Punjabi-Sikhs are very family oriented and have strong family ties, while also forming networks amongst their cultural communities. Punjab is a state located in northwestern India that gave rise to the Sikh religion. In fact, the culture for many of the Punjabi people revolves around religion. Sikhism is the world’s fifth largest religion and has millions of followers worldwide. While the majority of Sikh followers live in India, many followers reside in America. In Boston, the Sikh community formed in the late 1960s as a small study circle. Over the past few decades, the community has dramatically expanded and only continues to grow. There are four established Gurudwaras (Sikh temples) in Massachusetts where several hundred families attend to take part in prayer. These Gurudwaras are open to all and are located in Everett, Medford, Millis, and Milford (which has recently unofficially moved to Westborough). This paper will examine health values amongst Punjabi-Sikhs by briefly outlining Sikh origin and health in holy text, viewing the importance of diet, and merging traditional values into healthcare practices.
Sikhism
In Sikhism, it is believed that humans are reincarnated until they find their way to God’s feet to be absorbed into him by God’s grace (Labun, Emblen, 2007, p. 141). If over a number of reincarnations a person fails to do good, then they will continue to experience a number of other lives and other deaths as they take the long road to the feet of God. The beliefs held by Sikhs are conveyed through stories of truth found in holy text. According to one Sikh, “We believe our life is prearranged; in karma and reincarnation. All Sikhs abide under His will and get healthy under His will” (Labun, Emblen, 2007, p. 143). Health and spirituality are directly correlated in the eyes of the Sikh community.
These teachings encourage Sikhs to live in a manner different from that of the rest of society to promote health. One of the suggested habits include an alternating routine of prayer, food, and activity on a daily basis. Another is living a vegetarian-friendly lifestyle, however some modern day Sikhs believe that if meat must be eaten then one should eat meat where the animal was killed in a non-torturous way as “God does not want man to be cruel. He wants man to be gentle and kind” (Labun, Emblen, 2007, p. 143). Others include living in peace and harmony amongst the extended family, as it is common for multiple generations to live under the same roof in Punjabi culture, and also refraining from destructive habits such as drinking and smoking.
Identifying a Sikh
A Sikh is recognized by five distinct symbols of devotion—the five K’s (Labun, Emblen, 2007, p. 141). One is Kesh, the keeping or not cutting of the hair. The hair is a gift given by God that represents spirituality and men honor it by keeping their hair in a turban. Next is a wooden comb known as the Kanga, representing cleanliness. The third symbolizes restraint, as it is a steel bracelet known as a Kara, which also acts as a link to God. Then there is the symbol of courage carried in the Kirpan, a short sword worn to show the commitment to truth and justice. Finally, there is the undergarment called a Kaccha representing purity of moral character. These practices are observed by all baptized male Sikhs. Purity is of importance to Sikhs as practicing purity moves one towards the spiritual (Labun, Emblen, 2007, p. 143). Spirituality itself is a concept described to be pure, separate and not associated with sickness or disease. However, not all Sikhs are baptized and so there are many variations of the Sikh person. According to Jhutti-Johal (2013), “In literature these are revealed as:
Amritdhari—Khalsa—baptized Sikhs or ‘orthodox’ Sikhs Keshdhari—those who keep the Kes, unshorn hair but are not baptized
Mona/Sehajdhari—clean shaven Sikhs who cut their hair Gora Sikhs—Western converts to Sikhism, generally all of whom are baptized into the Khalsa and observe the articles of faith Patit—someone who may have taken amrit [holy water] but has since lapsed” (p. 263).
As followers of the religion spread out across the world, and generations pass, many Sikhs have adopted a modified faith to keep in line with the modern times of today’s day and age. This is especially applicable to the younger generation living in the Boston area.
The Establishment of Sikhism
The Sikh religion was initiated by Guru Nanak, the first of the Sikh gurus. Guru is a term applied to one who rids themselves free of ignorance and declares themselves in a state of enlightenment (Kalra, Bhui, Bhugra, 2012, p. 339). The Sikh religion has ten gurus, with the eleventh and final remaining guru being the Guru Granth Sahib. As Guru Nanak went through his life, he expressed his thinking and gained followers who believed in his teachings. He argued against the caste system and polytheism while preaching the unity of all of mankind (Singh, 2004, p. 94). The core of Sikhism revolves much around those teachings, writings, and pronouncements of that time. Before his death, Guru Nanak chose a successor who would continue his work and presented him with a book of his own hymns (Kalra et al, 2012, p. 339). The religion continued to flourish and grow over the next three centuries and eventually found Guru Gobind Singh to be the last guru. Guru Gobind Singh was a leader, warrior, and poet who held great significance in the establishment of the Sikh religion. By developing a way of rites to be initiated into the religion, as well as by creating a code of discipline followers must adhere to prohibiting certain diets and activities (no consumption of meat, fish, or eggs), Guru Gobind Singh founded a new community known as the Khalsa (the Pure Ones). With an emphasis on equality, he encouraged men and women from all castes to join the community, with all men taking on the last name Singh (lion) and all women taking on the last name Kaur (princess). Guru Gobind Singh “declared that after him there will be no Guru and the diktat of Granth Sahib shall be final, the Shri Guru Granth Sahib (Granth – book; Sahib – Supreme) thus is the final Guru of Sikhism” (Kalra et al, 2012, p. 340).
The Guru Granth Sahib
With contributions from all ten gurus, Sufi tradition, and other significant poets and scholars of the time, the holy book revered as a guru, known as the Guru Granth Sahib, was formulated. The religious text was composed by the Sikh Gurus from 1469 to 1708 and consists of 1430 pages sectioned with uniform organization of hymns describing the qualities of God and why one should mediate on God’s name (Kalra et al, 2012, p. 340). For Sikh devotions, the holy book is the visible focal point. The Guru Granth Sahib has a dominating role in the day to day lifestyle of Sikhs including in ceremonies, festivals, rituals, and theology. Sikhs recognize the Guru Granth Sahib to be their spiritual guide, finding emotional and psychological support through prayer. The center of Sikh practice takes place at a Gurudwara, a religious temple housing the Guru Granth Sahib, which can also be found in the households of most Sikhs. Apart from congregating, reading, and interpreting the religious scriptures, Gurudwaras provide a common free-service kitchen, offering food and shelter to those in need.
Unity With God. Sikhism takes on a monotheistic approach with an opposition to materialism where the ultimate reality is a unity with God (Kalra et al, 2012, p. 340). Timeless and formless, God’s essence is that of power and love (Singh, 2004, p. 94) Ignorance may make man miss the chance to meet the Lord. “The reasons for this vary from birth, environment, karma (the notions of cause and effect), maya (a materialistic view of the world) and self-dependence rather than an acknowledgement that God also has a role” (Kalra et al, 2012, p. 340). Recognizing one to be dependent on God and obeying his will (hukam) is the key to liberation, which is different from rebirth in that it breaks the cycle of death, releasing man to be united with God. Through naam simran (remembering the name) one may meet the guru and become liberated. The core of Sikh ethics are formed by work, worship, and charity, dissuading one from self-conceit which may lead to greed, anger, lust, and materialism. The concepts of good deeds, heaven (suarg), and hell (narak) form the basis of spiritual aspects of the religion where good deeds are encouraged as without the karma of good actions, heaven is not attainable.
Dukh and Sukh in the Guru Granth Sahib. Emotions are discussed in the Guru Granth Sahib, where anger, hatred, vengeance, greed, jealousy, and pride are looked down upon (Kalra et al, 2012, p. 341). The religious text also addresses happiness (sukh) and sadness (dukh). If one is detached from God, then the discussion of the concepts highlight the intrinsic unhappiness that exists in the world which can only be overcome by self-devotion to God. As the Lord is the creator of dukh and sukh, he is also the one who relieves it being both Dukh-bhanjan (destroyer of dukh) and Sukhsaagar (ocean of peace and happiness). Happiness is a jewel that can be found in oneself. However, this is a jewel that one may receive only if God wishes to give them it. This concept becomes paramount in understanding illness, pain, and emotions one may possess. It is stated that the mind is prone to the disease of doubt, superstition, and duality, keeping one in dukh. “The state of a person afflicted with melancholy has been symbolically referred to a tree with dried leaves and branches, which become green in an instant with the ambrosial name of the Lord (amrit naam)” (Kalra et al, 2012, p. 341). So to rid oneself of the melancholic experience and to gain sukh, they must remember God, as those who sing his praises remain in ecstasy. Furthermore, karma is tied into dukh and sukh. Bad deeds leave one to sit and weep, while good deeds assure that one will never enter into any dukh. Good deeds done in the past determine one’s future and the rewards can move across births.
Mind-Body Connection. Punjabi-Sikhs take a holistic approach to health, involving both the mind and body so one may think positively, have a healthy body, or be full of health (Labun, Emblen, 2007, p. 144). The mind and body cannot be separated as health is a state of mind and does not just pertain to the body. In line with these views, the Guru Granth Sahib states a clear mind-body connection. On page 55 of the religious text, it is written, “‘man juthaey tan juth hai jihva jooth hoe’ – if the mind is polluted, then the body is polluted as well, and the tongue is polluted too” (Kalra et al, 2012, p. 342). There is no distinguishing between the mental and the physical but rather it is one seamless, connected concept. A sick mind produces a sick body. The Lord is considered to be the true healer and physician where his name is similar to medicine and can cure dukh and pain in an instant as saying his name cools and soothes the mind. This once again reiterates the importance of naam simran to Sikhs.
Punjabi Diet
The Punjabi diet is rich and flavorful. Punjab is mostly an agriculture based economy and so its people are used to eating fresh fruits, fresh vegetables, and wheat-based dishes. Some Punjabi foods can be unhealthy as they are high in fat and sugar and may be fried or use quite a bit of oil. Punjabi people are known to savor spice but they enjoy intricate sweets just as much. Sikhism encourages the provision of food into worship practices as part of seva (selfless service) in the common kitchen at Gurudwaras. These offerings of food, though for religious intentions, often serve as a symbolic gesture of family social and economic status (Sidhu, Griffith, Jolly, Gill, Marshall, Gale, 2016, p. 507). Some families take food to the Gurudwara so that the prayers will “go into the food for a special blessing” (Labun, Emblen, 2007, p. 146). Food is important in health, especially since “food creates blood, blood feeds the heart, from the heart come our actions, from the actions comes the hereafter” (Labun, Emblen, 2007, p.145). Sikhs believe in karma and those actions taken are fueled by food, so quality food is necessary in the diet so that a Sikh may take good actions.
Home Remedies
Punjabi-Sikhs use natural ingredients in health-related home remedies, such as onion, garlic, and ginger, which are used in daily cooking to continuously promote good health. The use of such ingredients help combat colds, flu, chest-infections, sore-throat, nausea, and stomach problems (Oliffe, Grewal, Bottorff, Dhesi, Kang, Ward, Hislop, 2010, p. 762). Some of these stomach problems are digestive complaints such as indigestion, constipation, diarrhea, stomach aches and flatulence. Other commonly used spices with therapeutic effects are cayenne pepper, cinnamon, lemon, fennel, and cardamom (Sandhu, Heinrich, 2005, p. 634). These can all be used for culinary purposes, but there are several species of plants that are only used therapeutically including Acanthus ilicifolius (Acanthaceae), Acorus calamus (Araceae), Panax ginseng (Araliaceae), Ricinus communis (Euphorbiaceae), Cassia senna (Fabaceae), Hypericum perforatum (Hypericaceae), Ocimum sanctum (Lamiaceae), Ajuga bracteosa (Lamiaceae), Aloe vera (Liliaceae) and Lawsonia inermis (Lythraceae). Other important uses include stimulants, anti-diabetics, analgesics, antiseptic use, dermatitis, asthma and bronchitis, rheumatism and rheumatic pain, eczema, as well as for anti-inflammation. Some less common uses are for insomnia, sores and ulcers, depression, kidney stones, gout, and anorexia.
Punjabi Culture as Shaped by America
In Punjab, ghee (clarified butter), butter, and homogenized milk is consumed liberally. However, “Here, ghee is not good for you. Everyone I know has [high] blood pressure…In India it does not matter how much ghee you ate. You do not have this problem”(Choudhry, 1998, p. 271). Upon adjustment to America, it was discovered amongst Punjabi women that being overweight can lead to diseases including heart attacks and stroke. For this reason, many Punjabi women try to be conscious of their weight. These health discoveries are important because women do much, if not all, of the food preparation for their families. If a Punjabi woman is making health conscious choices, then she is doing the same for her family.
It becomes tempting to break the Sikh law of vegetarianism as buying meat becomes easy since it is more available and affordable in America as compared to Punjab. Similarly, with the switch of simple foods to fast foods, negative health choices are easy to make as there is always a fast food restaurant nearby. With Punjab being a booming center of agriculture, it is apparent that food values are lost in fresh fruits and vegetables upon arrival to America due to the difference in agricultural practices (Labun, Emblen, 2007, p. 146). The use of the freezer to store food in is not a luxury one has in Punjab. It is believed that by storing food in the freezer the value of the food contents is also lost (Choudhry, 1998, p. 272).
God’s Hukam
To Sikhs, life is a God-given gift which makes it sacred. The pain, illness, and suffering one endures is not viewed as good or evil but is rather a result of their past karma. A Sikh must be capable of dealing with suffering due to the moral fortitude they are required to possess (Jhutti-Johal, 2013, p. 264). This makes suffering a means by which people are brought closer to God as “Suffering is the medicine, and pleasure the disease, because where there is pleasure, there is no desire for God” (Jhutti-Johal, 2013, p. 264). The time at which death approaches is under the hukam of God. Though efforts should be made to sustain life, one must not interfere with the terms of death as life presents the Sikh with opportunities to get closer to being united with God and to end it prematurely to avoid hardship would be counterproductive. It may seem humane to prevent a patient from further suffering by withdrawing treatment to hasten death, but to a Sikh this is the notion of playing God. Ending a life prematurely against God’s hukum may halt the progression of an individual’s liberation from the cycle of rebirth and ultimately from union with God.
Miscommunication of Healthcare Providers and Patients
There is a disconnect in communication amongst Sikh patients and their healthcare providers. This may lead to misunderstandings and induce anxiety because some patients do not speak or understand English. Without a common language, the patient may be afraid or hesitant to communicate their religious beliefs which may influence their medical preferences. Baptized elderly men and women may feel unable to discuss the importances of their five K’s, their religious needs in terms of hygiene and care, or even the want for a health provider of the same sex (Jhutti-Johal, 2013, p. 266). Health professionals may not realize the importance of family on one’s healthcare. There is a strong expectation that elderly parents will be cared for and looked after by family members, especially sons and their wives. Rather than being autonomous, older patients are likely to depend on family-shared decision making. A son may want to be involved to the utmost extent and expect medical professionals to involve him in all aspects of care and decision making. It is common amongst Punjabi families to wish to receive the medical information at hand prior to sharing it with the patient so that they have control over what is disclosed to the patient with the intentions of protecting them. This censoring of information goes against western medical practice where the primary focus of decision making is patient autonomy where the patient is given complete disclosure. However, it is crucial that healthcare professionals recognize the influence culture has on health-related decision making if they wish to provide their patient with the comfort needed to improve the quality of care they are receiving.
Potential Modifications Relating to Care
Healthcare providers often view ethnic minority groups to have similar needs that may be addressed culturally, religiously, and spiritually by homogenous practices for all (Jhotti-Johal, 2013, p. 260). This is not the case as within specific groups there exists a diverse range of views and practices. This applies to the Sikh community as well. To better accommodate Sikh patients, a number of things can be done. Indication of the patient’s religious beliefs must be documented initially. Healthcare professionals can partake in cultural and religious diversity training. Different foods can be provided in accordance with the patient, whether it be vegetarian, kosher, halal, etc.. Though it may be costly, provision of non-animal derived treatments would be greatly culturally sensitive to the Sikhs. It would also be helpful, especially for female patients who may feel particularly uncomfortable, if healthcare professionals of the same sex were provided to the patient. Providing a space or area for religious practice or worship would provide further comfortability, alongside access to religious texts that healthcare professionals would know how to handle, treat, and store. By being culturally/religiously sensitive, patients feel more welcomed who may otherwise feel frightened, anxious, or nervous about their healthcare experience.
Conclusion
The Punjabi-Sikh culture is one that is rich, lively and intricate. The religion is relatively new, but booming with followers. As the community continues to expand, it is important for healthcare providers to become culturally competent in their practices. The initial step must be to create awareness, where the values and beliefs are conveyed and shared. Quality healthcare depends on the trust between a patient and their provider. One’s faith is important to a Sikh. For this reason, the faith must also be important to the healthcare provider. In doing so, this creates a relationship where the patient feels as though they can be open and honest. This is necessary because the aim of a provider is to be thorough and efficient. Understanding that a Sikh does not wish to remove their hair, recognizing their vegetarian diet, and respecting their wishes pertaining to their religion makes it easier for a healthcare professional to identify with their patient, delivering quality personalized care, truly believing that the health of their patient comes first.