When the troubled patient from Puerto Rico arrived at Dr. Hector Flores's office, she had already been seen by three other doctors for depression. None of their treatments seemed to have had any effect. Despondent and anxious after her failed marriage, the woman was unable to work.
Although she was well educated and understood why Flores prescribed antidepressants and therapy, the patient nonetheless had a special and rather unorthodox request. She wanted Flores to talk with a healer in her community who understood sorcery. So Flores contacted the person, a "curandera," and discussed the patient's problems, including her belief that someone had put a spell on her. It was then that the curandera prescribed something Flores had never considered before.
"The curandera recommended that she take a picture of her ex-husband, put it in a cigar box -- because he liked smoking cigars -- and bury it in her backyard," says Flores, who is codirector of the Family Practice Residency Program and chair of the Department of Family Medicine at White Memorial Medical Center in Los Angeles.
Flores was convinced that the ceremony "allowed her to concretely bury the relationship." After a couple of weeks, she was visibly better, and the woman began Flores's recommended treatments. Within a few months, she was well enough to return to her job. The physician believes that the curandera's advice was crucial to his patient's recovery.
"It was remarkable," he says.
The medical divide
Flores isn't the only health care provider trying to help their patients by incorporating practices outside of standard Western medicine. Across America, many hospitals and clinics have involved traditional healers in treating immigrants and refugees from as far away as Laos, Africa, and the Middle East, and as close as Mexico and Central America. Many immigrants have brought with them religious and cultural beliefs about healing that differ from those reflected in Western medicine. In some cases, this means that patients avoid doctors completely, ignore treatments they don't understand, or show up in emergency rooms dangerously ill with preventable conditions.
To help newcomers get the care they need, many health providers are learning to navigate unfamiliar cultural terrain. Working with trained interpreters and traditional healers, who function much like "cultural brokers," doctors and nurses have learned how to talk with immigrant families about illness without breaking cultural taboos. They've also learned to recognize subtle cues that in treatment may mean the difference between life and death.
In Merced, California, for example, many members of the Hmong community from the mountains of Laos had never seen a doctor before coming to the United States. Health care providers who saw them at the local hospital were appalled at how close to death many of them were when they finally sought medical care.
"We saw ruptured appendixes, complications from diabetes, hypertension, end-stage renal disease, many more strokes and people presenting with end-stage cancers," says Marilyn Mochel, a registered nurse and diabetes educator who worked in public health in Merced for years.
Mochel and other health care providers knew that the Hmong often seek out the help of a shaman when they are ill. By working closely with Hmong community leaders, they also learned why many of the Hmong were uncomfortable with doctors and nurses who practice Western medicine.
Palee Moua, the wife of a Hmong clan leader, says that her community has a different view about how the body functions. "Hmong people believe that when they're born, that's all the blood they'll have," she says. "If they're skinny, and they get sick and the doctor wants to take a blood test, they believe they'll lose blood and are afraid they'll feel more weak and black out." To the Hmong, illness is often a sign that a spirit has been wronged, is seeking revenge, or wants to settle a favor bestowed in the past.
And although few patients would welcome the news from a doctor that they need an organ or part of their body removed, for the Hmong such an operation also has religious significance. It means that in their next life they'll be born without that organ or body part. The Hmong are also wary of surgery because they believe that the soul could wander away while they're under anesthesia.
A shaman certification program
To turn the tide, Mochel, Moua, and other community health advocates in Merced decided to teach Hmong shamans about Western medicine. Because the Hmong's distrust of Western doctors was so widespread, they also invited shamans into the local hospital so that patients would be less fearful when they were admitted.
At least 89 shamans have been educated about germs and how they are spread, and about the way Western doctors and other health care workers manage chronic conditions like diabetes, hypertension, and stroke. At a recent class on tuberculosis, shamans crowded around a microscope, exclaiming in delight at a human hair magnified thousands of times. "If this can make a hair grow as big as my finger, then I believe it could show a virus!" declares Ka Yeng Vue, a female shaman who appears to be in her early 30s.
"By offering the shaman class, at minimum we are reducing fear within the community," Mochel says. It's a beginning step, she adds, but it seems to be working. After a class on how medicine could reverse or prevent damage in someone having stroke symptoms, Mochel heard that the shamans planned to change their advice to critically ill patients.
According to Mochel, a shaman told her, "Before, we would do ceremonies and wait three days before sending the family to medical services. Now that we understand, we'll send them immediately to the emergency room."
The shaman certification program has led to more contact between doctor and shaman in patient care. "If a patient is having nightmares, hallucinations, or is screaming out, I'll get a call from the hospital," says Maxwell Moua, a retired small business owner and a graduate of the shaman training program.
"I'll go to the hospital and bring magic healing to chase the ghosts away," says Moua, who's been in the United States for 30 years. "Hmong become afraid in the hospital, because they think that because a lot of people die there, their ghosts stay there."
Respecting diverse values
Whether you're new to the United States or a longtime resident, a doctor or nurse's bedside manner can make or break trust. For health providers working with nonEnglish speakers, learning how to interpret cultural nuances and respect diverse values is a specialized skill.
In fact, reaching out to patients using a culturally sensitive approach may lessen the likelihood of emergency room visits and hospitalization, according to a recent study in the journal Chest.
Researchers developed a program to educate 198 asthma patients from a mostly Latino community in New York City about asthma triggers and how to manage the condition. After participating in the education program, which offered materials in English and Spanish, the patients were followed for a year. Researchers found that the there was a 28 percent decline in the number of times patients visited the emergency room than in the year before enrolling in the program, and they were 41 percent less likely to be hospitalized. In contrast, among another Latino asthma patients who did not take part in the education program, there was no reduction in emergency room visits. Among this group, there was only a 7 percent reduction in hospitalizations for the same period.
Another study, published in the Journal of the American Medical Association, suggests that medical schools should devote more attention to cross-cultural medicine. The overwhelming majority of medical residents surveyed -- 96 percent -- felt that addressing cultural issues was "moderately or very important" when providing care. But of those residents, 25 percent felt ill prepared to care for new immigrants or patients whose beliefs were at odds with Western medicine. "Although cross-cultural care was perceived as important, there was little clinical time allotted during residence to address cultural issues, and little training, formal evaluation, or role modeling," the JAMA report concluded. "These mixed educational messages indicate the need for significant improvement in cross-cultural education."
When health providers in San Francisco are stumped about how to help a patient from an unfamiliar cultural background, they often call up Shotsy Faust.
Faust is a family nurse practitioner and an associate clinical professor at the University of California San Francisco Medical Center. She has worked with refugees and immigrants for more than 20 years and has cared for patients at San Francisco General Hospital's Refugee Center, often the first place many immigrants get care when they come to the United States from war-torn parts of the world. Many come with a variety of poorly controlled chronic health problems, tropical diseases, and mental health problems such as post-traumatic stress disorder and depression.
Once, Faust received a call from someone at a clinic who could find no clinical reason why an Ethiopian patient was in pain.
"Often people don't say they're sad or depressed," says Faust. But after talking with her, Faust discovered the woman had suffered from domestic violence in the past. "She had escaped from Ethiopia and a family member had been killed here. She manifested those problems with chronic pain."
Admitting to depression or mental illness of any kind is taboo among Ethiopians, as it is in many cultures, according to Dr. Asefaw Woldeslassie, an Ethiopian doctor working on developing health projects through the San Franciscobased African Immigrant and Refugee Resource Center.
"You don't speak about mental illness even to people in your own family, because if you have mental illness, people won't want to marry anyone in your family. They will refuse," explains Woldeslassie. Instead of understanding that mental illness is a disease or a mood disorder, he says, Ethiopians think, "It's something spiritual, you didn't follow a taboo, or it's a punishment from God."
To avoid the shame that would come with such an association, Faust says she was careful to use different language to get the Ethiopian woman to feel at ease and talk about her problems.
"I explained to her when you have pain in life, you have pain in the body. I didn't say 'you're depressed.' I called what she had 'suffering' instead of 'depression.' "She used the same strategy to convince the woman to take antidepressants, talking to her about "relieving symptoms of sleep deprivation" that made it hard for her to get through the day.
Sticking with the treatment
Although it may be easier to treat immigrants with obvious physical symptoms, convincing them to stick with treatment is harder. When Annette Burns, a nurse practitioner at the Family Health Center at San Francisco General Hospital, saw a Vietnamese man she's known for six years, she noticed that his heart rate was too fast. Using an interpreter on a video screen, she discussed his treatment.
"Have you been taking your medication for high blood pressure?" she asks, to which he answers yes. Burns asks him how much he's taking, and he tells her one pill a day. "I asked you to take one and a half pills every day," she says, and asks to see the pill bottle. She notices that it's almost full and the prescription was filled six months ago. "The blood pressure medication is from April. It should be empty already. It makes me wonder, Does he forget sometimes?" she says to the interpreter, who communicates that to the patient. The patient apparently has been forgetting to take the medicine, but refuses Burns's request to bring a technician in the room to do an on-the-spot electrocardiogram test to check his heart, saying, "I don't need it."
"Your heart is working very hard. This medication helps your heart so it doesn't have to work so hard," Burn responds. He writes on the bottle, and Burns makes a follow-up appointment in three days. "I'll be able to see if he's taking the medication then," she tells me.
To convince a patient that he needs medicine, even when he feels just fine, Burns often uses visuals to get her point across.
"I have a favorite [picture] of a normal vessel that shows blood circulating to the kidney, brain, and heart. Then I show them that with high blood pressure, the vessel is skinnier and not as much blood is getting to the brain, kidney, and heart. Their eyes widen," explains Burns. The clincher is when she fills in the narrowed vessel to show what cholesterol does. "Then they're like, 'Oh my god,' " she says. If that doesn't work, she'll arrange for a public health nurse to visit to make sure they're taking their medicine.
Health staff who deal with the immigrant population often have to probe more deeply to discover why someone from another country isn't getting the care they need. Hali Hammer, MD, the medical director of San Francisco General Hospital's Family Health Center, recalls that her staff members were baffled and worried because Russian immigrants who needed treadmill tests emphatically refused to take them. After Russian interpreters investigated, they found out why. 'There was a famous story going around among a lot of the Russian speakers about a man doing a treadmill test who had a heart attack and immediately dropped dead."
To correct the misunderstanding, an outreach health worker gave a presentation to the community at one of the local Russian Orthodox Churches in San Francisco. According to Hammer, that helped turn things around.
Visual diagrams. Sanctioning the participation of traditional healers. Working with interpreters to find the words to earn a person's trust. Whatever the tool, many health care providers have found that collaboration is the best way to make sure that newcomers can get the health care they need.
Arthur Cantos, RN, a cardiology nurse who worked in San Francisco for 15 years, says that working with immigrants isn't just about culture. Many immigrants simply can't afford medicine or believe that common cure-alls will work even for the gravest of illnesses. He recalls one immigrant patient whose incision wasn't healing after heart surgery, and he noticed the smell of Tiger Balm whenever he entered the room. As it turned out, she had been rubbing Tiger Balm on the wound site, which led to a local infection -- something that was cured with a course of antibiotics.
Now president of Bayani Nurse Center in Manila, Cantos trains about 200 Filipino nurses a year to work in the United States. Part of their training, he says, is to learn about and appreciate patients' languages and cultures, their family values, economic background, even the food they're used to eating at home.
Whether patients "bring pictures of saints, novenas [prayers], or chanting," says Cantos, "you need to respect it."
Interview with Hector Flores, MD, co-director of the Family Practice Residency Program and chair of the Department of Family Medicine at White Memorial Medical Center in Los Angeles.
Interview with Marilyn Mochel, RN and diabetes educator in Merced.
Interview with Palee Moua, Hmong health advocate, in Merced.
Interview with Maxwell Moua, graduate of Hmong shaman training program, by phone.
Tatis, Vianessa et al. Results of a Culture-directed Asthma Intervention Program in an Inner-City Latino Community. Chest: The Cardiology and Critical Care Journal. 2005; 128: 1163-1167.
Weissman, Joel, PhD, et al. Resident Physicians' Preparedness to Provide Cross-Cultural Care. Journal of the American Medical Association, Vol. 294, No.9, September 7, 2006.
Interview with Hali Hammer, MD, medical director of the Family Health Clinic of San Francisco General Hospital in San Francisco.
Interview with Annette Burns, RN, associate professor in Family Practice at UC San Francisco.
Interview with Arthur Cantos, RN, president of Bayani Nurse Center in Manila in the Philippines.
Interview with Shotsy Faust, RN, MN, FNP, assistant clinical professor in the department of Family Health Care Nursing, who teaches courses in cross-cultural medicine.
Snowden, Lonnie R., PhD, in partnership with Social Policy Research Associates. Multicultural Health Evaluation: Toward Culturally Competent Evaluation in Health and Mental Health. The California Endowment: University of Southern California, Fall 2003.
American Academy of Family Physicians. Cross-cultural medicine.
National Center for Cultural Competence, Georgetown University. Shamans and physicians partner for improving health for Hmong refugees.
Australian Centre for International and Tropical Health, University of Queensland. Hmong: A guide for health professionals.
Healthy House. Strategic plan: goals and objectives, 2006-2008.
San Francisco Department of Public Health. Newcomers health program: programs and services.
United Nations Refugee Agency. Improving refugee health worldwide.