Cross-cultural Medicine - Europe PMC

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combination with cultural expectations, make the United States' medical system an arena where the ... cluding New York, Chicago, Los Angeles, and San Fran- .... The doctor has time to take care of patients, they call you and remind you to go.
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Between 1980 and 1990, Russian immigrants to the

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US increased by 10,000%, to a total population of around 180,000 Unlike other immigrant populations, a notable proportion (at least 10%) of Russian emigres are aged 65 years or older

Cross-cultural Medicine A Decade Later Older Russian Emigres and Medical Care MERYL BROD, PhD, and SUZANNE HEURTIN-ROBERTS, PhD, San Francisco, California

Although emigration from the former Soviet Union is dramatically increasing nationwide, little information has been reported on the medical problems of these emigres. For older emigres in particular, the medical realities of aging, in combination with cultural expectations, make the United States' medical system an arena where the stresses of emigration are expressed and help is sought. We describe the influences of culture and aging on older emigres' health and interaction with the American medical system. A qualitative, exploratory study was done of problems and issues in health care use by older Russian emigres at the ambulatory medical clinic of Mount Zion Medical Center, San Francisco. Cultural expectations and beliefs about health, adaptive health behaviors learned in the former Soviet Union, the stresses of emigration, and the medical realities of aging can result in serious problems in the care and treatment of older Russian emigres. Recommended solutions include educating emigres and health care professionals, integrating mental health services into the primary care setting, and expanding supportive services in the community such as adult day health care. (Brod M, Heurtin-Roberts S: Older Russian emigres and medical care, In Cross-cultural Medicine-A Decade Later [Special Issue]. West J Med 1992 Sep; 157:333-336)

Emigration from the former Soviet Union is increasing dramatically nationwide. From 1971 to 1991, about 181,000 Russian Jews entered the United States,' and the number is expected to continue to grow.2 In 1991 alone, 35,219 Russian Jews emigrated, representing two thirds of all Russian emigres for the year. The greatest proportion come from the former republics of Russia and the Ukraine and have relocated predominantly to major urban areas, including New York, Chicago, Los Angeles, and San Francisco, although most cities have received at least a few immigrants.I Secondary immigration patterns make it difficult to estimate accurately the number of emigres in any given location. About 20% of these emigres are older than 65 years,3 making this group one of the oldest immigrant populations. Little information has been reported on the medical problems of these emigres.4 With few exceptions, the implications of immigration for illness behavior and medical care in this population have been either ignored or referred to only tangentially. Yet, for older immigrants in particular, the medical realities of aging, in combination with cultural expectations, make the medical system a natural arena where the stresses of emigration are expressed and help is sought. The medical system often represents a primary area of interaction with American life for this large subgroup of Russian emigres. The clinic is viewed as much as a place to socialize as to obtain health care.4 Unique cultural and aging influences have direct implications for how well this interaction works. Physicians and other health care professionals are at a disadvantage in treating this population because of the lack of information about

sociocultural influences on health behavior. In this article we describe these influences and discuss the implications for older emigres' health and interactions with the medical system. Case examples are presented from an exploratory study conducted with a small sample of nursing staff (n = 2), older Russian patients (n = 8), interpreters (n = 3), and physicians (n = 3) at the ambulatory medical clinic of Mount Zion Medical Center, San Francisco, California. Patients were aged 60 or older, had been in the United States for a year or less, and were all Jews from the former Ukrainian Republic. All of the patients and interpreters identified themselves as "Russians" rather than "Soviets." The interviews were open-ended, semistructured, and standardized. Interviews with Russian patients were conducted with the help of a native Russianspeaking interpreter.

Cultural Expectations and Aging Influences Reluctant Emigre' Status The emigration policy of the former Soviet Union considered the unit of emigration to be the intact family rather than the individual.6 When younger members of a family wished to leave the Soviet Union, their aging parents were forced to leave with them if no other younger family members remained behind. As a result, older emigres have often left their homeland more "for the sake of the children" than because of a personal commitment or desire to emigrate. As one interpreter put it, "You can't leave your old mother or father behind. They must come if they want to or not." It is no wonder, then, that the older Russians were characterized by a medical resident as "genuinely sick, unhappy, displaced people."

From the Center for Clinical and Aging Services Research, San Francisco, California. Reprint requests to Meryl Brod, PhD, Director, Center for Clinical and Aging Services Research, 3330 Geary Blvd, San Francisco, CA 94118.

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Cohort Effects This group of older Jewish Russian emigres, by virtue of their life experiences, is at great risk for having depleted emotional, physical, and financial resources. Many have experienced two world wars, civil wars and political revolutions, religious persecution, Communist rule, inadequate medical care, nutritional deprivation, and economic instability.4 As Jews, they have spent their entire lives on the edge of society, in constant fear and anxiety about their well-being. For some, the basic reason for migration was rooted in antiSemitism.4 "There was insufficient medical care plus there was much suffering in our country," an interpreter explained. "There was the first war, then big starvation, World War II, then Stalin. You cannot live like that and be perfectly healthy." An older emigre couple described their experience. The wife explained first: The cause [of illness] is nervous. He [her husband] frequently visited the psychiatrist. He got depressed.. . The cause of our illness is immigration and war. After the war I got sick, very sick. I was starving. There was nothing to eat, I was very small and got ill in the stomach.

The husband then related: . nervous and depression, noI have the same problems as my wife sleeping attacks [insomnia] at night. The causes are immigration problems in the Soviet Union. We asked to leave, but they refused. We had to wait. I have a high level of sugar, but no care. We had bad conditions of living. We were upset that we were not able to leave.

The wife added: "We lost all our rights. We must stay at home, they took away everything. The cause of illness is that we suffered too much."

Cultural Disequilibrium Individual Versus Government Responsibilities In the former Soviet Union the perception of personal responsibility for providing basic necessities differed from that found in the United States. Although conditions may have been harsh and the standard of living low in the Soviet Union, basic survival did not depend on individual work and initiative to the extent that it now does for these people in the United States. All were guaranteed a minimum personal income. An interpreter commented: "They had benefits in Russia, social security, and they think they will have the same here." Soviet emigres now find themselves in a political and social system where personal initiative and responsibility are stressed. Few emigres are prepared for the economic and psychological burdens this imposes. For the first time in their lives, they must depend economically and emotionally on either themselves or other family members rather than on the government. A patient said: "Now we are here, there is no problem with food, but other problems. We do not know the language, we are deaf and dumb. We are like children." Another patient said, "In Russia, we all thought we would get jobs, plenty of jobs, we would make money like Americans. Here one month, two months, . . . a year, a year and a half go past, and still no job." Emigres are simply not prepared for the dire economic straits and dependent status in which some, especially older persons, find themselves; nor are they prepared for the implications of poverty in America. In addition, many of today's older Russian emigres were professionals in their homeland. In the United States they are unable to obtain jobs in their fields or are of retirement age. As a result, they are not able to contribute to the family income as they were accustomed to do back home.

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Russian Medical System Medical care in Russia, as well as being state run, adhered to an authoritarian and paternalistic philosophy of care, leaving little room for a free exchange of information.6 A patient noted: "In Russia, the doctor gives you medicine and you take it. No questions." Also, preventive medicine is virtually unknown. "In Russia, you don't pay attention, you don't think about your health until after you are ill [interpreter]." "In Russia, you only take medicine when you are very sick. Here they push me to take it for prevention. I agree, it's just that I'm not used to it [patient]." In addition, many emigres have a negative attitude toward the use of mental health services because a psychiatric diagnosis in Russia carried with it severe economic and social consequences ranging from loss of social status to imprisonment.7 Expectations of Health Care Physicians, nurses, and interpreters agree that emigre expectations regarding the American medical system are unrealistically high. "They come expecting as soon as they cross the border 'the doctors will make me well immediately.' There is a big legend [in Russia] about how American medicine is wonderful, so people expect miracles [interpreter]." "They think, 'Here I am in America, America's very great, a very rich country' . . . they want studies, they want a big workup [physician]." An older emigre said, "You [should] go to a doctor if you feel unhappy. In such a country as USA, they will help everyone to be happy and healthy."

Health Beliefs The interviews suggest that Russian emigres' perceptions of the causes of illness emphasize the social aspects of health and illness, in contrast to the American biomedical model. In none of the patient or interpreter interviews did respondents mention biologic causes of illness (except starvation) in response to the question, "What causes illness?" Rather, they cited macrosocial factors such as war, immigration, political difficulties, and a poor medical system. The emigres' explanations of the causes of illness reflected their experience: "I don't know why people get sick here, they should not get sick, because life is not bad here. In the Soviet Union, it is food shortages and housing." The lack of recognition of biologic influences on health or functional status does not reflect naivete concerning the causes of illness; rather, it demonstrates the Russian health care system's primary emphasis on social and environmental influences on health. In keeping with this emphasis on social causes of illness was the Russians' characterization of good care. Emigres were impressed with American medical technology, but the social and personal aspects of health care were considered fundamentally important. Patients expressed appreciation of American physicians' efforts to communicate and explain. The doctor has time to take care of patients, they call you and remind you to go. Here the doctors give more attention to the patient . . . it is all about attention here in America. . I do like how the doctors explain the problem and find just the right medicine.

Another patient described her and her husband's experience of "good care" in America. When in hospital they care for me . they helped even without English or Russian, they helped with looks and touch .. very good attention to him [husband]; they like him and he likes them and everybody is liking all people. They pay attention to him and give him hugs, very good, great.

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The psychosocial aspect of health care is of key importance to Russian emigres.

Realities of Aging A declining ability to perform activities of daily living, cognitive impairments, sensory deficits, and increased chronic illness combine to make adapting to immigrationlearning a new language and a new way of life-all the more difficult and stressful. Older Russian emigres suffer from the same illnesses that commonly affect aging people-diabetes mellitus, heart disease, and arthritis. Yet many appear to emphasize their symptoms out of proportion to disease activity at any given time.6 For example, diabetic Russian emigres report having more impaired function than either AngloAmerican or African-American diabetic patients. This impairment is above and beyond the influence of age, disease severity, or duration of illness. Russians with diabetes report substantially greater difficulties coping, perceive more pain, and report poorer overall health than the other two groups.8 As one physician said, "They seem to have general feelings of . . . unwellness, there are a lot of somatic complaints. They seem to have a great need to be sick." Another physician echoed these thoughts: Their complaints are hard to evaluate. They exaggerate comfort complaints, the small things. Chronic complaints of life are blown out of proportion, but the more life-threatening things are put off and not addressed.

Effects of Cultural and Aging Influences These cultural and aging influences have a profound effect on the illness behavior, medical status, and health care of older Russian emigres. Cohort effects-particularly a lifetime of inadequate medical care and poor nutrition, in combination with the continued stress of cultural disequilibrium, economic dependency, and reluctant emigrant status-are manifested by high levels of psychological distress and somatic complaints.5 Emigres resist using specialized mental health services, preferring to see primary care physicians for psychosocial support and assistance.7 Counseling services are not trusted by Russian emigres, and the concept of "just talking" is not culturally valued.9 In addition, contact with a physician as a high-status person helps to satisfy the needs of these people whose own status and social identity have been compromised by emigration. A patient discussed what he did when experiencing emotional difficulties: "You can talk to a relative or a friend, but you can go to a doctor as well. My cardiology doctor is the best psychiatrist, better than going to a psychiatrist. He knows me." The problem is well recognized by clinic staff. For example, a nurse explained: Usually they have simple problems that can be better taken care of by discussion, not medication. They're lonely; they need attention; they need company. There's lots of depression . they come here to talk to the doctors, to talk to us. They come here to socialize, that's what they need . not medication.

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Immigrants rely on old habits and operate under expectations that are inappropriate in a new environment. Emigres do not fit easily into the American medical system and, as misfits, are neither subtle nor quiet. They are accustomed to literally having to make noise to receive care in Russia; they have been described as pushy, manipulative, and abrasive.6 "They are nice people but 'over-everything,"' said a clinic nurse:

They overdo, they are overbearing. They had to demand more in Russia to If you ask why they want to be seen, get anything; they had to be pushy. they will say chest pain; they know it is the worst thing they can say. They know that we will have to see them. It has worked before; it will work again.

Older emigres are accustomed to living in a society of scarcity and so have become proficient in "working the system" to obtain needed services.9 These behaviors, which worked well in the Russian system, are maladaptive in America but are still used. An interpreter explained: They come from a different system full of corruption. You are supposed to have a right to care, but there is much corruption. You have to pay and bribe. We come from a rotten system, always They think it is the same here. standing in line. In Russia, you get out of line and come back because everyone is used to just standing there. They think they can come back here, and it makes people angry. .

The medical system is often the Russian emigres' primary point of interaction with American society. Emigres recognize early on that the medical system, particularly physicians, acts as a gatekeeper to a broader world of social benefits. Here privileges depend on what the doctor says, whether you have a right to

SSI, welfare, and so on. They want everything immediately in their first month so they pressure the doctor. They are scared, observed a Russian interpreter. According to a physician, [Russian emigres] tend to have very high expectations that multiple services be endlessly provided. They seem to believe there is no end to social, medical, and financial supports. They tend to feel that supportive services are necessarily linked to health care. A clinic nurse echoed this opinion: "They use the system to get what their needs are: housing, money, whatever, transportation vouchers. They use the medical system to get all their needs met." Another physician reflected on the problem: "Part of it's they're just trying to grab and become part of the system. I'm sure they feel displaced, and they're kind of lost." Again, emigres' use of the medical system is frequently viewed by health care professionals as excessive and can

inappropriate. Misunderstandings on the part of emigres about how the system works adversely affect continuity of care and further decrease quality of care. Patients consistently complained that they always saw a different physician at the clinic, and each time they had to retell their medical and social history. Physicians, too, complained about a lack of continuity in treating Rtissian emigres: They should have a primary care doc, but they're only available at certain times they need to understand how to get a primary doc and how to keep them right now they can't make the best use of the system. The jarring incongruence in expectations creates a tension that is almost palpable in many clinics serving Russian patients. Physicians feel frustrated and often helpless in treating this group, often labeling them difficult or resistant patients. As one physician commented, "I become very frustrated with what they want and what I can actually give .

Unfortunately, emigres' negative attitudes toward mental health services prevent them from seeking appropriate mental health care. Rather, they seek "a cure" from their physician, who is often ill equipped to deal with emotional problems or simply does not have enough time. Real problems of depression and demoralization are not addressed, and the emigrant returns again and again in hopes of feeling better. The result is excessive and inappropriate use of medical services.

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Along with being frustrated, physicians are concemed

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that the care they are providing is inadequate due to language problems, inadequate information on and preparation for treating the Russians, and the emigres' inadequate understanding of the American medical system. We need education, we weren't really told anything about treating Russians now I just sort of limp through day by day. or what happened in Russia . often it's like veterinary medicine You learn by practice, trial and error . there's a lot of guessing,

complained a medical resident. Another physician admitted: Treating the Russians is scary. You can't know what you need to know in the time given. I worry about missing things . I think I'm getting a sqnse of how to make that leap of judgment, but I'm not very comfortable with it.

Another physician summed up the worries and concerns American physicians have in treating Russian emigres: Their problems are psychosocial. We need some kind of support . there's just nothing for them. And we need education as to what is their baseline. . What is health care like in Russia? What was their health before? How can you tell what's really a depression in a Russian and what's not? How do you deal with it? What do they want? What are they used to?

A vicious cycle is set into motion between patients who feel the medical system is unresponsive to their needs and physicians who feel they are forced to deal with difficult patients. The physician-patient relationship suffers, and, as a result, the quality of care is diminished. Ironically, the Russians interviewed felt they were getting good care. They claimed to be thoroughly satisfied with their experiences, and the interviewer had to press them to say anything negative at all about their health care. When pressed, they admitted they did not like the occasional long waits in clinics or business offices and were unhappy that they had to speak to their physicians through interpreters. Otherwise, "they never complain about the doctor or quality of health care, just the mechanics of the system," observed a Russian interpreter. Emigres spoke in consistently positive terms about the care they had received. "I am satisfied, yes, yes, the doctors are good, the service is good, everything is good." One must wonder whether this emphatic statement of satisfaction with care could be the result of fear and a mistrust of criticizing bureaucracy or of speaking too freely about dissatisfactions. Health Status Implications It is widely recognized that cultural health beliefs influence health behavior. 10 The emigres' social explanations for illness, reduced perceptions of personal responsibility for health care and impaired functional status, and lack of appreciation of preventive health care have adverse implications for their ability to learn self-management. Emigres often do not understand the rationale for or perceive a need to engage in self-management of their illnesses. Because these behaviors are vital to the control of many chronic illnesses for which older persons are at increased risk, older Russian emigres are at greater risk for complications from diseases such as diabetes mellitus, cardiovascular disease, and hypertension. Impaired functional status in older Russian emigres, particularly increased perception of pain, also has major implications for both the quality and the quantity of patient interactions with the medical system. Pain is one of the most frequent reasons why older persons in general seek medical care. Pain causes health-related problems such as physical limitations,"-"3 mental health problems,'4 social limitaI2 and sleep disorders,11 all of which may lead to an tions,"' increased use of health care services and higher costs. 13 One

nurse said, "They magnify normal aches and pains but then aren't concerned about what the tests find because that is not what they think is important." To the extent that these problems are related to the pain, the recognition of pain and painrelated problems by health care professionals is essential to adequate care. Greater perceived pain may account for some of the reported overuse of services by older Russian immigrants.4

Conclusion To address the conflict in the interaction between older Russian emigres and the US medical system, the dynamic relationship between sociocultural and aging influences must be understood and appreciated. Behaviors learned during a lifetime spent in a different cultural and political reality are ingrained. For American health care professionals, these behaviors may be difficult to understand or respect. The solution begins with education for both emigres and physicians. The emigres must be taught how the American system works and its underlying philosophy. Physicians must be educated about the cultural influences that have shaped the behavior and attitudes of the emigres. Reshaping the system to integrate mental health services into the primary medical care setting would address the Russian reluctance to seek mental health services outside of the medical system. In addition, programs such as adult day health care and senior day care programs can be targeted to older Russian emigres to provide a setting in which social support, health services, and acculturation can occur. The experience of L'Chaim, the Russian Adult Day Program of the San Francisco Institute on Aging, has been promising in this regard. Decreased levels of depression and somatic complaints and fewer requests for medical care by emigres have been reported after participation in that program. 5 The plight of older Russian emigres is simply expressed by an elderly Russian woman: "In Soviet Union, medicine is different. It is difficult to change." REFERENCES 1. Hebrew Immigrant Aid Society (HIAS): Report of Annual Statistics, 19791991. New York, NY, HIAS, 1991 2. Gold S: Soviet Jews in the United States. Zellerbach Report-New Faces of Liberty. San Francisco, Calif, San Francisco Study Center, 1990, pp 1-17 3. Office of Refugee Resettlement: Report to Congress. Washington, DC, Refugee Resettlement Program, 1982 4. Kohn R, Flaherty JA, Levav 1: Somatic symptoms among older Soviet immigrants: An exploratory study. Int J Soc Psychiatry 1989; 35:350-360 5. Jacobs D, Paul E (Eds): Studies of the Third Wave: Recent Migration of Soviet Jews to the United States. Boulder, Colo, Westview Press, 1981 6. Wheat ME, Brownstein H, Kvitash V Aspects of medical care of Soviet Jewish emigres, In Cross-cultural Medicine [Special Issue]. West J Med 1983; 139:900-904

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7. Brodsky B: Mental health attitudes and practices of Soviet Jewish immigrants. Health Soc Work 1988; 13:130-136 8. Brod M, Stewart A, Zegger R: Translating Diabetic Medical Status into Functional Outcomes in Three Ethnic Groups [Abstri. Proceedings of the Gerontological Society of America Annual Meeting 1991; 31:287 9. Sloane P: Experiences and expectations of govemment services: The older Soviet immigrant. J Cross-cult Gerontol 1991; 6:193-197 10. Kleinman A: Patients and Healers in the Context of Culture. Berkeley, Calif, University of Califomia Press, 1980 1 1. Roy R, Michael T: A survey of chronic pain in an elderly population. Can Fam Physician 1986; 32:513-516 12. Ferrell BA, Ferrell BR, Osterweil D: Pain in the nursing home. J Am Geriatr Soc 1990; 38:409-414 13. Lavsky-Shulan M, Wallace RB, Kohout FJ, Lemke JH, Morris MC, Smith IM: Prevalence and functional correlates of low back pain in the elderly: The Iowa 65 + Rural Health Study. J Am Geriatr Soc 1985; 33:23-28 14. Dworkin SF, Von Korff M, LeResche L: Multiple pain and psychiatric disturbance-An epidemiologic investigation. Arch Gen Psychiatry 1990; 47:239-244 15. Brod M: Elderly Russian Emigres: An At-Risk Population. Presented at the National Conference on Health and Mental Health of Soviet Refugees, Chicago, Ill, December 1991