“Issues in Immigrant Health and
Cross Cultural Communication”
John O. Gibson, MD, FAAFP, DIMPH, CTropMed
Director of Global Health
TCOM
OBJECTIVES
1. 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 CROSSCULTURAL 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.
B.
True
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.
B.
C.
D.
E.
Japan
China
Thailand
Vietnam
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.
B.
C.
D.
E.
Saudi Arabia
Egypt
Somalia
Indonesia
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.
B.
True
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.
B.
C.
Honest and truthful
Aggressive
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.
B.
C.
D.
E.
West Germany
Canada
India
USSR
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.
B.
C.
D.
E.
Japan
China
Taiwan
Malaysia
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
appointment
D. 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
60%
15%
Arrivals originated from 58 countries
www.RefugeeHealthTx.org
14
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
FY2014 Refugee Program Arrivals to Tarrant Co.
Tarrant County received 1,865 arrivals in FY2014
(vs. 1,785 in FY2013), a 4% increase.
Arrivals originated from 30 countries.
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.”
Like a Computer Program
Our “Program”: language, customs, ideas,
feelings, values, behavior, relationships…
Other Cultures: Different “Programs”
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
Somalia
Failed 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 Somalia

Food or waterborne diseases: bacterial and

Vector borne diseases: dengue fever,

Water contact disease: schistosomiasis,

Animal contact disease: rabies (2009)
protozoal diarrhea, hepatitis A and E, and typhoid
fever
malaria, and Rift Valley fever
cholera
Case from Somalia




18 yo young man from Somalia with
red urine, fever and poor weight gain.
Arrived in the US 3 years ago. Sent
to Pediatric Urology for hematuria
Million dollar workup: Leukopenia,
chronic low grade fever, intermittent
hematuria, CT, MRI, Urine C&S,
Cystoscopy all negative
Hematology suspects lymphoma BMB
is equivocal.
Case from Somalia





No longer able to be seen at
pediatric hospital, so comes to JPS
IHC with reams of previous workup
Seen by Global Health resident who
orders CBC, UA and Urine and Stool
for O&P.
CBC: WBC low, normal differential
H&H 28/9
Urine: grossly bloody
Urine and Stool Exam
What’s the diagnosis ?
Burma
(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
Malaysia
Mae La. There are 43,000 people living
in the camp.
Armed Conflict
with 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 Burma



26 yo female from Kachin State or
northern Burma. Newly arrived and
has 26 week pregnancy with no
prenatal care. G3 P2, two deliveries
in Thailand. Father and both
children are seen for checkups also.
Mother positive for Hep B SA on
initial prenatal lab.
What is the next step ?
Sudan

Current Humanitarian Situation
in Darfur
Civilian protection in Darfur remains a
serious concern. More than 2.6 million
IDPs are in Darfur and over 250,000
Darfuris are living in refugee camps in
Chad. Insecurity continues and many
displaced people are still unable to return
home, despite increasing pressure for
people to do so.
Traditional Health Practices



Sudanese that practice traditional spirituality typically
believe in a variety of supernatural beings and spirits
of animals. During illness, it is not uncommon for the
Nuer, for example, to try to determine what evil spirit
or bad energy has caused a condition, and then try to
rectify it through an offering or an animal sacrifice.
The “evil eye” is also a common belief among this
group, whereby a bad person can send negative
energy to another and cause misfortune or poor
health.
Traditional medicines have been used for centuries by
East Africans like the Somalis and Sudanese, and vary
widely by geography and culture.
Bhutan
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
Victims of the “Gross National Happiness”
http://www.photovoice.org/bhutan/camptour
.php

125,000 Displaced
• 20,000 in India
• 105,000 in 7 refugee camps in Nepal

US Agrees to resettle 60,000
Patient from Nepal/Bhutan


58 yo man from Bhutan who spent 20
years in Nepali refugee camp. He has
chronic cough and a history of
“Asthma”. He has never smoked
tobacco. He uses an “inhaler” 5 or 6
times a day to help his breathing.
Exam: Decreased breath sounds
bilaterally with increased AP diameter
of chest
CXR of Nepali patient
What is the Dx ?
What is the etiology of the process above ?
Cross Cultural Communication
Revisited
• 42 yo man recently arrived from Iraq
complains of back pain and sleeplessness
• The rest of the story…..
46 yo Somalian female for
evaluation of infertility
The rest of the story…..
Syria: the new frontier in Refugees

Situation in Syria

Response from the US and Europe
Common Health Issues to all
Refugees

Mental Health Issues (PTSD)
• Adjustment Disorders
• Physical torture, rape and family
separation

Women’s Health Issues
• Obstetrics
• Abnormal Paps
• Female Circumcision


Well Child and Immunizations
Tropical Disease and Parasites
Culturally Appropriate Care
Family Oriented Care
Training of
Translators for
Refugee
population
Resources For Further Learning

http://www.culturalorientation.net/
• http://www.culturalorientation.net/learn
ing/populations/

www.RefugeeHealthTx.org

Epidemiological Report
Global Health Initiatives at UNT

Office of Global Health Education
Contact: John.Gibson@unthsc.edu
Global Health Certificate
Certificate course through SPH
Launch : Fall 2015
Contact:
Witold.Migala@unthsc.edu
John.Gibson@unthsc.edu
Thanks for your time and may we
continue to improve our cross-cultural
communication and medical skills!