“Issues in Immigrant Health and Cross Cultural Communication” John O. Gibson, MD, FAAFP, DIMPH, CTropMed Director of Global Health TCOM.

“Issues in Immigrant Health and Cross Cultural Communication”

John O. Gibson, MD, FAAFP, DIMPH, CTropMed

Director of Global Health

TCOM

OBJECTIVES1. Identify the primary counties of origin for our

refugee population and discuss the factors creating this situation

2. Enhance competency in cross cultural communication and understanding to better meet the needs of our refugee population.

3. Understand some of the disease processes common to the differing people groups immigrating to our area to enhance our medical knowledge and ability to treat our patients effectively.

Cross Cultural Communication

• Is it just a matter of getting the translator to help ?

• Some examples of challenging clinic visits:– 42 yo man recently arrived from Iraq complains of

back pain and sleeplessness– 46 yo Somalian female for evaluation of infertility

WHAT’S YOUR CROSS-CULTURAL I.Q.?

“CQ”

What’s Your Cross-Cultural I.Q.?

1. When invited to dinner in Thailand, you should try to be a little late so not to embarrass your hosts by arriving before they are ready.

A. TrueB. False

What’s Your Cross-Cultural I.Q.?

2. In which country would you not expect to be told directly that your proposal was unacceptable?

A. JapanB. ChinaC. ThailandD. VietnamE. All of the above

What’s Your Cross-Cultural I.Q.?

3. In which country is a man not supposed to touch a woman unless she is his wife?

A. Saudi ArabiaB. EgyptC. SomaliaD. IndonesiaE. All of the above

What’s Your Cross-Cultural I.Q.?

4. South Americans, Africans, and Arabs stand closer when talking than is customary in the United States, and backing away may suggest dislike or aloofness.

A. True B. False

What’s Your Cross-Cultural I.Q.?

5. Among some cultural groups in Latin American and Asian countries, if you try to maintain eye contact with your native host while discussing business, you are likely to be interpreted as:

A. Honest and truthfulB. AggressiveC. Attentive

What’s Your Cross-Cultural I.Q.?

6. In which country should both hands be used when passing an object to a native?

A. West GermanyB. CanadaC. IndiaD. USSRE. All of the above

What’s Your Cross-Cultural I.Q.?

7. In which country are people less likely to “open up and let you know what they are going through”?

A. JapanB. ChinaC. TaiwanD. MalaysiaE. All of the above

What’s Your Cross-Cultural I.Q.?

8. In the Middle East, after waiting outside the office of a Saudi businessman for two hours beyond the time of your appointment, you should

A. Inform his secretary of your busy schedule and ask her to inform her boss that you are waiting B. Wait patiently until he can meet with you C. Leave, and call back later to make another appointmentD. Write him a polite note and leave

Our Challenge

• Competent and compassionate treatment of our refugee and immigrant patients require an understanding of what culture is and how it affects the perception of our advice and treatment

Texas Refugee Program FY2014(10/01/13 – 09/30/14)

Texas received 12,800 arrivals in FY2014 - A 24% increase from FY2013

Texas resettled:- 11% of all Refugees nationwide- 18% of all Special Immigrant Visa holders

Arrivals originated from 58 countries

14

60%

15%

www.RefugeeHealthTx.org

Texas FY14 Refugee Program Arrivals

by County (by %)

15

16

FY2014 Refugee Program Arrivals to Dallas Co.

Dallas County received 2,428 arrivals in FY2014 (vs. 2,315 in FY2013), a 5% increase.

Arrivals originated from 37 countries.

17

Tarrant County received 1,865 arrivals in FY2014 (vs. 1,785 in FY2013), a 4% increase.

Arrivals originated from 30 countries.

FY2014 Refugee Program Arrivals to Tarrant Co.

18

WHAT IS CULTURE?

“An integrated system of learned ideas, feelings, values and their

associated patterns of behavior and products shared by a group of

people.”

Our “Program”: language, customs, ideas, feelings, values, behavior, relationships…

Other Cultures: Different “Programs”

Like a Computer Program

Culture Is Learned

• Culture is learned through a process of socialization (enculturation) rather than by biological instinct.

• The cultural traits and values are transmitted to the new generation.

Culture is Integrated

• All aspects of a culture have a tendency to function in an interrelated whole.

• Change in one area of culture will affect the other areas (e.g., health care practices)

Culture Is Symbolic • A symbol is a physical phenomenon (artifacts,

objects, sequence of sounds, gestures, implements, ceremonies) that has meaning bestowed on it by those who use it.

• Language (written & spoken) is the most basic set of symbols of a culture. We cannot understand a culture without learning its language.

Culture Is Dynamic

• Some cultures change more rapidly than others

• Superficial changes – dress, language-happen quicker

• Profound changes – values, beliefs, religious practices – take much longer, if ever.

ETHNOCENTRISM

“The tendency to believe that our culture is the only valid one and to

evaluate other cultures by our values and standards”

Ethnocentrism Sources

• Isolation - don’t know other groups

• Stereotypes - accepted uncritically

• Pride - need to feel superior to others

• Apathy - don’t care enough to make an effort

• Competition – for the same resources

• Fear – afraid to take the initiative to meet others

How to overcome ethnocentrism• Recognize - we all have this tendency

• Repent - if we have had pride

• Resolve - to cultivate a friendship

• Resist – efforts to perpetuate stereotypes

• Realize - opportunity; build bridges

“When you personalize you demythologize”

Three Cultural Perspectives

• 1. The Patient’s – Personal Culture & Experience with Health Providers

• 2. The Health Provider’s Personal Culture

• 3. The Culture of Organized Medicine – “Corporate Culture.”

Basic Values

• Proximics – (comfort in personal space?)

• Eye Contact – (direct or indirect?)

• Hepatics – (frequency & location of touch)

• Social Orientation – (collective or individual?)

• Family (nuclear or extended?)

Basic Values

• Language – Regional variations (country of origin)– Generational variations (1st, 2nd, 3rd)– “Language of the heart” in life-threatening

situations.

• Others?

APPLICATION

• 1. It helps us to learn about a person’s life experience & cultural world

• 2. Simple things such as ethnic meals and restaurant trips can provide opportunities to establish understanding

• 3. Respect for a person’s culture/religion is essential

• 4. Above all, we need to listen

Application

• 1. Be willing to listen sympathetically

• 2. Many people have moral/religious struggles

• 3. We do not have to approve of the lifestyles or behaviors of people to care for them

JPS IHC: Communicating in the Melting Pot of the Metroplex

SomaliaSomaliaFailed State status following a failed socialist dictatorship (Barre) and prolonged war with Ehtiopia and civil wars with emergence of rival Warlords.

Refugee issues since 1990

Over 500,000 dead

1.5 Million Internally Displaced

500,000 in nearby countries

3.5 Million subsist on foreign subsidy

Refugee Camps

Dadaab camp in northern Kenya, which has facilities for about 90,000, has 280,000 refugees who have no access to basic necessities, including clean water.

In Ethiopia, the Bokolmayo camp has about 10,000 people. At least 1,000 people arrive there every month

Endemic Health Issues for SomaliaEndemic Health Issues for Somalia Food or waterborne diseases: Food or waterborne diseases: bacterial and bacterial and

protozoal diarrhea, hepatitis A and E, and typhoid protozoal diarrhea, hepatitis A and E, and typhoid feverfever

Vector borne diseases: Vector borne diseases: dengue fever, malaria, dengue fever, malaria, and Rift Valley feverand Rift Valley fever

Water contact disease: Water contact disease: schistosomiasis, schistosomiasis, choleracholera

Animal contact disease: Animal contact disease: rabies (2009)rabies (2009)

Case from SomaliaCase from Somalia 18 yo young man from Somalia with 18 yo young man from Somalia with

red urine, fever and poor weight gain.red urine, fever and poor weight gain. Arrived in the US 3 years ago. Sent to Arrived in the US 3 years ago. Sent to

Pediatric Urology for hematuriaPediatric Urology for hematuria Million dollar workup: Leukopenia, Million dollar workup: Leukopenia,

chronic low grade fever, intermittent chronic low grade fever, intermittent hematuria, CT, MRI, Urine C&S, hematuria, CT, MRI, Urine C&S, Cystoscopy all negative Cystoscopy all negative

Hematology suspects lymphoma BMB Hematology suspects lymphoma BMB is equivocal. is equivocal.

Case from SomaliaCase from Somalia No longer able to be seen at No longer able to be seen at

pediatric hospital, so comes to JPS pediatric hospital, so comes to JPS IHC with reams of previous workupIHC with reams of previous workup

Seen by Global Health resident who Seen by Global Health resident who orders CBC, UA and Urine and Stool orders CBC, UA and Urine and Stool for O&P.for O&P.

CBC: WBC low, normal differentialCBC: WBC low, normal differential H&H 28/9 H&H 28/9 Urine: grossly bloodyUrine: grossly bloody

Urine and Stool ExamUrine and Stool Exam

What’s the diagnosis ?

Burma Burma (Myanmar)(Myanmar)

Long Term Refugee Situation :

Totalitarian government run by State Peace and Development Council (SPDC), or Military Junta (formerly SLOR)

Brutal repression of democracy, forced military conscription and persecution and displacement of large numbers of tribal and minority populations

Burmese Refuges in Thailand and Burmese Refuges in Thailand and MalaysiaMalaysia

Mae La. There are 43,000 people living in the camp.

Armed Conflictwith children as victims

Health Issues Common to Burmese Immigrants

Infectious diseases are the leading cause of morbidity and mortality

LE at birth for males is 46.5 years and 51.4 years for females.  

The infant mortality rate is 72/1000, and child mortality per 1000 is 121 for males and 106 for females.

Leading Problems

Multidrug Resistant Malaria (Mae Sot) Malnutrition Hepatitis HIV-AIDS Leptospirosis Scrub Typhus Melioidosis

Family from BurmaFamily from Burma

26 yo female from Kachin State or 26 yo female from Kachin State or northern Burma. Newly arrived and northern Burma. Newly arrived and has 26 week pregnancy with no has 26 week pregnancy with no prenatal care. G3 P2, two deliveries prenatal care. G3 P2, two deliveries in Thailand. Father and both children in Thailand. Father and both children are seen for checkups also.are seen for checkups also.

Mother positive for Hep B SA on Mother positive for Hep B SA on initial prenatal lab.initial prenatal lab.

What is the next step ?What is the next step ?

SudanSudan Current Humanitarian Situation Current Humanitarian Situation

in Darfurin DarfurCivilian protection in Darfur remains a Civilian protection in Darfur remains a serious concern. More than 2.6 million IDPs serious concern. More than 2.6 million IDPs are in Darfur and over 250,000 Darfuris are in Darfur and over 250,000 Darfuris are living in refugee camps in Chad. are living in refugee camps in Chad. Insecurity continues and many displaced Insecurity continues and many displaced people are still unable to return home, people are still unable to return home, despite increasing pressure for people to despite increasing pressure for people to do sodo so..

Traditional Health PracticesTraditional Health Practices Sudanese that practice traditional spirituality typically Sudanese that practice traditional spirituality typically

believe in a variety of supernatural beings and spirits believe in a variety of supernatural beings and spirits of animals. During illness, it is not uncommon for the of animals. During illness, it is not uncommon for the Nuer, for example, to try to determine what evil spirit Nuer, for example, to try to determine what evil spirit or bad energy has caused a condition, and then try to or bad energy has caused a condition, and then try to rectify it through an offering or an animal sacrifice. rectify it through an offering or an animal sacrifice.

The “evil eye” is also a common belief among this The “evil eye” is also a common belief among this group, whereby a bad person can send negative group, whereby a bad person can send negative energy to another and cause misfortune or poor energy to another and cause misfortune or poor health.health.

Traditional medicines have been used for centuries by Traditional medicines have been used for centuries by East Africans like the Somalis and Sudanese, and vary East Africans like the Somalis and Sudanese, and vary widely by geography and culture. widely by geography and culture.

BhutanBhutan

Hidden mountain Kingdom for centuries

Refugee Crisis begins in 1988 with persecution and racial purification of population. Resulted in massive displacement of Lhotshampa minority to Nepal and India

Lhotshampa of Bhutan BhutanVictims of the “Gross National Happiness”Victims of the “Gross National Happiness”

125,000 Displaced 125,000 Displaced • 20,000 in India20,000 in India• 105,000 in 7 refugee camps in Nepal105,000 in 7 refugee camps in Nepal

US Agrees to resettle 60,000US Agrees to resettle 60,000

http://www.photovoice.org/bhutan/camptour.php

Patient from Nepal/BhutanPatient from Nepal/Bhutan 58 yo man from Bhutan who spent 20 58 yo man from Bhutan who spent 20

years in Nepali refugee camp. He has years in Nepali refugee camp. He has chronic cough and a history of chronic cough and a history of “Asthma”. He has never smoked “Asthma”. He has never smoked tobacco. He uses an “inhaler” 5 or 6 tobacco. He uses an “inhaler” 5 or 6 times a day to help his breathing.times a day to help his breathing.

Exam: Decreased breath sounds Exam: Decreased breath sounds bilaterally with increased AP diameter bilaterally with increased AP diameter of chestof chest

CXR of Nepali patientCXR of Nepali patient

What is the Dx ?What is the etiology of the process above ?

Cross Cultural Communication Cross Cultural Communication RevisitedRevisited

• 42 yo man recently arrived from Iraq 42 yo man recently arrived from Iraq complains of back pain and sleeplessnesscomplains of back pain and sleeplessness

• The rest of the story…..The rest of the story…..

46 yo Somalian female for evaluation of infertility

The rest of the story…..

Syria: the new frontier in RefugeesSyria: the new frontier in Refugees

Situation in SyriaSituation in Syria

Response from the US and EuropeResponse from the US and Europe

Common Health Issues to all Common Health Issues to all RefugeesRefugees

Mental Health Issues (PTSD)Mental Health Issues (PTSD)• Adjustment DisordersAdjustment Disorders• Physical torture, rape and family Physical torture, rape and family

separationseparation Women’s Health IssuesWomen’s Health Issues

• ObstetricsObstetrics• Abnormal PapsAbnormal Paps• Female CircumcisionFemale Circumcision

Well Child and ImmunizationsWell Child and Immunizations Tropical Disease and ParasitesTropical Disease and Parasites

Culturally Appropriate CareCulturally Appropriate Care

Family Oriented CareFamily Oriented Care

Training of Training of Translators for Translators for

Refugee Refugee populationpopulation

Resources For Further LearningResources For Further Learning

http://www.culturalorientation.net/• http://www.culturalorientation.net/learni

ng/populations/

www.RefugeeHealthTx.org Epidemiological Report

Global Health Initiatives at UNTGlobal Health Initiatives at UNT Office of Global Health EducationOffice of Global Health Education

Contact: [email protected]

Global Health CertificateCertificate course through SPHLaunch : Fall 2015

Contact: [email protected]@unthsc.edu

Thanks for your time and may we continue to improve our cross-cultural

communication and medical skills!