. From 1968 to 1976, many Thai profes- sionals such as physicians, pharmacists, and engineers immigrated to the United States to further their studies under scholarship programs, and many of them never returned to Thailand (Wikipedia, 2006). They found professional careers and remained in the United States. In general, Thais have continued in their migration to the United States in search of better opportunities.

Educational Status and Occupations In Thailand, education is compulsory for at least 9 years (grades 1 through 9) (Fig. 36-1). However, the Thai government provides free education to all Thais who go to government schools up to grade 12. The lit- eracy rate in Thailand was 92.6 percent in 2002 (CIA World Factbook, 2011).

The system of higher education is well developed in Thailand, with government universities perceived as being of higher quality than private universities. Government universities are competitive, however, be- cause of their difficult entrance examination require- ments. Those students who are not accepted in government universities can still opt to enroll in the more expensive private schools. In 2002, 27.4 percent of Thais aged 17 to 24 years enrolled in college (Thailand Investor Service Center, 2004).

Many Thais with graduate degrees work in the United States in professional fields such as medicine, nursing, and engineering. Others own Thai restaurants or grocery stores and provide work for other Thais.

Communication Dominant Language and Dialects The standard Thai dialect is derived from Pali and Sanskrit (ancient South Asian languages) and is the

official language in Thailand. The Thai language is a fixed tonal language having five tones. Thus, the same phonetic sound can have different meanings depend- ing on the tone. The written alphabet is a complicated system of 44 letters with over 33 vowels or vowel combinations.

English is used in international schools, tourist places, and sometimes among Thai elite society. Although English is taught in Thai schools, the English proficiency of Thai people in general is not very high, especially when compared with certain other Southeast Asian countries such as Malaysia or Singapore. This may be due in part to Thailand’s having never been colonized.

The north, northeast, and southern regions of Thailand are all areas with unique dialects of their own. The dialect in northern Thailand is Pasah Nua, literally “the northern language.” Thais in the North- east speak Pasah Isaan, “the northeast language,” which is a mixture of Laotian and other dialects. Pasah Isaan usually sounds very foreign to the ears of people in other regions of Thailand. The dialect of southern Thailand is Pasah Dai, “the southern lan- guage,” and is the fastest-sounding among the dialects. A recent trend, however, has been that many parents in the northern or northeastern regions choose not to teach their children their regional dialects, in part, because they believe that the dialects do not sound modern or cultured.

Cultural Communication Patterns Age and status in Thailand contribute greatly to how Thais communicate with one another. According to the Thai culture, a younger person is expected to show respect for an older person through his or her gestures and language. A Thai female uses the word “Kah” and a Thai male uses “Kraab” at the end of a sentence to add politeness in a conversation. Looking in a person’s eyes and conversing quietly reflects respect and polite- ness. A distance of 11/2 to 2 feet between two speakers is preferable.

In terms of body language, kisses and hugs be- tween a male and a female are not traditional in the Thai culture. Thais usually greet each other with the “Wai” motion—putting the palms of both hands to- gether in a prayer-like gesture and bowing the head slightly. This gesture is used by both men and women of all age groups. Respect for older people, an impor- tant aspect of Thai culture, is always signaled by a younger person gesturing with the “Wai” to the older person first.

Temporal Relationships Traditional Thai families are nuclear in nature. Today, however, single families are becoming more common in Thailand. In any case, it is not uncommon for a sin- gle Thai to live with her or his sibling(s), cousin(s),Figure 36-1 A grade school in Thailand.

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aunt(s), uncle(s), grandparent(s), or parent(s). A friendship between two individuals who are not biologically related can often evolve into a family-like relationship. Thus, a Thai may become like a brother, a sister, an aunt, an uncle, a parent, or a grandparent to a friend.

As mentioned previously, respect for seniority is crucial among Thais. Visiting and bringing along a present or giving money to elders during the Thai New Year is an important role obligation for younger Thais. When the elders in a Thai family become too old to take care of themselves, younger members are morally required to care for them. Only in very rare circumstances do elderly Thais live alone.

Format for Names Most Thais have long first and long last names. A Thai is usually referred to by his or her first name, even in an official setting like school or work. The names usually have clear meanings in Thai. The first name is often given by a Buddhist monk or fortune- teller based on the date, day of the week, and time of a newborn’s birth. But often parents name their chil- dren themselves. More recently, some parents have begun to give their children Western first names, such as John, Matthew, or Amy.

In general, when a woman marries she usually takes her husband’s last name. A couple’s children also take their father’s last name. A recent Thai law, however, regulates that a married woman does not have to use her husband’s last name if she prefers not to, thus legally sealing an already existing cultural shift.

When Thai names are transcribed in English, the spelling is merely a kind of phonetic translation from its spelling in the Thai alphabet. Because Thai is a tonal language, however, the correct pronunciation of names cannot be ascertained from their spelling in English. For health-care providers in the West, the best course is to ask Thai patients how to pronounce their names and do the best one can in approximating it.

Importantly, almost all Thais have a short nick- name used by their family and close friends and often by colleagues at work. Nicknames normally have no relationship with first names. They are often humor- ous to Thais themselves. Nicknames are usually either Thai or English words. They might be derived from names of colors, body types, fruits, or any number of other things. Health-care providers should feel free to ask their patients if they wish to be called by their nickname. The client may well prefer it.

Family Roles and Organization Head of Household and Gender Roles Gender is another important aspect in Thai families. A man is the head of the household in a traditional Thai family, usually being the breadwinner and managing

important tasks. This view is reflected in an elder’s teaching on a wedding day: “The man is the front step of an elephant. The woman is the hind step.”

In most Thai families, responsibilities involving household chores and taking care of children belong to a woman. If a woman works outside the home, a maid is sometimes hired to help with the household chores and babysitting. Many Thai men have much more leisure time than Thai women, regardless of the employment status of a woman. However, more Thai families today have begun to divide household chores between men and women.

Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Thai children are taught to respect elders. Talking back to elders is discouraged. The role of children as students in school is very important. Many Thai par- ents choose a career deemed suited to their child’s abil- ities and characteristics. The degree to which children assist with household chores depends upon a family’s economic status; the poorer the family, the more chores children do.

Thai female adolescents have traditionally been ex- pected to protect their virginity until marriage. Dating with a chaperone present is preferable to parents. However, more and more Thai adolescents date on their own today. Social attitudes are changing rapidly in Thailand, and those of the youth culture are strongly influenced by global trends related to music, entertainment, and social mores. These are often chal- lenging to older traditions and can conflict with those inherited through Buddhist theology.

Family Goals and Priorities Children are the center of the family for Thais (Fig. 36-2). Many Thai children, therefore, sleep with their parents from birth until some point in time before they reach adolescence. Thai parents do not feel comfortable leaving their infants in a separate bed- room. Often, children are spoon-fed by adults until they are 6 to 7 years old. This can sometimes appear unusual to Westerners.

Most Thai parents hope their children will go to college. They will pay whatever they can for tuition fees and support even through graduate school. Edu- cation is so vitally important for Thais that Westerners are often amazed when a Thai spouse will leave his or her partner or children behind for years to further studies aboard.

Marriages in Thailand used to be mainly arranged by the parents. Today, young Thais have more freedom to select a spouse. Nevertheless, sometimes parents may make the final decision as to whether or not a bride or groom is acceptable. However, in this context, younger Thais are clearly expected to care for older people, including older in-laws, when they are in need.

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People of Thai Heritage 5

Alternative Lifestyles Gays and lesbians in Thailand are more accepted today than in the past. Before the mid 1980s, commer- cial lounges and bars were the main or the only places for gays and lesbians for social gatherings. Since the mid 1990s, Thai gays and lesbians have had more ven- ues to meet and advance a positive lifestyle. These new places include launched boutiques, hotels, restaurants, karaoke clubs, pubs, and spas (Utopia, 2011).

The first Thai lesbian organization was founded in Bangkok in 1986 by a popular Thai singer. Eight years later, the first Southeast Asian gay and lesbian center was established. The center is a resource for gays and lesbians to find books and presents. Both of the organizations have at least two common goals, which include a movement for lesbian and gay rights and efforts to combat HIV/AIDS (Utopia, 2011). At present, gay marriage is not supported by Thai laws.

Workforce Issues Culture in the Workplace Most Thais usually try to avoid personal conflicts at work and are hard workers. Although the family is

deemed very important for Thais, in many circum- stances, especially for economic reasons, work comes before family (Fig. 36-3). For instance, a husband and his wife in Thailand often work in different provinces. A good number of the Thai couples reunite once a month. Taking a leave from work for a major surgery or a death or dying of family members besides one’s spouse, child, or parent may not be supported by Thai agencies.

In general terms, Thai Americans tend to socialize among themselves rather than mix with Americans or people from other cultures. Therefore, some Thai Americans may not deeply understand American cul- ture. However, other Thai Americans relate well to their surrounding culture, especially first-generation American-born Thais who tend to help change or adaptation come more easily to their parents (Advameg Inc., 2011).

Issues Related to Autonomy Like many other American Asians, Thai Americans respect their supervisors because seniority is strongly valued in their culture. Thus, they might not be as- sertive at work. Therefore, supervisors may be wise to provide open discussions and expression of opportu- nities for their Thai American colleagues.

As mentioned previously, English proficiency among some Thais is low. Therefore, with Thai Americans who are learning English as their second language, the language used in the workplace should be clear. Slang expressions should be avoided. If used, slang expres- sions need to be clarified.

Biocultural Ecology Skin Color and Other Biological Variations An estimated 75 percent of the population in Thailand are pure “Thai”; 14 percent are Chinese; and the rest (11 percent) are Malay, Lao, Mon, Cambodian, Vietnamese, Asian Indian, Caucasian, or hill-dweller

Figure 36-2 A Thai family photo.

Figure 36-3 Selling noodles at the floating market in Thailand.

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tribes—Karen, Lisu, Ahka, Lahu, Mien, and Hmong (Fig. 36-4) (CIA, 2011).

Some Thais in northeast Thailand (Isaan) emi- grated from Laos or Cambodia. In general, Isaan Thais have darker skin color (dark brown) than other Thais who live in the north and central regions. The facial profile of Isaan Thais is akin to that of Lao- tians, with a relatively flat nose and broad prominent cheekbones (Fig. 36-5). Some Thais in the north im- migrated to Thailand from China or Burma. They tend to have finer skin texture and lighter skin color than other Thais in the country. Their noses are a little longer and their cheekbones narrower than those of Isaan Thais. Central Thais generally have medium skin color compared with that in the rest of the coun- try. Their facial profile is a mixture of Isaan Thais and northern Thais. Southern Thais, some of whom mi- grated from Malaysia, are likely to have darker skin color. Their facial profile is similar to that of Malay.

Other Thais have combined Thai and Chinese, Vietnamese, Malaysian, Laotian, or other heritage, with skin color and facial profiles representing mix- tures of such racial combinations. Overall, regardless of skin color or facial profile, the Thais’ size and body structure are usually much smaller than those of Caucasians.

Diseases and Health Conditions Thai scientists in collaboration with scientists from Riken Yokohama Institute in Japan and Yale Univer- sity in the United States successfully identified a ge- netic pattern common to Thais by analyzing blood samples from 280 Thais from all four regions of the country (National Center for Genetic Engineering and Biotechnology [BIOTEC], 2006). This breakthrough, hopefully, will help scientists to better understand

Thais’ responses to a variety of antigens, drug metab- olism, and genetic disorders.

Glucose-6-phosphate dehydrogenase deficiency (G-6-PD) is the most common genetic disorder among humans. Sixty-five percent of Thai newborns’ jaundice is caused by this deficiency (Nuchprayoon, Sanpavat, & Nuchprayoon, 2002). Usually, the en- zyme regulates how red blood cells function. When a person lacks the enzyme, her or his red blood cells can be hemolyzed by certain medications, foods, or infec- tions. The condition is called “hemolytic anemia.” In most cases, when the cause of the anemia is removed, symptoms disappear. In rare cases, people with G-6-PD deficiency have persistent anemia and need to be moni- tored on a regular basis (Nuchprayoon et al., 2002).

Thalassemia is another genetic disorder prevalent among Thais. Thirteen percent of Thais have inherited this disorder, and 50 percent of those who are affected by the disorder come from Isaan, or the northeast of Thailand (Fucharoen et al., 2006). Symptoms among Thais with thalassemia range from asymptomatic to severe anemia (Fucharoen et al., 2006). When Thai pa- tients show anemic symptoms, they should be tested for thalassemia and identified for care if necessary.

Variations in Drug Metabolism Different ethnic groups may have different pharmaco- kinetic functions (Bjornsson et al., 2003). Recent lit- erature reporting some variations in drug metabolism between Thais and non-Thais is mostly associated with antiretroviral medications. For example, a study

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Figure 36-4 An interracial boy (American Thai) in front of a vendor’s wagon in Thailand.

Figure 36-5 Isaan dance.

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People of Thai Heritage 7

revealed that using indinavir/ritonavir dose (400 mg/ 100 mg) as a combined antiretroviral drug among Thais is more preferable than using indinavir/ritonavir dose (600 mg/100 mg) as used among Caucasians owing to the smaller body size of the Thais (Cressey et al., 2005). This lower-dose medicine results in fewer side effects and greater adherence for Thais than the higher-dose medicine. Although the lower-dose med- ication provided lower plasma concentrations among the Thai participants, the low dose seems to be effec- tive as evidenced by a suppression of viral replication through 48-week follow-ups (Cressey et al., 2005). Therefore, when treating Thai patients, dosing recom- mendations derived from Caucasian patients may not be appropriate. As a general rule, a lower dose may be more beneficial for Thais, possibly resulting in fewer severe side effects and greater adherence to the medications.

High-Risk Behaviors Health-Care Practices The Thai Ministry of Public Health (2008) examined the most significant major health problems among the Thais by age group. These examinations were conducted during 2005 and 2007. Results are presented below:

≤14 years old: Low birth weight and perinatal as- phyxia

15 to 29 years old: HIV/AIDS, road traffic injuries, drug abuse, schizophrenia, and alcohol abuse

30 to 59 years old: HIV/AIDS, road traffic injuries, diabetes, and liver cancer

≥60 years old: Cerebrovascular diseases, emphysema, and diabetes

In this section, we will pay particular attention to working-aged Thais (15 to 59 years old). Since HIV/ AIDS is the major health problem and cause of death in this age group, information regarding HIV/AIDS is presented first. Information on alcohol consump- tion, a significant behavior associated with HIV infec- tion, follows.

HIV/AIDS HIV/AIDS History in Thailand The first patient with AIDS in Thailand, reported in September of 1984, was a Thai gay man who studied in the United States and moved back to Thailand. Since that year, inci- dences of HIV infection have been reported through- out the country. HIV infection rates in Thailand peaked at 4 percent in 1991, with over 140,000 new cases in that year. Rates declined to 1.5 percent by 2003, partly due to the 100 percent condom use cam- paign promoted among high-risk groups by the Thai government (Ministry of Public Health, 2005).

In the past, high-risk groups included female com- mercial sex workers (CSWs) and injection drug users

(IDUs). HIV-positive rates among Thai female CSWs climbed to over 33 percent in 1994 but fell to 4 to 8 percent in 2004, also mainly due to the 100 percent condom use campaign. The extent to which high-risk behavior among homosexual men played a part in the early spread of HIV and AIDS in Thailand is difficult to ascertain due to a lack of reliable information. However, a recent survey revealed that 17 percent of gay men who did not frequent CSWs were HIV-positive (Cairns, 2004).

Thailand has been commended for its general re- sponse to HIV/AIDS. However, Thailand has in large measure ignored the problems of HIV/AIDS among homosexual men. Adding to complications, the problem is interrelated with Thailand’s commercially successful male sex industry. Young male sex workers sell their services—negotiating with sex, condoms, work, and so- cial stigma while living with the ever-present danger of an HIV infection (Mutchler, 2005). Today, the situation for gay men in Asian countries is similar to that in the West in the mid 1980s (Cairns, 2004). Recent HIV/AIDS Statistics It is estimated that 600,000 HIV-positive individuals lived in Thailand in the year 2009 (UNAIDS, 2011), with the prevalence rate of 1.4 percent among adult Thais (U.S. Department of State, 2011). In 2009, the number of total deaths in Thailand due to AIDS was reported at 28,000 (UNAIDS, 2011). The most severe HIV rates are found to be in some Northern provinces (e.g., 3 percent in Payao and Uttaradit) and tourist areas (e.g., 2 percent in Phuket, Cholburi, Trad, and Samut Songkram) (National AIDS Prevention and Alleviation Com- mittee, 2010). Thai Men’s Sexual Behavior and Prostitution At pres- ent, the major route of HIV transmission in Thailand is through sexual activity (>85 percent in 2004), par- ticularly because many Thai males frequent female or male CSWs without using a condom (Centers for Dis- ease Control and Prevention [CDC], 2006). Even though prostitution is illegal in Thailand, the country has over 200,000 overall sex workers at any given point in time (Manopaiboon et al., 2003). Only 27 percent of Thai customers use a condom when they visit female CSWs in Thailand, whereas 52 percent of other Asian customers and 76 percent of Western cus- tomers use a condom (Buckingham & Meister, 2003). The number of CSWs in Thailand has not decreased since 2005, while the number of nonbrothel settings potentially related to sexual activity (spas, parks, In- ternet, and informal social networks) has increased dramatically (Rongkavilit, 2010). These nonbrothel settings are five times more likely to precipitate new HIV cases than brothel settings because they are over- looked by the Thai government’s formal HIV preven- tion program and thus do not receive preventative interventions and HIV and STI information (National AIDS Prevention and Alleviation Committee, 2010).

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Many men in Thailand have sex with women other than their wives. A study revealed that 92 percent of Thai husbands had multiple sexual partners during the last 5 years of their marriage. Among the men in this study, approximately 85 percent had frequented female CSWs without using a condom. Furthermore, over half of the wives were not aware of their hus- bands’ promiscuity (Bennetts et al., 1999). It should be noted that this pattern of sexual behavior among Thai men in Thailand may or may not be generalized to those living in the United States, Canada, or other countries in which cultural patterns are different. New Groups of HIV Cases At present, newer and more prominently high-risk groups for contracting HIV include Thai youth, Thai men who have sex with men, seafarers, amphetamine users, and people who are intoxicated from alcohol (National AIDS Preven- tion and Alleviation Committee, 2010). Most alarm- ingly, the fastest-growing population of new HIV cases in Thailand is composed of very young adoles- cents, young pregnant women, and young adults aged 15 to 24 years old (National AIDS Prevention and Alleviation Committee, 2010). Higher HIV rates among these groups are accounted for by an increase in premarital sex among youth and overall promiscu- ity in the Thai society (National AIDS Prevention and Alleviation Committee, 2010; Rongkavilit, 2010). More and more Thai youth have casual sex at a younger age. Since the mid 1980s in Thailand, the youngest age for first-time sexual intercourse has fallen from 16 to 9 years old (Fongkaew, 2004). A report shows that only 20 to 30 percent of sexually active young Thais use condoms consistently (United Nations Development Programme, 2004). Moreover, research among HIV-positive Thai youth (male and female 16 to 25 years old) reveals that consistent condom use was found to be low (55 to 58 percent) among the sample during the 3-month study period (Rongkavilit, Naar-King, Cheunyam, Wang, Wright et al., 2008). Sexual promiscuity among Thai youth has also con- tributed to an increased risk for other sexual transmit- ted infections (STIs) and unwanted pregnancies. In 2008, it was reported that 20 percent of all pregnan- cies in Thailand belonged to women under 20 years old (National AIDS Prevention and Alleviation Committee, 2010).

Within the last decade, there has been more open- ness about homosexual orientation in Thailand. Ho- mosexual behavior has been found to be increasing by age brackets in Thai society. A study in Thailand in 24 provinces found homosexual behavior at 0.3 percent among high school students, 2 to 3 percent among vocational school students, and 4.7 percent among men in the military, with only 50 percent of men having sex with men using condoms consistently (National AIDS Prevention and Alleviation Commit- tee, 2010). HIV rates among men who have sex with

men are reported to be highest (17 to 31 percent) in large tourist cities like Bangkok, Chiang Mai, and Phuket, and this is becoming a great concern for health professionals and the Thai government (National AIDS Prevention and Alleviation Committee, 2010).

Seafarers, highly mobile and working on boats far from land, have become a newly vulnerable group prone to contract HIV. Most of them are single, young Thai or immigrant (from Myanmar or Cambodia) men who stay out to sea for weeks or months at a time. When they return to land, they often drink heavily and have sex with female CSWs without condom use. Their HIV-positive rate is strikingly high at 15.5 percent (Entz, Ruffolo, Chinveschakitvanich, Soskolne, & van Griensven, 2000). After contracting sexually transmit- ted diseases, they tend to treat themselves by using over-the-counter medicine (Entz, Prachuabmoh, van Griensven, & Soskolne, 2001). A qualitative study found that many migrant seafarers in Thailand feel vulnerable to HIV infection; yet, they are pressured by peers to drink alcohol and visit CSWs after returning to land (Ford & Chamratrithirong, 2008). Condoms were used with brothel CSWs by participants in this study but not other types of CSWs.

Amphetamine users and drinkers of alcohol tend to have sex while they are high or intoxicated, which puts them at increased risk for having unsafe sex. An estimated 600 million tablets of amphetamines are consumed annually in Thailand (Newton et al., 2003). Thai names for amphetamines are Yaa Bah (literally meaning “crazy drug”) or Yaa Mah (literally meaning “horse drug,” because of the horse emblem on the tablet) (Newton et al., 2003). Amphetamines are usu- ally taken by young people as a stimulant so that they can work for hours or days without feeling exhausted. An overuse of amphetamines can cause a person to be- come agitated and harm oneself or others. Withdrawal from amphetamine use generally leads to excessive sleeping and hypoglycemia (Newton et al., 2003). Among northern Thai men, the use of amphetamines is found to be associated with the use of other types of drugs (seven times more likely with heroin and ap- proximately six times with thinner, opium, and mari- juana) and also to be associated with different STIs besides HIV, such as gonorrhea and genital warts (Melbye et al., 2002). HIV-Positive Pregnant and Postpartum Women and Family Relations Among Thais, the family and ex- tended family members are all considered within the Thai culture to be a whole unit. When any member in the greater family suffers from HIV/AIDS (or any other hardship/illness), it affects every member of the family. Moreover, every family member has the re- sponsibility to support a suffering member, either through emotional, financial, or other tangible means (Ross, Sawatphanit, Suwansujarid, & Draucker, 2007a). Thus, one family member’s actions, whether negative

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or positive, belong to the whole family. The family’s unique oneness in the Thai culture can work either positively or negatively for a Thai family member with HIV/AIDS. For example, the concept of oneness can generate all kinds of support from the family. The par- ents and siblings of sick members are clearly expected to care for them. Also, maternal grandparents are ex- pected to care for the sick member’s children if the member were to pass away because of AIDS (Rende Taylor, 2005). Yet, the patient with HIV/AIDS can also be abandoned due to fears in the family of viral transmission and of family disgrace (Bechtel & Apakupakul, 1999; Bennetts et al., 1999).

Approximately 210,000 women and 1 to 2 percent of pregnant women in Thailand have contracted HIV (UNAIDS, 2011). Studies report that almost 80 per- cent of HIV-positive pregnant (n = 127) and postpar- tum Thai women (n = 85) experience depressive symptoms to some degree; those with higher self- esteem and social support report fewer depressive symptoms (Ross, Sawatphanit, & Zeller, 2009; Ross, Sawatphanit, Mizuno, & Takeo, 2011). Research shows that when family support is not available, critical emotional support from nurses can increase HIV-positive pregnant Thai women’s self-esteem and decrease their depressive symptoms, thus saving their lives (Ross et al., 2007a; Ross, Sawatphanit, & Suwan- sujarid, 2011; Sawatphanit, Ross, & Suwansujarid, 2004). Therefore, health-care professionals should as- sess and offer emotional support for their Thai HIV/AIDS patients, especially when family support for these patients does not exist. Summary of HIV Impact Overall, more incidences of HIV infection have begun to appear among Thai youth. HIV infection can cause severe financial, phys- ical, emotional, and social disruption for Thai patients and their families. Although the Thai government is planning to provide free antiretroviral medications to all HIV cases who need such help, Thailand’s present HIV/AIDS medical care cost is over US$420 million nationally (National AIDS Prevention and Allevia- tion Committee, 2010) and around $600 per year per family. In the perspective of the Thai economy, the gross national income per capita in Thailand is US$3,760 (ranked 122nd in the world), as opposed to US$46,360 in the United States (ranked 18th in the world) (World Bank, 2010). Thus, the long-term bur- dens posed by high rates of HIV/AIDS among Thais need to be studied, especially at the community level.

To prevent new HIV cases, the Thai government must invent new strategies. Besides existing HIV prevention campaigns, such as promoting condom usage among some groups of Thais (e.g., sex workers, HIV-positive individuals, etc.), strategies to enhance self-esteem and abstinence should also be promoted, particularly among Thai youth. Also, traditional aspects of Thai culture which cherish abstinence and

virginity before marriage should be encouraged within the larger Thai society. Otherwise, Thailand may fall too deeply to be bailed out from an impending and se- rious HIV crisis, considering that more than 1.2 million Thais with an HIV infection are now projected for the year 2020, along with 18,000 deaths from AIDS in that same year (Ministry of Public Health, 2008).

Nutrition Meaning of Food “We should eat to live, not live to eat” is a famous say- ing not only in Latin but also in Thai, reflecting the central importance and meaning of food in the Thai culture. Many Thais live their lives by following such a saying.

In general, an individual portion of a Thai dish is about one-third to one-fifth of a typical U.S. dish in terms of volume. As a result, most Thais are slim owing to these smaller portions and also the types of food they eat. Thais believe that foods containing adequate essential nutrients help to maintain life and growth and delay illness later in life (Kosulwat, 2002). A Thai bal- anced diet usually includes low-fat/low-meat dishes with a large percentage of vegetable and legumes. Rice and fish are main staples (Kosulwat, 2002).

Common Foods and Food Rituals In general, rice is the main source of carbohydrates in Thai dishes, but noodles are also found in many fa- vorite recipes. Vegetables and meats are usually fried or grilled and prepared in many combined variations to supplement rice. Overall, pork or chicken is eaten more than beef. All meats are consumed more spar- ingly in proportion to vegetables when compared with a Western diet. Fish and other forms of seafood are also regularly enjoyed. Thailand has a long coastline, especially in the south, with an old and rich tradition of fishing as an important industry.

Communal eating is an essential part of the Thai culture. Friends and families eat seated together either on the floor or at a table. Either way, when rice is part of the meal, Thais will begin with a large amount of rice on their plates and reach to central communal plates of combined meat and vegetable recipes to add to their rice. This is done by all in a free fashion throughout the meal, with some families using a serv- ing spoon to take from the communal dishes and oth- ers using their individual tablespoons. The tablespoons are the main instruments for eating, with the fork used only as a guide; knives are not often used because the meats in Thai recipes are usually precut. Noodle recipes are much loved by Thais and prepared with the noodles already mixed in with meats and vegetables.

For all foods, seasonings are critical to the Thai artistry of accommodating different palettes. Fish and oyster sauces are very often combined with soy sauce as

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a basic starting point for many recipes. Thai chili pepper is the basic ingredient added to control the degree of spiciness in foods. Many Thais love very spicy food, but not all. Tom-Yum is a traditional spicy Thai soup that is gaining popularity worldwide (Fig. 36-6). It has been found to have positive effects on people’s health because of its ingredients, which include lemon grass, galangal roots, kaffir lime leaves, hot chilies, red onions, and garlic (Siripongvutikorn, Thummaratwasik, & Huang, 2005). Tom-Yum’s antioxidant effects are the result of the in- gredients mentioned previously. The soup’s antimicro- bial effects come from its chilies, onions, and garlic (Siripongvutikorn, Thummaratwasik, & Huang, 2005). Onions and garlic can function against diabetes and hy- percholesterolemia. Fresh garlic, used as an ingredient in Som-Tum and many other Thai dishes, has been iden- tified as an antifungal, antiparasitic, and antiviral agent (Siripongvutikorn, Thummaratwasik, & Huang, 2005).

Som-Tum is a famous spicy Thai salad originating from the northeast of Thailand. Its ingredients in- clude fresh shredded papaya, cut tomatoes, tamarind juice, fish sauce, salt, sugar, fresh crushed garlic, and hot chilies. Sometimes, cooked or raw fermented fish is added. Som-Tum is usually served with hot sticky (sweet) rice, which is a favorite in the Northeast. Sources of protein, such as Thai beef/pork jerky and grilled chicken are often served with Som-Tum and sticky rice. Overall, this course of Som-Tum, sticky rice, and sources of protein is considered an enjoyable delicacy by Thais in all areas of society.

In the past, many Thais became sick and died from eating raw fermented fish, which contains Opisthorchis viverrini, a liver fluke, found to cause cholangiocarci- noma in humans (Watanapa & Watanapa, 2002). Today, because of increased health education pro- vided by nurses and other health professionals, Thais are more knowledgeable about the dangers of eating raw fish. Nevertheless, some Thais may persist in eat- ing raw fermented fish because of entrenched eating habits and their attraction to its taste and smell. An assessment regarding any preference for eating raw fermented fish could be helpful.

A study conducted in Thailand revealed that many healthy Thai dishes are being replaced by foods con- taining a high quantity of fat and meat, related to the country’s evolution from an agricultural to a newly in- dustrialized country. Food produced in Thailand is now more important for exportation purposes and the economy than for domestic consumption (Kosulwat, 2002). Thai families have less time to cook. They tend to eat at Western-style restaurants serving foods high in fats, meat, and sugar content. As a result, obesity rates among Thai children and adults have risen dra- matically since the mid 1980s (Kosulwat, 2002). A study revealed that Thai children with obesity have low self-esteem and are often ridiculed by their peers (Phakthoop & Ross, 2006).

In a study among 102 Thais in the United States, 79 percent changed their food intake habits when living in the United States (Siripongvutikorn et al., 2005). They skip more meals and consume more Western foods and snacks such as white bread, salty items, fruit juice, soft drinks, and sweets. When they dine out, they tend to go to American or Chinese restaurants. Forty percent of the participants indicated that their diet has become less healthy owing to a lack of time for food preparation and the unavailability of some Thai ingre- dients and food choices (Siripongvutikorn et al., 2005). An analysis of this study, as based on the Food Guide Pyramid, reveals that most Thai participants living in the United States consume enough fruits and veg- etables; not enough bread and milk; and too much meat, fats, oils, and sweets. Health professionals in the United States should assess their Thai patients’ food intake habits and encourage them to consume more fruits and vegetables. If needed, advice about an increase of bread and milk intake and limiting meat, fats, oils, and sweets should also be provided (Siripongvutikorn et al., 2005).

Dietary Practices for Health Promotion For Thais, hot or warm foods or drinks are considered healthier than cold ones. This idea is based in part on a belief in “cold and hot” or “Yin and Yang,” inher- ited from Thailand’s profound Chinese influence. Many types of herbs are considered to promote health and work against cancer development. Some herbs are considered a panacea. Therefore, Thai dishes usually contain some kind of herbs, particularly garlic and hot chilies. Positive effects of some herbs have already been described.

Nutritional Deficiencies and Food Limitations Iodine deficiency (IDD) used to be a major health concern in Thailand. In 1953, IDD was first identified in the northeastern and northern regions of Thailand, where there is no sea outlet. Aware of the problem, in 1965, the Thai government initiated a pilot project of salt iodization in a northern province. Owing to its

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Figure 36-6 Tom-Yum Koong with lemon grass.

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success, the project has been further expanded. The first IDD survey, conducted until 1988, was completed in 15 provinces of two regions of Thailand, showing an IDD prevalence rate of 19.3 percent. In 1993, the salt iodization project was expanded nationwide, result- ing in further success with an IDD rate of 1.3 percent in 2003. At present, the Thai government examines goiter rates among schoolchildren in 15 northeast and northern provinces and uses them as the Thai IDD indicator (Ministry of Public Health, 2005).

Despite the salt iodization program’s success, at the 2004 Review of Progress toward Sustainable Elimina- tion of Iodine Deficiency held in Thailand, the Thai Ministry of Public Health indicated that only 51 percent of Thai households consumed enough iodized salt (Network for Sustained Elimination of Iodine Defi- ciency, 2004). This was well below the international tar- get of at least 90 percent set for the end of the year 2005. More than 34 million Thais do not consume enough iodized salt, and 375,000 newborns may suffer from IDD. However, the Thai Ministry of Industry and the U.S. Food and Drug Administration have begun work- ing with salt producers to manage salt iodization pro- grams. Together they brought the goiter prevalence rate in Thailand down to 2.2 percent in 2008 (as compared to rates for the same year in other countries: 19.4 in Australia, 17.9 in India, 30.0 in Turkey, and 14.5 in Switzerland) (Network for Sustained Elimination of Iodine Deficiency, 2011).

In Thailand, only seven cases of anorexia nervosa have been reported (Jennings, Forbes, McDermott, Hulse, & Juniper, 2006). However, evidence exists that young Thais in particular are increasingly becoming sus- ceptible to developing eating disorders. A study among 101 Thais in Thailand, 110 Caucasian Australians, and 130 Asian Australians found that the Thai participants reported the highest scores on eating disorder attitudes and psychopathology (Jennings et al., 2006). Recently, pressure to be thin has become more extreme in Thailand than in Australia. The evidence suggests that eating disorders may not be limited to Westerners, as we used to believe. Such disorders will become more preva- lent among Thais in the near future.

Pregnancy and Childbearing Practices Fertility Practices and Views Toward Pregnancy Thai women view pregnancy as a special time in their lives when they need extra care physically and emo- tionally (Nigenda et al., 2003). They acknowledge that this is a time when their moods can be unstable. Ide- ally, the age of 20 years is the optimal time for preg- nancy owing to the women’s physical and emotional maturity. Thai women want their husbands and their mothers to be supportive of their pregnancies. Some women state that the most common side effects of

pregnancy are excessive white vaginal discharge, fre- quent urination, and morning sickness (Nigenda et al., 2003). Owing to modesty, especially during a vaginal examination, Thai women prefer female health-care providers over their male counterparts. They do not feel comfortable exposing their bodies to male providers (Nigenda et al., 2003).

Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family The descriptions in this section are based on literature review and the authors’ experience working with preg- nant and postpartum Thai women. During the child- bearing period, Thai women basically receive advice from their mothers about what to do or not do. Their mothers are the most significant persons who direct their practices during this time. Some of the practices presented herein are not stereotypical among all Thais; rather, they reflect some general practices or beliefs of some Thais in some particular areas of the country.

During pregnancy, the mothers of some pregnant Thai women may discourage their daughters from particular practices or behavior. For example, preg- nant women are advised not to complain or get upset so that newborns will be happy and stay happy for the rest of their lives. They may also be advised not to sit on stairs or doorsills to avoid a difficult labor and de- livery. When a pregnant mother blocks other people from going up and down stairs or in and out of a doorway, the unborn baby could be blocked inside the mother’s uterus.

Astrology and animism play major roles in many Thais’ lives. In general, Thai pregnant women are dis- couraged from visiting a hospitalized person (regard- less of the kind of sickness), attending a funeral ceremony, or visiting a house where there has been a death (Kaewsarn, Moyle, & Creedy, 2003a). Such practices are believed to prevent the pregnant woman and her unborn baby from catching any illness or getting haunted by a spirit or ghost.

In northeast Thailand, some women believe that eating eggs may result in having smelly newborns (Nigenda et al., 2003). Some avoid drinking coconut juice, believing that it can cause too much vernix caseosa (fat on the newborn’s skin), whereas others drink a lot of the juice, believing that it will help their newborns to have smooth and beautiful skin texture. Some believe that drinking chocolate milk, eating chocolate, or drinking coffee will cause their newborns to have a darker skin color. Most Thais view lighter skin as more favorable.

Pregnant women from the central region of Thai- land are often seen with a safety pin on their outfit over their belly. The pin works against a kind of ghost who always wants to steal the unborn baby from a

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mother’s womb. Also, pregnant Thai women, espe- cially those with Chinese descendents and their fami- lies, may ask their obstetric physicians to perform selective cesarean sections, believing that the date and time of their babies’ births can greatly affect their chil- dren’s future as based on the Chinese Zodiac calendar and fortune-telling (Ross et al., 2007a).

Like many other Southeast Asian women, postpar- tum Thai mothers practice the concept of “Yin” and “Yang” (cold and hot) (Kaewsarn et al., 2003a). After a child is born, the mother is left cold and wet. There- fore, the mother should gain some heat to dry out her body, especially her uterus (Kaewsarn et al., 2003a). To gain heat, some Thai mothers practice Yue Fai, which literally means “being with fire.” There are a couple of ways to perform Yue Fai. The new mother lies down either on a bed above a bonfire or on a wooden plank nearby. The fire is tended for as long as the mother is supposed to be near the fire, which may be from 1 to 30 days. Reasons given by Thai mothers for practicing Yue Fai include desiring an increase of milk, faster involution of the uterus, and illness and bone ache prevention (Kaewsarn et al., 2003b). Some drawbacks of this ritual, however, include inconven- ience, discomfort, and complications, such as heat rashes, sweating, dehydration, and minor burns (Kaewsarn et al., 2003b). To be able to perform Yue Fai, space is needed and a family member must keep tending the fire. Without enough space and a 24/7 support person, Yue Fai is not possible.

When Yue Fai, the ultimate practice for gaining heat during the postpartum period, is not possible, Thai mothers are advised by their mothers or nurses to use a combination of practices, including a perineal heat light, a hot Sitz bath, sauna heat belts, and warm showers (Kaewsarn et al., 2003b). Warm and hot drinks and foods are consumed; ice chips or ice cubes are avoided.

In general, all Thai mothers are allowed by their mothers to drink warm and hot nonalcoholic liquids. However, there is no consensus about the types of protein, vegetable, and fruit the postpartum mothers should consume. Whereas some mothers are encour- aged to eat certain food items, others are not (Kaewsarn et al., 2003b). Many postpartum Thai women are not restricted to proteins, vegetables, and fruit, but some are.

Sources of protein include pork, chicken, fish, eggs, milk, catfish, internal organs, beef, water buffalo meat, and shrimp (Kaewsarn et al., 2003b). However, some mothers might be advised to not eat eggs, chicken, or buffalo meat, believing that the new mothers’ per- ineum may not heal. On many occasions, the first au- thor has heard the mothers of postpartum Thai mothers’ give their reason as to why chicken is a taboo food for women after delivery: They stated that usu- ally a chicken likes to scratch the ground to look for

food. The chicken meat, therefore, could scratch open the perineum.

Eggs are avoided by some mothers, believing that they could cause a big scar on the perineum. Water buffalo meat is tough and cheap and, therefore, seen as unhealthy by Thais. Based on this belief, it is thought that the healing process of the new mother’s perineum could be jeopardized by its consumption.

Vegetables eaten by postpartum mothers may in- clude lettuce, banana flower, lemon grass, onion, ginger, cabbage, hairy melon, snake beans, chili, peppers, and bamboo shoots (Kaewsarn et al., 2003b). Acceptable fruits after the postpartum period may include oranges, bananas, tamarind, watermelon, jack fruit, and durian, an oval fruit with a hard spiny rind (Fig. 36-7). How- ever, some women avoid durian because of its strong smell. For traditional Thai families, especially those from rural Thailand, the new mother might be re- stricted to a few items of food for the first few weeks. For example, she might be allowed to take only rice soup with salt without any protein or fruit. Some post- partum Thai women drink Ya Dong, a Thai nonalco- holic or alcoholic drink infused with herbs. Herbs used in Ya Dong may include ginseng, galangal, peppermint, cinnamon, Spirulina, and plant roots. As perceived by many Thais, Ya Dong is famous for its medicinal qualities. When used by postpartum women, the drink helps with blood production and drying out the uterus quickly.

Expecting Thai fathers, like those of many cultures today, have for their part also begun to participate more in the childbearing experience. They tend now to desire more strongly, for example, to protect the un- born baby and to become more involved with the mother in preparing for postpartum care (Sansiriphun et al. 2010). Particular regional cultural practices may influence how some Thai fathers respond to society’s changing expectations for them. Moreover, Buddhist theology has been found, in general, to be “embedded in the beliefs and strategies” of expecting Thai fathers (Sansiriphun et al., 2010).

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Figure 36-7 Beautiful Thai fruits at a commencement ceremony.

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Death Rituals Death Rituals and Expectations Because most Thais are Buddhists, only the funeral rites in connection with Buddhism are addressed here. Like other Buddhists, Thai Buddhists believe that after a person dies, the person will be reborn somewhere else based on that person’s Karma (Dhammanada, 2002). “Karma means ‘action’ and . . . refers to the process by which a person’s moral behavior or actions have con- sequences for the person’s future, either in the present or later life” (Ross, Sawatphanit, & Suwansujarid, 2007b, p. 4).

In general, Thai Buddhists follow the custom of cre- mating the bodies of the deceased, because when the Buddha passed away, his body was cremated. Accord- ing to the Buddha’s teaching, a funeral ceremony should be simple. Unfortunately, many Thai Buddhists (and some other Buddhists) have transformed what was a traditionally simple cremation ceremony into one that is overly extravagant.

The consciousness or mental energy of the departed person has no connection with the body left behind. . . . A dead body is simply an old rotten simple house which the departed person’s life occupied. The Buddha called it “a useless log.” Many people believe that if the de- ceased is not given a proper burial or if a sanctified tombstone is not placed on the grave, then the soul of the deceased will wander to the four corners of the world and weep and wail and sometimes even return to disturb the relatives. Such a belief cannot be found in Buddhism (Dhammanada, 2002, p. 246).

In the funeral ceremony, often Buddhist monks are invited to chant verses to the dead and the family (Fig. 36-8). Food and candles are offered to the monks. Many Thai Buddhists believe that such chant- ing will benefit the spirit of the dead, regardless of Buddha’s teaching about the unbound relationship between the body and the spirit. The ashes from the cremation are buried at a cemetery. Sometimes, a por- tion of the ashes is sprinkled in a river. If possible,

when the family of the dead returns home after a so- journ away from Thailand, some of the ashes may be sprinkled again in a river or near the deceased’s hometown.

Responses to Death and Grief During the funeral ceremony, the family gets together. The sons of the deceased are expected to be ordained for a short period of time, ranging from a week to 3 months. The ordination is believed to help the dead go to heaven. Female relatives normally wail quietly. The family members pray quietly to the dead before the cremation to ask for forgiveness and wish the dead to be reborn in a happy and peaceful home. Often, in their prayer, family members wish for themselves to be reborn in the same family with the same relation to the dead in their next life.

Spirituality Dominant Religion and Use of Prayer Approximately 94.6 percent of the Thais are Buddhist; the rest are Muslim (4.6 percent), Christian (0.7 percent), and Hindu or other (0.1 percent) (CIA World Fact- book, 2011). In the United States, over three million people are Buddhist, most coming from Asian coun- tries, including Thailand (Eck, 2001). Buddhism is an exceptionally tolerant religion with its roots in Hinduism. Although precepts grounded in Buddhism (as discussed later) are fundamental to the spiritual makeup of most Thais, animistic beliefs generally have equal meaning for them and play a parallel role in their belief system.

Although not in agreement with all other religious beliefs, Thai Buddhists are free to incorporate any other religious values and animism to their beliefs and practices when deemed good. Most Thais in all socioeconomic strata to some degree incorporate animism, fortune-telling, and astrology. Studies have shown that ancient spirits are prayed to by many Thai patients (or their caregivers) and fortune-telling plays a major role in how Thais deal with illnesses (Ross et al., 2007a; Rungreangkulkij & Chesla, 2002).

Many families in Thailand have a spirit house where they believe that the ancient spirits of the land (Pra Poom) dwell: Two little statues of the Pra Poom (one male and one female) are placed inside a unique little abode that rests on a post or column. This house is usually at least as high as the eye level of an adult so as to indicate the respect of the family for the Pra Poom. Their abode can be either very simple or quite decorative, depending upon how much the family can afford, and faces either north or east (in the belief that these two directions are superior to the south and west). Miniature figures of a couple of horses and elephants are often placed in front of the Pra Poom figures to accompany them. Fresh flowers, food, and

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Figure 36-8 A Buddhist funeral.

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drink are placed in tiny plates, bowls, and cups as of- ferings. These may be placed everyday, or about once a month. The family members pray to the Pra Poom as often as they wish. Usually, the family prays and gives offerings to the Pra Poom more often when ask- ing for blessings and faster healing of an ill family member.

Meaning of Life and Individual Sources of Strength For most Thais, family support along with Buddhism is a crucial source of strength. In the Thai culture, parents are obliged to care for their ill children, regardless of a child’s age or type of illness (Rungreangkulkij & Chesla, 2002). Children or the unborn babies of HIV-positive pregnant Thai women have been identified as a major source of strength for their mothers (Jirapaet, 2001; Ross, Sawatphanit, Draucker, & Suwansujarid, 2007c).

In a study among Thai mothers of schizophrenic adult children, the mothers practiced Thum-jai as a way to cope with a situation perceived to be unchange- able (Rungreangkulkij & Chesla, 2002). Thum-jai means “let it be” or “whatever will be, will be.” By practicing Thum-jai, a person will be able to accept the reality of a challenge or problem and try to move on in his or her life with calmness and peace. The mothers in Rungreangkulkij and Chesla’s study (2002) stated that when their sick children misbehaved, they smoothed their own heart with “water.” For the Thai, a metaphor of “water versus fire” indicates “calmness versus anger/frustration.” The “fire” should be put out by “water” in a person’s heart to defeat a crisis sit- uation. The mothers in this study offered that calm- ness and gentle speech usually worked better than scolding in calming down their schizophrenic children (Rungreangkulkij & Chesla, 2002).

Spiritual Beliefs and Health-Care Practices Buddhism significantly pervades the life of many Thais (Burnard & Naiyapattana, 2004). When coping with difficulties or illnesses, many Thai laypeople and health-care professionals follow Buddha’s teaching (Ross et al., 2007b). Like most Buddhists, the ultimate goal for a Buddhist Thai is to reach Nirvana. This is the end of reincarnation or the cycle of rebirths. When there is no rebirth, there is no suffering. Either they are happy or suffering. “Peace” is the ultimate goal (Dhammanada, 2002). Results from a study reflect this belief by reporting that the ultimate goal of HIV- positive postpartum Thai women (alongside goals for their children) is to live with their HIV infection in peace. The women thus stated that they followed the Buddha’s teachings through their beliefs in Karma, the Five Precepts, and the Four Noble Truths in order to live in peace with HIV (Ross et al., 2007b).

As mentioned earlier, Karma is strongly associated with belief about rebirth. Many Thai patients (or

caregivers) believe that unwholesome Karma from their past life has caused them to become ill in the present life. They believe that the illness can be im- proved by following the Five Precepts so that their present or next life (or the lives of their loved ones) will be improved (Ross et al., 2007b). Merit making— a way to decrease selfishness and greed and a way to be hopeful for a better present and future life—is per- formed by many Thais. Merit making includes activ- ities such as freeing animals or birds, donating money to the poor or temple, offering food to monks, and tangibly helping those in need, emotionally, or finan- cially (Ross et al., 2007b; Tongprateep, 2000).

The Five Precepts are comparable with half of the Christian Ten Commandments and stress abstinence from killing, stealing, lying, sexual misconduct, and illicit drugs and alcohol consumption (Smith, 1994). A study with seven HIV-positive postpartum Buddhist Thai women revealed that the participants all decided to carry their pregnancies to term instead of ending them. They all stated that ending a pregnancy is a type of killing, which is considered a sin. Furthermore, all of the women in this study believed that such un- wholesome action would follow them in their next reincarnation as bad Karma (Ross et al., 2007b). In another study, it was found that the Five Precepts are observed by older Thai people to help them feel happy and peaceful (Tongprateep, 2000).

The Four Noble Truths reflect tenets about life, suf- fering, and the cessation of suffering. The First Noble Truth maintains that life is suffering, and that suffering as such is found in four unavoidable life moments—namely, birth, illness, aging, and death. The Second Noble Truth maintains that the cause of all suffering is Tanha, or personal desire. The Third Noble Truth is a belief that overcoming Tanha is at- tainable. The Fourth Noble Truth outlines paths to end suffering (Smith, 1994).

A qualitative study reported that the Four Noble Truths were followed by HIV-positive pregnant Thai women to cope with their infection (Ross et al., 2007b). The women stated that they began dealing with their illness by accepting the truth that everyone dies anyway at some point in life (The First Noble Truth) and that their suffering came from their per- sonal desire (The Second Noble Truth). In other words, their desire arose by thinking of themselves as a real existence in the world rather than as an illusion. “Self ” is like a mirage, or an imagined being (Flanagan, 2005). Therefore, when a person becomes selfless, the person is freed from suffering (Smith, 1994). The women in the study tried to think that their body and soul were not theirs, but instead imagined elements. To overcome desire, the participants tried to focus on universal life (The Third Noble Truth) by thinking about their infants instead of themselves and by meditating and praying. They also tried to follow the

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Middle Way, or a path between the two extremes of self-pleasure and self-mortification (Dhammanada, 2002), as a means to end their suffering. In accordance with the Buddha’s teaching that any extremes of thoughts, behavior, or speech are not wholesome, they reported trying not to feel too badly about themselves in order to be peaceful.

Meditation and prayer are ways for many Thais to cope with an illness. Studies revealed that both Thai pregnant and nonpregnant women meditated and prayed to the Buddha and supreme beings in order to help them cope with HIV/AIDS (Dane, 2000; Jirapaet, 2001; Ross et al., 2007b). Meditation is a means for Thai older people to enhance their self- awareness, peace of mind, sleep, and physical health (Tongprateep, 2000). For Thai older people in the United States, meditation and prayer also help them feel peaceful, perceive life as valuable, value tranquil relationships with family and friends, and experience meaning and confidence in death. For Thais, health and spirituality are intertwined and are important aspects of life (Pincharoen & Congdon, 2003).

In conclusion, the spiritual concepts of Karma, Nirvana, the Five Precepts, the Middle Way, and the Four Noble Truths are all important for Buddhist Thais. Ideally, when health professionals in the United States are aware of Buddhist concepts in car- ing for their sick or healthy Thai patients, the quality of care can be significantly enhanced.

Health-Care Practices Health-Seeking Beliefs and Behaviors In Thailand, most Thais rely on government health-care facilities, especially in the northeast region, or Isaan. People in Isaan hold strong traditional beliefs and prac- tices. They tend to be poorer and less educated than the rest of the country. In the Isaan area, statistical rates of gynecological problems are relatively low, yet, Isaan women’s self-reports show high rates of gynecological complaints associated with vaginal discharge and pain “in the uterus” (Boonmongkon, Nichter, & Pylypa, 2001). This contrast is often explained by a lack of com- prehension among some Isaan women who do not understand clearly the physiological changes of their menstrual cycle and the amount of vaginal discharge. Some of the pain “in the uterus” with which they are concerned may well be related to physiological pain during ovulation.

Boonmongkon and colleagues (2001) reported that Isaan women’s complaints and concerns about vaginal discharge and pain in the uterus may have an extreme impact on their lives. The women believe that such problems will turn into cervical cancer. This belief causes them to visit health-care facilities often, self- treat by relying on small doses of inappropriate an- tibiotics, be unhappy with their sexual relationship

with their husband, and suffer from worries of their “ailments” (Boonmongkon et al., 2001).

Most Isaan women in Boonmongkon and col- leagues’ study (2001) believed that their sustaining problems of vaginal discharge and pain “in the uterus” stemmed from their inappropriate practices after postpartum or significant past events. For in- stance, over 25 percent of the women stated that their chronic symptoms resulted from their inadequate practices of “lying by fire” and this caused their uterus to stay wet. Examples of other past experiences that the women believed caused their sustaining gynecol- ogical problems include hard work in youth, abortion, pushing too hard during delivery, and sterilization. Some women in the study indicated that they did not receive adequate information about their problems from health professionals but did not feel like asking questions for fear of being scolded. Therefore, U.S. health-care professionals should bear in mind that Thai women, especially from Isaan, may need more information regarding physiological changes related to their menstrual cycle and may need encourage- ment to ask any questions they have regarding their gynecological concerns.

Responsibility for Health Care Health promotion and disease prevention behavior among the Thais are very limited. Although all Thais are covered by some kind of health insurance, including the Universal Coverage of Health Care Scheme (75-cent health care), only 5.3 percent of the population used health promotion services, which include immunization, prenatal care, family planning, postpartum care, yearly checkups, dental care, and some other services (Ministry of Public Health, 2005). Among those who did use such services, one-third went to urban health centers, 28.7 percent to community hospitals, and 11.3 percent to general/regional hospitals. One-third of the services used were yearly checkups, and one-third included immunization (Ministry of Public Health, 2005).

Folk and Traditional Practices Folk practices are common among less-educated, rural Thais. Many Thais believe that bad Karma and negative supernatural power causes mental illness. Therefore, folk therapies from traditional healers are the first resource for many Thai families. When such therapies do not seem to work, they go to contem- porary medical facilities as their second resource. Folk therapies may include healing ceremonies, using shamans (as a mediator) to converse with supernatural beings (such as black magic, evil be- ings, and ancient/natural spirits), negotiating with them that the sick person might be released from their illness. In such ceremonies, holy water or oil is usually used to anoint the sick (Rungreangkulkij & Chesla, 2003).

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Khwan is a Thai concept about the “power inside,” or the “life spirit.” Thais believe that Khwan enters the newborn’s anterior fontanel during delivery. Khwan is different from self-esteem; it is thought of as a “life force” that can vanish when people are in a stage of shock, mental illness, or far away from home (Burnard & Naiyapatana, 2004). In a Khwan ceremony, fresh flowers are offered by the sick or the person who has lost her or his Khwan. A monk or an older person then ties a blessed white thin string around a person’s wrist, believing that the blessed string will tie the Khwan again to the person’s body (Burnard & Naiyapatana, 2004).

Barriers to Health Care For Buddhists, when one is too extreme in one’s speech, thoughts, or behavior, it is considered un- wholesome, as based on their belief in the Middle Way (Dhammanada, 2002). In this sense, some Buddhist Thais may not seek health care until their symptoms become severe. In addition, stigmatization attached to mental illness and beliefs in animism and Karma tend to prevent some Thais from seeking professional help when mental health problems arise. Some may not seek assistance from health-care professionals until they realize that traditional healers, Shamans, cannot help them (Rungreangkulkij & Chesla, 2003).

Cultural Responses to Health and Illness Adhering to their belief in the Middle Way, many Thais may appear stoic in trying to withhold expres- sions of pain or suffering from their illness. Health- care professionals may need to rely more on nonverbal clues for pain or some psychological-emotional dis- tress when assessing their Buddhist Thai patients.

Many Thais, and even some health professionals, equate depression with psychosis (Ross et al., 2007a). Thus, when clinical depression is diagnosed, health-care professionals should make extra efforts to encourage depressed Thai patients to get help and treatment, along with assuring them that depression and psychosis are different disorders.

Blood Transfusions and Organ Donation No religious beliefs against blood transfusion exist for Thais. However, donating and receiving organs is an- other matter. Although acceptable among many Thais, belief in their rebirth might prevent some from donating their organs, believing that they might not have the organ when needed in the next life.

Health-Care Providers Traditional Versus Biomedical Providers Like Hindus, Thais in the United States and else- where tend to consult their family and friends first

when they feel ill or have medical problems. Thai women usually seek female providers for childbear- ing care and gynecological problems owing to their modesty and their culture. However, if female providers are not available, they are generally willing to accept male providers. Traditional healers, or Shamans, in relation to Thai patients were discussed earlier.

Status of Health-Care Providers Respect for seniority is a strong cultural value among Thais. Thus, less-experienced health profes- sionals in Thailand are expected to respect those with more experience in the same profession. In gen- eral, when comparing physicians, head nurses, and junior nurses, Thai physicians receive the most re- spect, followed by head nurses and junior nurses (Fig. 36-9). In some cases, very senior head nurses receive the same level of respect as physicians (Burnard & Naiyapatana, 2004).

Based on a concept of “Thainess,” as expressed by many Thais, and especially in terms of being Bud- dhist, Thai nurses reported that they often incorporate Buddhist ideas and beliefs in caring for their chroni- cally ill patients (Burnard & Naiyapattana, 2004; Sawatphanit et al., 2004).

Like many other patients in developing countries (Withell, 2000), some Thai patients, and especially those of lower socioeconomic status, can be passive in voicing their needs and requesting care and services from health-care providers (Jirapaet, 2001). Therefore, health professionals in countries outside of Thailand are advised to evaluate the level of passivity among their Thai patients so that their needs can be ad- dressed with an eye toward optimal care.

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Figure 36-9 A nurse in a Thai nursing uniform.

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