Culturally Competent Teaching

RespectingRespecting Differences,Differences, CelebratingCelebrating DiversityDiversity Understanding and Working with Health Care Clients and Students from Other Cultures

Kern Resource Center 5801 Sundale Avenue Bakersfield, CA 93309 (661) 827-3266 (661) 827-3304 (fax) www.health-careers.org

October 2005 ○○○○○○○○

2 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

This project is supported by Carl D. Perkins Vocational Education Act of 1998 funds (Title 1, Part A, Section 112), P.L. 105-332, administered by the California Department of Education. The activity which is the subject of this handbook is supported in whole or in part by the U.S. Department of Education and the California Department of Education. However, the opinions expressed herein do not necessarily reflect the position of either the U.S. Department of Education or the California Department of Education, and no official endorsement by the U.S. Department of Education or the California Department of Education should be inferred. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 3

Contents Basic Information Introduction ______7 Immigration Facts ______7 Legal Status ______8 Countries of Origin ______8 English Language Proficiency ______9 Refugees ______9

Working with Health Care Clients from Other Cultures ______10 Clients Who Speak Little or No English ______10 Culturally Competent Health Care ______12 Suggestions for Culturally Competent Patient Interaction ______14 Cultural Concerns in Caring for the Dying Patient ______17 Working with Latino/Hispanic Clients ______17 Working with Asian Clients ______19 Working with Middle-Eastern Clients ______20 Religion and Health Care ______21 Buddhism ______22 Islam ______22 Confucianism ______23 Taoism ______23 Complementary and Alternative Medicine ______25

Working with Students ______26 Immigrants and English Language Learners in California Schools ______26 Latinos in California High Schools ______27 What’s in a Name? ______27 Culturally Competent Teaching ______28 Conclusion ______32 References and Resources ______33 Countries of Origin for California’s Largest Immigrant Groups Latin America Mexico ______39 El Salvador ______49 Guatemala ______57 Eastern Asia China ______67 South Korea ______79 Japan ______ 87 ○○○○○○○○

4 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Contents, cont.

Southeast Asia Philippines ______99 Vietnam ______107 Laos ______115 Thailand ______125 Cambodia ______133 Other Countries India ______145 Iran ______153 Armenia ______163 Russia ______169

Basic Information Introduction Immigration Facts Working with Health Care Clients from Other Cultures Religion and Health Care Complementary and Alternative Medicine Working with Students Conclusion ○○○○○○○○○○○○○○○○○○○○○○○○ 6 ○○○○○ Respecting Differences, Celebrating Diversity:

Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 7 Introduction Virtually every health care professional and educator in California encounters immigrants Virtually every health care as a regular part of the day’s work. Whether these interactions are positive or negative, professional and educa- satisfying or frustrating, depends at least in part on the knowledge and understanding the tor in California encounters immigrants as a regu- health care professional or educator brings to the encounter. We all have good days and bad lar part of the day’s work. days in which we meet the full range of clients and students, but even on the worst of days Whether these interac- with the most recalcitrant client or unresponsive student, understanding where that client tions are positive or nega- or student is coming from will almost always contribute to a positive outcome. tive, satisfying or frustrat- This handbook provides basic information about the countries from which California’s ing, depends at least in largest immigrant groups come. As of the 2000 census, Hispanics—both immigrants and part on the knowledge California-born—made up 32 percent of our state’s population, with the majority of new and understanding the immigrants coming from Mexico. According to the 2003 American Community Survey, health care professional nearly 10 million California residents have Mexican heritage. Together with Asians and or educator brings to the encounter. other groups, the various minority Californians combine to outnumber white residents. With the nation’s largest immigrant population, California is a microcosm of what the entire United States is projected to look like in 2050, when Hispanics are expected to make up nearly one-fourth of the nation’s residents and Asians close to 10 percent. In 2002, the population of Los Angeles was 44 percent Latino and 12 percent Asian, and more than 100 languages were spoken by students in the city’s schools. Health care professionals and educators need to equip themselves with information that will help them meet the challenge of working with immigrants, non-English speakers, and English language learners competently and compassionately. Rather than viewing immigrant clients and students as problems, with increased knowledge we may come to appreciate the contributions they make to our nation—which is, after all, made up almost entirely of immigrants. The Center for Religion and Civic Culture at the University of Southern California observed, in a recent report on immigrants in Los Angeles, that these new arrivals have much to share: “Anchored in community, immigrants know something about extended family ties, the value of community, and the importance of preserving a cultural heritage while contributing to the new society.” Immigration Facts In 2004, the foreign-born in the United States, some 34.2 million people, accounted for 12 percent of our total population. Fifty-three percent of the immigrant population was born Much of the United States at some time belonged to in Latin America, 25 percent in Asia, 14 percent in Europe, and 8 percent in other regions. other nations, most nota- U.S. citizens are some of the most fortunate people in the world. Except for Native bly Mexico, which for Americans, we all are the descendants of immigrants, a fact that we tend to overlook in our centuries counted Califor- dealings with more recent arrivals to our nation and state. Much of the United States at nia and other Western some time belonged to other nations, most notably Mexico, which for centuries counted states as part of its terri- California and other Western states as part of its territory. The fact that we live in the richest tory. and most powerful nation in the world should not blind us to the fact that our position is a matter of good fortune rather than divine favor. To get an idea of the lure of the United States, we might imagine ourselves as citizens of a nation ravaged by civil war, earthquakes, famine, tsunamis, multinational corporations— alone or in combination—who live in shanties on land we do not own, with no reliable ○○○○○○○○○○○○○○○○○○○○○○○○ 8 ○○○○○ Respecting Differences, Celebrating Diversity:

source of water, no hope of employment, no access to medical care. This is the reality of life for millions of the world’s people, and we should not be surprised that many will risk death for the chance to make a better life for themselves and their families in this country. Legal Status Immigrants are differentiated between those who have become U.S. citizens and those who Non-citizens fall into one of four major legal status remain non-citizens. U.S. citizens are classified as native-born or naturalized. According to groups: legal permanent the Urban Institute, more than half of all legal immigrants to the United States eventually residents, refugees, tem- become naturalized citizens. Non-citizens fall into one of four major legal status groups: porary residents, and un- ➊ Legal Permanent Residents. These individuals have permanent visas or “green cards.” documented immigrants. Most achieve their status as a result of family reunification laws allowing citizens and legal permanent residents to apply for permission for spouses, parents, siblings, and children to immigrate. Others are admitted when employers apply for visas for them. After five years as a legalized permanent resident (three years if married to a U.S. citizen), an individual may apply for citizenship. ➋ Refugees/Asylees. These are people admitted for humanitarian reasons, generally fleeing war or persecution in their native countries. They are screened by the U.S. Department of State and international organizations before admission. Once in the United States, refugees are usually resettled by family members or resettlement organizations. Unlike most other immigrants, refugees are eligible for a variety of federal social services. Individuals fleeing persecution who arrive in the United States without approval can apply for asylum. ➌ Temporary Residents. Most of these individuals have visas for temporary employment or education. ➍ Undocumented Immigrants. These immigrants have no authorization to be living or working in the United States. Most estimates show the population of undocumented immigrants doubling from 4 million to more than 8 million during the 1990s. Immigrants move freely between these four groups as their circumstances change. In 2000, between 10 and 11 million foreign-born in the United States were naturalized citizens; the same number were legal permanent residents; some 8.4 million were undocumented immi- Census 2000 identified grants; 2.5 million had arrived as refugees after 1980; and about 1.5 million were temporary more than 100 countries residents. The Urban Institute estimates that each year during the decade of the 1990s the as home to the nation’s following numbers of immigrants entered the United States: foreign-born population. ■ In a survey conducted by Legal Residents: 700,000 to 900,000 ■ Refugees/Asylees: 70,000 to 125,000 the Urban Institute in ■ Undocumented Immigrants: 300,000 to 500,000+ 1999–2000, immigrant A study by the Pew Hispanic Center released in June 2005 estimated the total of un- families in Los Angeles documented immigrants now in the United States at 10.3 million, about a third of the County, home to one of the nation’s most diverse foreign-born population. communities, were found to have come from Countries of Origin 75 different countries. Census 2000 identified more than 100 countries as home to the nation’s foreign-born population. In a survey conducted by the Urban Institute in 1999–2000, immigrant families in Los Angeles County, home to one of the nation’s most diverse communities, were found to have come from 75 different countries. While new immigrants continue to settle in Califor- nia, Florida, New York, and Texas, traditionally the destination of the largest numbers, the 2000 census showed states in the Midwest, South, Northeast, and Pacific Northwest among those with the fastest-growing immigrant populations. Some 22 states that had relatively Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 9 low immigrant populations in 1990 saw those numbers grow by over 90 percent by the 2000 In the 2003 American census. California remained the principal first destination for immgrants, but as housing Community Survey, prices continue to rise and living in California becomes increasingly expensive, more immi- seven California cities grants will settle elsewhere. In the 2003 American Community Survey, seven California and five California coun- cities and five California counties were in the top ten cities and counties for foreign-born ties were in the top ten population. cities and counties for for- Countries/regions of origin for the foreign-born identified in the 2000 census are: eign-born population. ■ Mexico: 9.2 million, 30 percent ■ Asia: 8.2 million, 26 percent ■ Other Latin America: 6.9 million, 22 percent ■ Europe and Canada: 5.7 million, 18 percent ■ Africa and Other: 1 million, 3 percent English Language Proficiency Census 2000 showed that 47 million U.S. residents, or 18 percent of the population age 5 “Food insecurity and and older, speak a language other than English at home, with 40 languages listed. Some 28 other hardship measures million of these speak Spanish. The fact that most of these people have limited proficiency were more closely asso- in English poses a significant challenge to their integration into U.S. life. Those with lim- ciated with limited En- glish proficiency than ited English proficiency tend to have less desirable jobs, earn lower wages, and experience with either legal status or hunger. An Urban Institute report states: “Food insecurity and other hardship measures length of residency in the were more closely associated with limited English proficiency than with either legal status United States.” or length of residency in the United States.” The Urban Institute As immigrants live longer in the United States, their language proficiency generally increases. Some 44 percent of all foreign-born residents counted in the 2000 census were limited English proficient. About 10 percent of all U.S. public school students are English language learners (ELLs); their numbers have doubled to more than 2 million since 1990. In California, the 2003 American Community Survey identified 40.8 percent of the population over age 5 who spoke a language other than English at home. Nearly 1.5 million California students were classified as English language learners in 2002. Refugees Between 1975 and 2000, the United States admitted 2,284,956 refugees, with the largest Between 1975 and 2000, number coming from Asia. Before arriving in the United States, many refugees have spent the United States admit- time as refugees in an intermediary country. Large numbers of Hmong, for example, have ted 2,284,956 refugees, spent long periods of time in refugee camps in Thailand before settling in California or with the largest number other states. Both between resettled groups and within groups there is great diversity, de- coming from Asia. pending upon the status and experience of the individuals prior to fleeing their native land and/or being resettled from a refugee camp. In the case of resettlement, refugees generally receive health screenings and orientation to U.S. life prior to their arrival. The Justice De- partment conducts interviews to establish that they are indeed in danger if they return to their native country. Voluntary agencies, working with State Department contracts, facilitate the resettlement process and provide for or arrange housing, medical care, job training, school enrollment, and other social services for a limited time. Some of the best information on refugee health issues has been compiled by Charles Kemp and is found on the Baylor University Web site: http://www3.baylor.edu/ ~Charles_Kemp/refugee_health_problems.htm. Kemp notes that refugees first come into ○○○○○○○○○○○○○○○○○○○○○○○○ 10 ○○○○○ Respecting Differences, Celebrating Diversity:

the health care system through local health departments, where they undergo a screening called the Refugee Domestic Health Assessment to eliminate health-related barriers to successful adaptation to the new culture. Refugees are screened for TB and other communicable diseases. Often, only TB and sexually transmitted diseases are treated in the health department, with other conditions being referred more or less successfully to the primary care sector. Caseworkers or previously settled family members assist new refugees in navigating the health care system, but this is not always a flawless process.

From seemingly small matters, such as a Working with Health Care Clients patient’s preference for water without ice, to life- from Other Cultures and-death situations in- Putting oneself into another person’s shoes is a difficult task. California health care profes- volving the reporting of sionals at all levels must be able to do that in order to provide culturally competent care to symptoms or directions the immigrant patients and families with whom they interact every working day. From for medication use, the seemingly small matters, such as a patient’s preference for water without ice, to life-and- inability of health care death situations involving the reporting of symptoms or directions for medication use, the providers to understand inability of health care providers to understand the language and culture of clients is a the language and culture barrier to giving and receiving appropriate care. of clients is a barrier to An article in the journal Academic Medicine states: “Without understanding the funda- giving and receiving appropriate care. mental nature of culture and the integrity of differing belief systems, the risk of conflict and its negative impact on health outcomes is inevitable.” Researchers from UCLA studying clinical trials for psychiatric drugs recently found that only 8 percent of more than 9,000 patients studied were minorities, even though the importance of cultural factors in the treatment of mental disorders has been well documented in medical journals. A psychiatrist at Columbia University stated: “If we understand that our definition of pathological isn’t pathological in other countries, we can make better decisions on when to treat, especially with medications.” The Web site Diversity Rx, discussing the importance of language and culture, puts the matter in a nutshell: All health care personnel should learn to regard the patient and his or her family as unique and aim to develop skills to assess the role of culture in any given situation. For professionals in the health care setting, awareness of personal biases is a prerequisite for cross-cultural competence. The competent professional cultivates a non-judgmental attitude of respect, Nearly 50 million people interest, and inquiry. From this viewpoint, the cross-cultural encounter is approached as an in the United States speak opportunity for learning and growth. a language other than English as their primary Clients Who Speak Little or No English language; in California, Nearly 50 million people in the United States speak a language other than English as their 20 percent of the popu- primary language; in California, 20 percent of the population has limited English ability. A lation has limited En- 2002 study by The Commonwealth Fund reported that many patients have difficulty un- glish ability. derstanding health care information, with more than 50 percent of both Hispanic and Asian American patients reporting difficulty. The report of a 2003 dialogue among health care professionals in San Francisco opened by stating: “Even for those who are fluent in English and acculturated to the American medical system, the complexity of information coupled with the emotion and anxiety of illness creates substantial opportunities for miscommunication.” Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 11

In a 2003 survey of California immigrants conducted in 11 languages and dialects, In a 2003 survey of Cali- researchers found that half of all immigrants who do not speak English reported problems fornia immigrants con- understanding medical information. More than half of the Hispanics, Hmong, and Iranians ducted in 11 languages surveyed reported being confused by post-hospitalization instructions, and one-third of all and dialects, researchers immigrants have trouble understanding prescription drug labels, which some cannot even found that half of all immigrants who do not read. Throughout the United States, refugees and immigrants who speak no English or speak English reported have limited English proficiency pose challenges to health care providers. problems understanding The Office of Civil Rights of the Department of Health and Human Services in 2000 medical information. issued guidelines requiring that recipients of federal funds provide oral interpreter services, More than half of the His- translated written materials, a means to make services accessible to non-English speakers, panics, Hmong, and Ira- and staff training. Even though Title VI of the Civil Rights Act of 1964 and the Joint nians surveyed reported Commission on the Accreditation of Healthcare Organizations also require health care being confused by post- insitutions to provide translation services, many health care providers will find themselves hospitalization instruc- in situations where they must cope on their own. When translators or interpreters are avail- tions, and one-third of all immigrants have trouble able, an interpreter is preferable because he/she is professionally trained to interpret the understanding prescrip- meaning of words and phrases between health care provider and client. As Dr. Alice Chen tion drug labels, which of Language Access, a service of New California Media in San Francisco, explains: some cannot even read. Not just any bilingual person can be an effective medical interpreter. Children, family members, and friends usually aren’t familiar with specialized medical terminology in their own languages let alone in English. Nor have they been trained to develop the memory and communication skills needed to interpret accurately and efficiently. They make mistakes that can have serious and sometimes dangerous consequences.

The Office of Minority Health of the U.S. Department of Health and Human Services published 14 standards for culturally and linguistically appropriate services (CLAS) in health care in December 2000. The standards encourage, but do not require, health care organizations to ensure that patients receive understandable and respectful care consistent with their When a community advo- preferred language and health beliefs and practices. cacy organization tested When a community advocacy organization tested hospitals in 2003 for compliance hospitals in 2003 for with federal and state laws requiring that they provide access to services for those with compliance with federal limited English proficiency, in more than half of the 70 hospitals surveyed by phone and and state laws requiring personal visit no Spanish-speaking staff person could be contacted. In the Bay Area, 60 that they provide access percent of the hospitals surveyed were able to access a Spanish speaker; in the Los Angeles to services for those with area, the figure was 56 percent. In a state where Hispanics make up 32 percent of the limited English profi- population, this is surely a cause for concern. ciency, in more than half of the 70 hospitals sur- The National Alliance for Hispanic Health has excellent resources for working with veyed by phone and per- Spanish-speaking patients and clients. In A Primer for Cultural Proficiency: Towards Quality sonal visit no Spanish- Health Services for Hispanics, the organization discusses six approaches to overcoming lan- speaking staff person guage barriers, organized from the most effective to the least effective method: could be contacted. ➊ bilingual/bicultural professional staff ➋ interpreters (never from non-health care staff ) ➌ language skills training for existing staff ➍ internal language banks (back-up measure only) ➎ phone-based interpreter services (emergency back-up) ➏ written translation (never use as only means of communication) Printed patient education materials are available in many languages on a wide variety of topics from a number of Internet sources; some of these are listed in the Resources section. ○○○○○○○○○○○○○○○○○○○○○○○○ 12 ○○○○○ Respecting Differences, Celebrating Diversity:

The use of printed patient The use of printed materials assumes that the patient or some family member or friend is education materials as- literate in the native language, which is not always a safe assumption. Appropriate transla- sumes that the patient tion from English to other languages is complicated by cultural nuances—both between the or some family member health care provider’s culture and the culture in which the translated materials are to be or friend is literate in used, lack of equivalent terms in other languages, and selecting an appropriate reading level the native language, that is neither too simple for clients with good reading skills nor too complicated for the less which is not always a literate. safe assumption. Habel, in an on-line education module for nurses, suggests the following means of communication for those providing patient education in situations where the patient does not speak English: ■ Use pictures, models, and demonstrations with actual equipment. ■ Use simulations to show what is being taught. ■ Use audiotapes made in the patient’s language. ■ After giving the information, test the patient’s understanding by asking him/her to communicate in some way what he/she is supposed to do.

In many cultures, a fam- In most cases family members or friends should be included in the patient teaching. In ily member other than many cultures, a family member other than the client is the primary decision-maker; that the client is the primary person will be largely responsible for the patient’s understanding of and compliance with decision-maker; that per- treatment directions. son will be largely re- Many helpful resources are available through state and county health departments, sponsible for the which often have patient education materials available in languages spoken by significant patient’s understanding percentages of their clients. The California Health Department Web site offers excellent of and compliance with patient education materials in languages spoken by the state’s citizens. Their guide to breast treatment directions. cancer diagnosis and treatment, for example, can be downloaded in Chinese, Korean, Span- ish, Russian, and Thai in addition to English. The California Healthcare Interpreting As- sociation provides a brochure about the role of interpreters in Spanish, Hmong, Chinese, Korean, and Russian. The California Primary Care Association, established in 1994 to help ensure that the state’s low-income and minority residents receive high-quality health care, recently published an excellent manual for health care providers working with limited English proficient patients. It includes a wealth of information and promising practices drawn from California Major challenges include the scarcity of capable in- community clinics and health centers in rural and urban settings serving Asian and Span- terpreters proficient in ish-speaking clients, as well as materials that can be used with clients. The manual addresses medical terminology, the the major challenges health care providers face in serving their clients: the scarcity of ca- shortage of bilingual pable interpreters proficient in medical terminology, the shortage of bilingual staff, and staff, and cultural norms cultural norms that conflict with Western medicine. that conflict with Western This handbook includes some useful words and phrases in the individual country pro- medicine. files. Handbooks for working with clients who speak Spanish or Punjabi can be downloaded from www.health-careers.org. Culturally Competent Health Care The success of provider-client interactions is influenced significantly by the patient’s cultural and language background and by the ability of the provider to understand, appreciate, and take into account that background. It is only natural that every individual grows up believing that his or her culture is, if not the only one, certainly the best—an ethnocentric point of view. DiversityRx cautions: “All health care personnel should learn to regard the Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 13 patient and his or her family as unique and aim to develop skills to assess the role of culture in any given situation.” Kagawa-Singer and Kassim-Lakha state:

The objective of health practitioners is to improve health outcomes and increase the quality of life for each individual patient. . . . When we understand that the purpose of every culture is to ensure the individual’s survival and well-being, the stage is set to negotiate with patients Cultural competence in and their families among a wider set of options. health care may be considered ‘the ability of sys- Cultural competence is being widely discussed these days. The Internet provides many tems to provide care to excellent resources, in addition to the language resources mentioned above, to help health patients with diverse val- care professionals understand and work effectively with clients from other cultures (see Re- ues, beliefs and behav- sources). Cultural competence in health care may be considered “the ability of systems to iors, including tailoring provide care to patients with diverse values, beliefs and behaviors, including tailoring deliv- delivery to meet patients’ ery to meet patients’ social, cultural, and linguistic needs” (Betancourt et al. 2002). The social, cultural, and lin- University of Michigan Health System Web site, which offers comprehensive materials for guistic needs.’ Betancourt et al. health care providers, suggests that culturally competent health care: ➊ makes more effective use of time with patients ➋ increases disclosure of patient information ➌ helps with negotiating differences ➍ increases patient compliance in treatment protocols ➎ positively affects clinical outcomes ➏ improves communication with patients ➐ decreases stress ➑ builds trust in a relationship ➒ increases patient satisfaction ➓ meets increasingly stringent government regulations and medical accreditation The health care practitio- requirements ner who takes the time to Camphina-Bacote advises health care providers to seek common ground with clients by learn about the beliefs using the LEARN Model (Berlin and Fowkes, 1982) of listening, explaining, acknowledg- and practices of another ing, recommending, and negotiating. She and others make the important point that there is culture must remember to take into account the more variation within any specific culture than between two different cultural groups. The perspective and experi- health care practitioner who takes the time to learn about the beliefs and practices of an- ence of each individual other culture must remember to take into account the perspective and experience of each client from that culture. individual client from that culture. Camphina-Bacote cautions: Interacting with patients from diverse cultural groups will refine or modify one’s existing beliefs about a cultural group and will prevent stereotyping. However, the [health care professional] must be cautious and recognize that interacting with only three or four members from a specific ethnic group does not make one an expert on the cultural group. . . . [T]hese three or four individuals . . . may not truly represent the stated beliefs, values, and/or prac- Our traditional Western tices of their specific cultural group. worldview places primary Jezewski and Sotnik suggest that health care providers working with individuals from value on individualism, in other cultures need both knowledge of the specific culture of the persons with whom they contrast to the worldview are working and knowledge about the basics of working with clients from any culture other of many cultures in which the individual is less im- than that of the service provider. They draw attention to the importance of understanding portant than the family the client’s worldview—fundamental beliefs about existence that form the basis of an and community. individual’s approach to life, including health care. Our traditional Western worldview places primary value on individualism—self-expression, assertiveness, etc.—in contrast to the worldview of many cultures in which the individual is less important than the family and community. ○○○○○○○○○○○○○○○○○○○○○○○○ 14 ○○○○○ Respecting Differences, Celebrating Diversity:

Elements of worldview These two differing worldviews make for very different approaches to and expectations that enter into a client’s of health care. Individual clients from other cultures will have adopted aspects of the West- expectations of and re- ern worldview, or become acculturated, based on such factors as length of residence in the ceptivity to the health United States, language ability, nature and extent of interactions with people in this country, care interaction include: and the strength of their identification with their culture of origin. attitude toward age, con- Rankin and Stallings discuss ways in which to assess the client’s degree of what they cept of fate, attitude to- call “cultural embeddedness” by considering the following: ward change, concept of ■ saving face, source of How recently did the patient immigrate? ■ Was the immigration voluntary or involuntary? self-esteem, concept of ■ Did the patient live in intermediate countries before coming to the United States? equality, concept of time, ■ What country did the patient immigrate from and how different is that culture from and attitudes about non- U.S. culture? verbal behavior. ■ Whom does the patient associate with? ■ What type of neighborhood does the patient live in? ■ Does the patient follow traditional dietary habits? ■ Does the patient wear native dress? ■ Does the patient leave his/her neighborhood to participate in the larger culture? ■ Does the patient use folk medicine or use the practices of a native healer? ■ Does the patient come from an urban or rural area in the native country? Elements of worldview that enter into a client’s expectations of and receptivity to the health care interaction include: attitude toward age, concept of fate, attitude toward change, concept of saving face, source of self-esteem, concept of equality, concept of time, and attitudes about nonverbal behavior such as eye contact, shaking hands, etc. See the chart on the facing page for a comparison of cultural norms and values.

Suggestions for Culturally Competent Patient Interaction The University of Michigan Health System suggests using the following questions to help lay the foundation for an effective relationship with a patient from another culture: ➊ Can you tell me what languages are spoken in your home and the languages that you understand and speak? ➋ Please describe your usual diet. Also, are there times during the year when you change your diet in celebration of religious or ethnic holidays? ➌ Can you tell me about beliefs and practices including special events such as birth, marriage, and death that you feel I should know? ➍ Can you tell me about your experiences with health care providers in your native country? How often each year did you see a health care provider before you arrived in the U.S.? Have you noticed any differences between the type of care you received in your native country and the type you receive here? If yes, could you tell me about those differences? ➎ Is there anything else you would like to know? Do you have any questions for me? (Encourage two-way communication.) ➏ Do you use any traditional health remedies to improve your health? ➐ Is there someone, in addition to yourself, with whom you want us to discuss your medical condition? ➑ Are there certain health care procedures and tests which your culture prohibits? ➒ Are there any other cultural considerations I should know about to serve your health needs? Diversity Resources provides the following tips for working effectively with patients from other cultures: ■ Everyone likes to feel special. Check your records. What cultural groups did you serve last month? Decide to learn a little about one of those cultures every week. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 15

Comparing Cultural Norms and Values Aspects of Culture U.S. Culture Some Other Cultures ◗ informal ◗ formal Sense of Self and Space ◗ handshake ◗ hugs, bows, handshakes

◗ explicit, direct communication ◗ Communication and implicit, indirect communication ◗ emphasis on content; meaning found ◗ emphasis on context; meaning found Language in words around words

◗ “dress for success” ideal ◗ dress seen as a sign of position, Dress and Appearance ◗ wide range of accepted dress wealth, prestige ◗ more casual ◗ religious rules ◗ more formal

◗ ◗ Food and Eating Habits eating as a necessity; fast food dining as a social experience ◗ religious rules

Time and Time ◗ linear and exact time consciousness ◗ elastic and relative time consciousness ◗ ◗ Consciousness value on promptness time spent on enjoyment of ◗ time=money relationships

◗ focus on nuclear family ◗ focus on extended family Relationship, Family, ◗ responsibility for self ◗ loyalty and responsibility to family Friends ◗ value on youth; age seen as handicap ◗ age given status and respect

◗ individual orientation ◗ group orientation ◗ independence ◗ conformity Values and Norms ◗ preference for direct confrontation of ◗ preference for harmony conflict ◗ emphasis on relationships ◗ emphasis on task

◗ egalitarian ◗ hierarchical ◗ challenging of authority ◗ respect for authority and social order ◗ ◗ Beliefs and Attitudes gender equity different roles for men and women ◗ behavior and action affect and ◗ fate controls and predetermines the determine the future future

◗ linear, logical ◗ lateral, holistic, simultaneous Mental Processes and ◗ problem-solving focus ◗ accepting of life’s difficulties Learning Style ◗ internal locus of control ◗ external locus of control ◗ individuals control their destiny ◗ individuals accept their destiny

◗ rewards based on individual ◗ rewards based on seniority, Work Habits and Practices achievement relationships ◗ work has intrinsic value ◗ work is a necessity of life

Source: Lee Gardenswarthz and Anita Rowe: Managing Diversity: A Complete Desk Reference and Planning Guide. Burr Ridge, Ill.: Iwrin, 1993). p. 57. Found at http://www.med.umich.edu/multicultural/ccp/tools.htm ○○○○○○○○○○○○○○○○○○○○○○○○ 16 ○○○○○ Respecting Differences, Celebrating Diversity:

In some cultures, it’s con- Hint: Start with the calendar. Are there any festivals or holidays that your patients sidered rude to smile at will observe this month? Ask the first patient you see from each cultural group if there is any specific greeting that is used for that occasion. Write it down and learn strangers and impolite to to say it in the patient’s language. Even if you mispronounce it, the patient will be look directly at anyone really pleased with your effort. who is older or in a posi- ■ When speaking to patients who are not proficient in English, avoid too much “small tion of authority. talk.” Keep your language simple and not cluttered with extraneous questions or information. Hint: “Friendly chatter” is not considered friendly in many cultures even if the person does understand you. It may be considered inappropriate to disclose personal information about yourself or “prying” to ask people about their job or their family. ■ Smile and look at the patient when greeting him or her, but don’t feel offended if the patient doesn’t smile back or establish eye contact. Hint: In some cultures, it’s considered rude to smile at strangers and impolite to look directly at anyone who is older or in a position of authority. ■ When taking patient information, use questions that begin with when, where, why, who, which, how. If the answer is vague or inappropriate, rephrase the question and start again. Hint: These questions require a basic understanding of the question itself in order to supply the necessary information. If the patient is unable to answer, there is a great possibility that he or she hasn’t understood the question. ■ If a patient says “What?” or “Sorry” or “Could you repeat that?” in response to something you have said or asked, it probably means that the patient doesn’t understand, not that he or she doesn’t hear. Rephrase your question or information In many cultures, health in other words. Hint: In general, it is a very good idea to give the same information decisions are not indi- or ask the same question in at least two or three different ways. Use different words vidual, but family deci- and expressions each time. ■ sions. You can save time Don’t make any assumptions about the patient’s basic beliefs about how to best maintain health or cure illness. Hint: Adopt a line of questioning that will help you and frustration, and gain learn some of the patient’s beliefs: “Many of our [name of country or culture] support for your medical patients believe/do . . . . Do you?” advice, if family members ■ Don’t be angry or disturbed if a patient is accompanied by one or even a group of are included in the con- friends or family when visiting a hospital or clinic or medical office. Try to accom- sultation should the pa- modate them. Hint: In many cultures, health decisions are not individual, but family tient request that they be decisions. You can save time and frustration, and gain support for your medical present. advice, if family members are included in the consultation should the patient request that they be present. ■ Be aware that patients may be reluctant to make health care choices or decisions. Wanting to be part of the decision-making process is a uniquely Caucasian- American cultural trait. Be sensitive to the possibility that asking the opinions of patients who belong to a culture in which the physician is viewed as the ‘knower’ who will make the best choices and take full charge of the patient’s cure may destroy the patient’s faith and trust in the physician or medical facility. Hint: The patient may turn the question back to you, saying, “I don’t know. What do you want me to do?” At this point, it is best to say something like, “Well, if it were I (my mother, my sister, my son . . .) I would do/choose X, but I’m required by law to have you make the final decision.” ■ Don’t discount or ridicule the power of the belief in the supernatural. You may not believe in those things, but if your patient does, it will affect his/her health and compliance and satisfaction with treatment. Hint: If the patient believes that he or she has been hexed, or bewitched, or punished for past sins, he or she is likely to take little responsibility for participating in treatment and may have little faith in your ability to cure this illness. ■ Make your practice or facility “patient friendly.” Learn what colors, images, and reading matter will appeal to diverse segments of your patient population. Make sure your waiting room looks and feels like a secure, comfortable place for all patients. Hint: If many of your patients are from Asia or the Middle East, you might have tea Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 17

available. Make sure you have magazines and/or newspapers in the languages of your In many cultures, a poor patients. Are health signs and posters meaningful to the cultures you serve? prognosis is never given ■ Be aware that cultural factors affect how to best relate bad news or to explain in to the patient, and certain detail the nature of a disease or complications that might result from a course of treatment to the patient. Hint: In many cultures, a poor prognosis is never given to words, like cancer, are the patient, and certain words, like cancer, are never used. Talk to the family first. never used. Follow their advice about how much to disclose to the patient. ■ A gesture or facial expression is worth a thousand words. When communicating through an interpreter, face and direct your comments to the patient, not the interpreter. Hint: Observe the patient’s body language and facial expressions carefully. They may tell you much more than the interpreter can. When the words and expressions don’t match, rephrase your questions or information.

Cultural Concerns in Caring for the Dying Patient The Stanford University Center for Biomedical Ethics, in the article “Understanding Cul- tural Difference in Caring for Dying Patients,” presents the following general guidelines for health care professionals working with patients nearing the end of life. Specific information for distinct religious and ethnic groups is included as available in the individual country profiles that follow this basic information section. ■ Assess the language used to discuss the patient’s illness and disease, including the degree of openness in discussing the diagnosis, prognosis, and death itself. ■ Determine whether decisions are made by the patient or a larger social unit, such as the family. To aid the complex effort ■ Consider the relevance of religious beliefs, particularly about the meaning of death, of interpreting the rel- the existence of an afterlife, and belief in miracles. evance of cultural dimen- ■ Determine who controls access to the body and how the body should be approached sions of a particular case, after death. ■ Assess how hope for a recovery is negotiated within the family and with health care make use of available re- professionals. sources, including com- ■ Assess the patient’s degree of fatalism versus an active desire for the control of events munity or religious lead- into the future. ers, family members, and ■ Consider issues of generation or age, gender and power relationships, both within language translators. the patient’s family and in interactions with the health care team. ■ Take into account the political and historical context, particularly poverty, refugee status, past discrimination, and lack of access to care. ■ To aid the complex effort of interpreting the relevance of cultural dimensions of a particular case, make use of available resources, including community or religious leaders, family members, and language translators. Working with Latino/Hispanic Clients In the following section on Working with Students, we discuss the complex question of appropriate terms to use for clients and patients from Spanish-speaking countries. The Pew Hispanic Center and the Kaiser Family Foundation conducted a national survey of Latinos in 2002; they devote many pages to a discussion of this issue. The study found that 88 percent of Latinos refer to themselves by their country of origin, e.g., as “Mexicans” or “Salvadorans,” and that 81 percent use either “Latino” or “Hispanic” as a self-descriptor. Researchers found that 53 percent had no preference as to which term was used, but that among those who had a preference “Latino” is the preferred term in California and among more recent immigrants. The American Public Health Association (APHA) notes that Hispanics may use folk remedies and practices along with Western medicine. Curanderismo, a healing tradition ○○○○○○○○○○○○○○○○○○○○○○○○ 18 ○○○○○ Respecting Differences, Celebrating Diversity:

Hispanic patients may embraced by many Latino cultures, is practiced in immigrant neighborhoods by curanderos/ find our system of pre- as using herbal medications, prayer, and massage, often to remove hexes that may make scriptions and referrals Western medicine ineffectual. Western health care professionals are increasingly paying difficult to understand attention to the importance of incorporating a Latino client’s use of curanderismo into an and navigate, as many overall health plan. Health care practitioners should ask appropriate questions (as indicated medications that require in the section above) and support the client in using any complementary practices that do prescriptions here are not conflict with the practitioner’s recommended treatment regimen. The APHA suggests available over the that respecting and integrating these practices can build patient confidence and increase counter in Latin Ameri- can countries. compliance. The agency further notes that Hispanic patients may find our system of prescriptions and referrals difficult to understand and navigate, as many medications that require prescriptions here are available over the counter in Latin American countries. The following general guidelines are adapted from Diversity Resources: What Lan- guage Does Your Patient Hurt In?: A Practical Guide to Culturally Competent Care: ➊ Show respeto. People from many Hispanic cultures offer (and expect to receive) Patients from many His- deference on the basis of age, sex, and status. Patients will naturally offer respeto to panic cultures expect to the health provider, an authority figure with high social, educational, and economic establish a one-on-one status. In return, patients expect to be treated with repect. Show respect by: ■ addressing adults by title and family name (Mr/Señor X, Mrs/Señora Y, or (but not informal) rela- Madam/Doña) tionship with the health ■ shaking hands at the beginning of each meeting provider. Establishing a ■ using usted (formal) rather than tu (familiar) for “you” when speaking Spanish relationship based on ■ making eye contact, without necessarily expecting reciprocation; some patients personalismo may seem may consider it disrespectful to look an authority figure in the eye time-consuming, but it ■ speaking directly to the patient, even when speaking through an interpreter ➋ can save time in the long Show personalismo. Patients from many Hispanic cultures expect to establish a one- run by laying a founda- on-one (but not informal) relationship with the health provider. Establishing a relationship based on personalismo may seem time-consuming, but it can save time in tion for patient under- the long run by laying a foundation for patient understanding and compliance with standing and compliance care. Show personalismo by: with care. ■ treating patients in a warm and friendly, but not informal, manner ■ showing genuine interest in and concern for patients by asking questions about themselves and their families ■ sitting close, leaning forward, and using gestures when speaking with the patient ➌ Involve the family in decision-making and care. Families are a source of emotional and physical support and are expected to participate in important medical decisions. Be aware that la familia may include parents, siblings, grandparents, cousins, aunts Out of their respect for and uncles, and close friends. When a member is hospitalized, the extended family authority, patients may may show support by visiting at the hospital. What may seem like an unruly and too readily agree to take noisy gathering is probably an important part of the healing environment for the a medication or follow a patient and should be accommodated when possible. treatment plan they do ➍ Accept a different sense of time. Many people from Hispanic cultures do not have a not really understand. precise sense of time in the matter of keeping appointments. In describing a medical The health provider must complaint, they may not be able to say definitely when it started or ended. They may verify that the patient un- link it to a season, a phase of the moon, or an occurrence such as a celebration. ➎ Make an effort to establish understanding and agreement. Out of their respect for derstands the treatment authority, patients may too readily agree to take a medication or follow a treatment and try to get the patient plan they do not really understand. The health provider must verify that the patient to agree to follow it. understands the treatment and try to get the patient to agree to follow it. ➏ Respect the spiritual side of physical complaints. Many Hispanic patients see illness as a result of both physical and spiritual/supernatural/psychological forces. The health care provider should ask the client what he/she believes is the cause of his/her complaint, and should not make light of the patient’s beliefs. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 19

Working with Asian Clients Most Asians consider the head the most sacred While there are many important differences between immigrants from the Asian countries part of the body. One represented in California, both health care providers and teachers can benefit from under- should not touch a standing some of the similarities in the worldview and outlook of their clients and students patient’s or child’s head from China, Korea, Japan, the Philippines, Laos, Cambodia, Vietnam, Thailand, and other without permission. If a Asian countries. People from all of these countries have been influenced by Buddhist, Con- child becomes ill after fucian, and Taoist teachings common to their cultures but still largely not understood in the being patted on the head United States. Salient points of these belief systems are discussed in the next section. The by a caregiver, that per- excellent resource from Diversity Resources: What Language Does Your Patient Hurt In?: A son may be blamed for Practical Guide to Culturally Competent Care, provides the following information that will taking the child’s soul and causing the illness. help health care providers understand and work effectively with Asian clients. ■ Follow the rules of etiquette. Age and social structure are more important in Asian societies than our own. Regardless of rank, younger people greet older people first and address them in a formal manner. Physicians generally hold a high position in Asian society, so clients may show respect by avoiding eye contact. When seated, avoid crossing the legs, leaning on a table or a desk, or pointing at anything with the foot when talking; these are considered signs of contempt. ■ Use proper forms of greeting and address. Chinese, Japanese, and Koreans address each other using surnames; they may address family members in terms of family position, e.g., Older Brother, Mother. ■ Understand the importance of the head. Most Asians consider the head the most sacred part of the body. One should not touch a patient’s or child’s head without permission. If a child becomes ill after being patted on the head by a caregiver, that person may be blamed for taking the child’s soul and causing the illness. ■ Understand the importance of the blood. Because most Asians view blood as a vital element that represents the essence of a person, blood is not drawn for medicinal purposes in traditional medicine. Some believe that drawing blood weakens the body Asians view health as the and upsets its natural balance. When blood must be drawn, health care providers balance between the should assure the client that his/her blood will not be given to anyone else. forces of yin and yang. Ev- ■ Yin and yang, hot and cold. Asians view health as the balance between the forces of erything in the universe is yin and yang. Everything in the universe is classified as either yin (negative, dark, classified as either yin feminine, cold), or yang (positive, bright, masculine, warm). Every aspect of life and (negative, dark, feminine, nature is believed to contain these opposite but complementary forces. They believe cold), or yang (positive, illness results when this balance is upset; it can be cured by searching for and remedying the imbalance. Health care providers need to understand that this use of bright, masculine, warm). hot/cold does not refer to temperature but rather to attributes of the substance. A Every aspect of life and disease or symptom considered “hot” is treated by a medication considered “cold” in nature is believed to con- order to restore balance. If clients hold the hot/cold theory, they may refuse tain these opposite but treatments or question the knowledge of caregivers who prescribe them. A common complementary forces. misunderstanding arises in the hospital setting, where iced water is generally served They believe illness results to all patients. Asian patients generally would prefer warm water or tea when sick or when this balance is up- following childbirth. Foods served to the hospitalized patient may be rejected as set; it can be cured by inappropriate to the hot-cold balance. ■ Understand the view of medications. Most Asians expect physicians to prescribe searching for and remedy- medication, but they are not used to taking pills and tend to believe injections are ing the imbalance. more effective. They may adjust the medication dosage down due to a belief that Western medicines are “hot” or overly potent to Asians. ■ Understand the importance of harmony and saving face. The widespread Asian concern for maintaining harmonious relationships and protecting their own and others’ dignity may interfere with their understanding of and compliance with treatment regimens. Rather than admit they do not understand a health care provider’s instructions, Asian clients may appear to understand and accept it. Caregivers can test for patient understanding by observing signs of confusion or by asking patients to describe what they have been told in their own words. ○○○○○○○○○○○○○○○○○○○○○○○○ 20 ○○○○○ Respecting Differences, Celebrating Diversity:

■ Hospital food may be Dietary preferences. Hospital food may be strange to the Asian patient, both due to strange to the Asian pa- hot-cold constraints and to other beliefs about the relationship of food to illness. Many Asians are lactose-intolerant and should not be served milk products. Some tient, both due to hot- Southeast Asians believe that persons who are ill should not eat beef or eggs. Rice cold constraints and to soup with chicken is often prepared for sick people. If possible, family members other beliefs about the should be allowed to provide the appropriate kinds of food for their hospitalized relationship of food to ill- relatives. ness. Many Asians are lac- ■ Qi/Ch’i. The Chinese and other Asian people pay considerable attention to the flow tose-intolerant and of qi, energy, in the body. They use acupuncture to restore the flow when it is should not be served milk disrupted by disease or a broken bone. ■ products. Some South- Traditional practices. Many Asians use both Eastern and Western medical practices, believing that certain illnesses or conditions are best treated by either one or the east Asians believe that other approach. Western physicians are frequently consulted for such things as heart persons who are ill attack, stroke, diabetes, and cancer, while traditional healers and herbalists are used should not eat beef or to treat such conditions as asthma, arthritis, and stomach problems. Even when a eggs. Rice soup with client consults a Western physician, he/she may also use herbal remedies and chicken is often prepared traditional practices. Common practices and remedies are described in the following for sick people. If pos- country profiles, but those widespread throughout Asia include acupuncture, coining sible, family members and pinching, cupping, moxibustion, and the use of herbal teas or slushes as well as should be allowed to pro- patent medicines. An important part of caregiver-client interaction involves determing what traditional practices the client is using. vide the appropriate kinds of food for their hospitalized relatives. Working with Middle Eastern Clients Within the larger group of people we refer to as Middle Easterners, we find wide diversity of ethnic and religions affiliation. While most Middle Easterners are Muslim, some are Jewish, Christian, or Coptic Christian. Beware of assuming that your Middle Eastern clients are necessarily Muslim. The following suggestions, adapted from Diversity Resources: What Language Does Your Patient Hurt In?: A Practical Guide to Culturally Competent Care, should help health care providers establish comfortable relationships with their patients and clients from the Middle East region. ■ Greet patients and their family members by title, shake hands, and say something personal about the patient, the patient’s family, or the patient’s country of origin. ■ Try to establish a close enough relationship with the patient that he or she will view Because of the impor- you as a friend and a person to be trusted with important information. In the tance of establishing a process, share information about yourself so the patient will know you are a trustwor- personal relationship, an thy person. Because of the importance of establishing a personal relationship, an appointment with a Middle Eastern patient may take longer than with a patient appointment with a from another group. Sharing food and drink is an important means of establishing Middle Eastern patient trust. If the caregiver offers a cup of tea, the patient may refuse out of politeness the may take longer than first time, so a second and third offer should be made. with a patient from an- ■ Patients may expect the health care professional to intuitively know things the other group. patient has not revealed. If you believe this is the case, use indirect questioning to elicit the necessary information. Sometimes patients are unwilling to complete history and physical questions, not seeing the relevance of these questions to their current medical complaint, or being unwilling to share information with strangers. ■ Use of a loud voice probably indicates the importance of the subject matter rather than anger. ■ Be sure to include the family in medical decisions, especially the eldest male. ■ Make sure the patient understands and intends to follow instructions. Authority figures are not to be questioned or contradicted, but this does not mean the patient agrees to follow the advice he or she has been given. ■ Personal space issues may arise because the comfort zone of Middle Easterners allows much closer physical contact than Western health care providers may be comfortable with. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 21

■ Matching patient and caregiver by gender is desirable whenever possible. Patients Matching patient and may refuse to disclose personal information or disrobe for an exam if paired with a caregiver by gender is de- health care provider of the opposite gender. ■ Negative medical news should be revealed in stages as part of other information, in sirable whenever pos- the presence of a family spokesperson. sible. Patients may refuse ■ In the case of Arab-American patients, such things as childbirth and death are to disclose personal infor- believed to be in the hands of Allah and not to be interfered with by humans. mation or disrobe for an ■ Muslim patients may not want to take a medication containing alcohol or be in exam if paired with a contact with anything derived from a pig. health care provider of ■ Arabs tend to believe that the more intrusive a medical intervention is, the more the opposite gender. effective it is, which means that they may choose surgery over radiation or chemotherapy in the case of cancer, for example. Religion and Health Care The Center for Religion and Civic Culture at the University of Southern California published a report in 2002 on immigrant religion in Los Angeles. The authors note: “Religious institutions, rather than merely incorporating people into the Americn mainstream, serve the dual functions of preserving national identities and aiding incorporation.” In the following country profiles, there is a section on the religions practiced in each country, with information on the role of religion in the life of the people. Health care providers Making generalizations about religion is certainly risky, and health care providers should should understand that understand that not all adherents of a particular religion will have the same attitudes and not all adherents of a particular religion will have beliefs about health care. Dr. Harold Koenig, director of Duke University’s Center for the the same attitudes and Study of Religion/Spirituality and Health, stated: “I recommend that physicians ask every beliefs about health care. patient if they consider themselves spiritual or religious. . . . Religion has a power to heal, and we have an obligation to value that alongside medicine.” More and more physicians and hospitals are coming to terms with the role of religion in their clients’ health care decisions. A 2005 Los Angeles Times article reported that 101 medical schools now incorporate patient spirituality in their curricula, an increase of 84 since 1995. Speaking at a conference in Kuala Lumpur in 2002 on religious pluralism , Harvard University professor Diana Eck stated:

New immigrants have come to American shores from all over the world and have become citizens. They have brought with them not only their luggage and economic aspirations, but their Qur’ans and Bhagavad Gitas, their images of Krishna and Murugan, their incense to light before the Bodhisattvas on their Buddhist altars.

She emphasizes that people of many religions must learn how to coexist peacefully in the “People of different reli- 21st century: “People of different religious traditions live together all over the world—as gious traditions live to- majorities in one place, as minorities in another.” She notes that U.S. history does not offer gether all over the a positive example of religious tolerance, what with early Pilgrims and Puritans treating the world—as majorities in Native Americans as heathens and burning supposed witches at the stake, not to mention one place, as minorities our long tradition of anti-Catholicism and anti-Semitism. Our nation’s founders wanted in another.” religious freedom for themselves, but they were often not tolerant of diverse practices. Both Diana Eck health care providers and educators will benefit from information about the religious heritage of their clients and students. Religion plays a central role in the lives and decisions of many immigrants and refugees and is often an important source of assistance in navigating both the health care and education systems. ○○○○○○○○○○○○○○○○○○○○○○○○ 22 ○○○○○ Respecting Differences, Celebrating Diversity:

Buddhist scriptures do Buddhism not directly address Health care providers in California will almost certainly come into contact with Buddhist health, but the Four patients of the Theravada (lesser vehicle) branch widely practiced in Cambodia, Laos, Thai- Noble Truths of Bud- land, Sri Lanka, and Burma, and/or the Mahayana (greater vehicle) branch more com- dhism have obvious ap- monly practiced by people from China, Japan, and Vietnam. Eck notes that in Los Angeles, plicability to the health Buddhist communities representing the full gamut of Buddhist practice can be found side care setting. by side, as immigrants from many Asian countries, as well as Western practitioners, flock to meditation centers of all kinds. The same could be said of many other large California cities. Buddhist scriptures do not directly address health, but the Four Noble Truths of Bud- dhism have obvious applicability to the health care setting: ➊ All sentient beings suffer. Birth, illness, death, and other separations are inescapable parts of life. ➋ The cause of suffering is desire, which is manifested by attachment to life, to security, and to others. ➌ The way to end suffering is to cease to desire. ➍ The way to cease to desire is to follow the Eightfold Path: (1) right belief, (2) right The Buddhist concept of intent, (3) right speech, (4) right conduct/action, (5) right livelihood/endeavor, (6) karma, which mandates right effort, (7) right mindfulness, and (8) right meditation. doing right to be born The Buddhist concept of karma, which mandates doing right to be born into a higher life in into a higher life in the the next existence, means that Buddhists often see their suffering in this life as the result of next existence, means sins committed in this or a previous life. The Buddhist outlook may be expressed in the that Buddhists often see following ways in the health care setting: their suffering in this life ■ Buddhists may be reluctant to complain or express pain as they see it as a natural as the result of sins com- part of life. mitted in this or a previ- ■ Buddhists often accept a blend of different approaches to health and healing, as they ous life. do not view the world in either/or terms. ■ Death itself may be seen as less important as the manner in which one lives and dies. Many patients and their families place importance on staying conscious during the dying process so that the person can focus on wholesome thoughts, letting go of life without clinging. A monk or lay religious leader may be called upon to lead chants, incense may be burned, and amulets may be placed near the dying person. ■ Most Buddhists have no problem with organ transplantation or autopsy, and the choice of burial or cremation of a dead body seems to be more cultural than religious. Islam The Islamic Medical Association of North America has a Web page containing useful information and links for health care providers working with Muslim patients. “Islam” means “peace and submission to the will of God (Allah).” Muslims believe in one God, Allah, and God’s last messenger, Mohammed. They also believe in angels, Satan, the Day of Reckon-

Muslims see illness as ing, Heaven and Hell, and the prophets of the Judaeo-Christian faith. The Five Pillars of atonement for their sins, Islam are faith, prayer (salat, at least five times daily), fasting (sawm), charity (zahat/zakat), and they consider death and Hajj (pilgrimage to the Muslim holy city, Mecca). Friday is the most important day of a part of their journey. worship; regular worship is held in mosques. Muslims see illness as atonement for their sins, and they consider death a part of their journey. The Muslim holy book is the Qur’an (Koran). The lunar holy month of Ramadan, which is observed at slightly different times each year, requires healthy adult Muslims to abstain from all food and drink from sunrise to sunset each day, or while there is enough natural light to distinguish a white thread from a black thread. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 23

Some Muslim Health Beliefs and Practices Muslim dietary restric- ■ Blood transfusions are permitted after proper screening. tions include pork and ■ Cleanliness is of the utmost importance; the mouth, hands, and feet are washed at meat from animals killed least five times a day before prayers. outside of Muslim cus- ■ Dietary restrictions include pork and meat from animals killed outside of Muslim tom as well as eating custom as well as eating with dishes or utensils that have come into contact with such food. This would include gelatin, ice cream made with animal fat, anything with dishes or utensils fried or roasted in lard, anything cooked with ham. that have come into con- ■ Muslims do not drink alcohol or eat anything made with it. They may make tact with such food. This exceptions for medications containing alcohol. would include gelatin, ■ Abortion is not allowed except to save the mother’s life. ice cream made with ■ Assisted suicide and euthanasia are not permitted. animal fat, anything fried ■ Maintaining a terminally ill patient on life support in a persistent vegetative state is or roasted in lard, any- not encouraged. thing cooked with ham. ■ Organ transplantation is allowed with some restrictions. ■ Muslims may have a living will. ■ Genetic engineering to cure a disease is acceptable. Tips for Caregivers ■ Respect the patient’s modesty and privacy. ■ If possible, provide same-sex physicians and nurses. ■ Always examine a female patient in the presence of another female. ■ In the hospital, provide vegetarian, Muslim, or Kosher meals because of dietary restrictions. ■ Allow the hospitalized Muslim to pray and read the Qur’an. ■ Allow the Imam (religious leader) to visit patients in the hospital. ■ Allow the family to bring the hospitalized Muslim food unless forbidden. ■ The Qur’an allows people who are ill to defer Ramadan fasting to another time. ■ In the case of death, allow the family and Imam to follow Islamic guidelines for preparing the body for an Islamic funeral. Non-Muslims should not touch the body. Confucianism Although it is more a philosophy or system of thought than a religion, Confucianism has Both health care provid- had a profound effect on the worldview of Asian cultures. The Diversity Resources Web site ers and teachers find that Asian clients and stu- discusses elements of Confucian thought that have an impact on health care. dents give gifts liberally. ■ The role of fate (ming). Confucian teachings indicate that individuals have a particular destiny and role in society and that they should practice moderation and This derives from a Con- avoid excess. fucian teaching that ex- ■ Social interaction. Key teachings regarding social interaction are reciprocity (pao) pressing good wishes re- and loyalty (chung). From these teachings developed the widespread respect for and quires the giving of gifts, obedience to elders and authority figures. Benevolence and righteousness are two with the expectation that other important teachings directing how people should treat one another. a gift or favor will be re- ■ Gift-giving. Both health care providers and teachers find that Asian clients and turned (in the form of re- students give gifts liberally. This derives from a Confucian teaching that expressing stored health or a good good wishes requires the giving of gifts, with the expectation that a gift or favor will be returned (in the form of restored health or a good grade, for example). grade, for example). ■ Attitude toward the body. The body is regarded as being on loan to a person on earth and is to be returned intact at death. This belief has implications for surgery and organ donation, among other things, if individuals believe that only by dying with an intact body will they go to heaven. Taoism The Diversity Resources Web site states that “much of the Asian perspective on health comes from Taoist thought.” Taoism is based on the teachings of Lao-Tse, who was born in ○○○○○○○○○○○○○

24 ○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

COMPLEMENTARY AND ALTERNATIVE MEDICINE GLOSSARY

Acupuncture patient with a goal of supporting this power through treat- Method of healing developed in China at least 2,000 years ments such as nutrition and lifestyle counseling, dietary ago. A family of procedures involving stimulation of ana- supplements, medicinal plants, exercise, homeopathy, and tomical points on the body by a variety of techniques. traditional Chinese medicine. American practices incorporate medical traditions from Osteopathic Medicine (Osteopathy) China, Japan, Korea, and other countries. The technique A form of conventional medicine that emphasizes dis- most studied scientifically involves penetrating the skin eases arising in the musculoskeletal system. The underly- with thin, solid, metallic needles that are manipulated by ing belief is that all body systems work together and that the hands or by electrical stimulation. disturbances in one system may affect function in other Aromatherapy systems. Some osteopathic physicians practice osteopathic Use of essential oils (extracts or essences) from flowers, manipulation, a full-body system of hands-on techniques herbs, and trees to promote health and well-being. designed to alleviate pain, restore function, and promote health and well-being. Ayurveda Alternative medical system practiced primarily on the In- Qi gong dian subcontinent for 5,000 years; includes diet and Component of traditional Chinese medicine that combines herbal remedies and emphasizes the use of body, mind, movement, meditation, and regulation of breathing to and spirit in disease prevention and treatment. enhance the flow of qi (“chee,” an ancient term for vital energy) in the body, improve blood circulation, and en- Chiropractic hance immune function. Alternative medical system that focuses on the relationship between bodily structure and function and how that Reiki relationship affects the preservation and restoration of Japanese word representing Universal Life Energy. Reiki health. Chiropractors use manipulative therapy as an in- is based on the belief that when spiritual energy is chan- tegral treatment tool. neled through a Reiki practitioner, the patient’s spirit is healed, which in turn heals the body. Dietary Supplements Products taken by mouth that contain dietary ingredi- Therapeutic Touch ents intended to supplement the diet; may include vita- Derived from an ancient technique known as the laying- mins, minerals, herbs or other botanicals, amino acids, on of hands, based on the premise that the healing force and substances such as enzymes, organ tissues, and of the therapist affects the patient’s recovery. Healing is metabolites. promoted when the body’s energies are in balance; by passing their hands over the patient, healers can identify Homeopathic Medicine energy imbalances. Alternative medical system based on the concept that “like cures like.” Small, highly diluted quantities of me- Traditional Chinese Medicine dicinal substances are given to cure symptoms; the same Based on the concept of balanced qi (“chee”) or vital substances given at higher or more concentrated doses energy that is believed to flow throughout the body and would actually cause those symptoms. regulate a person’s spiritual, emotional, mental, and physical balance. Qi is influenced by the opposing forces of yin Massage (negative energy) and yang (positive energy). Disease Manipulation of muscle and connective tissue to enhance results from disturbance in the flow of qi resulting in an function of those tissues and promote relaxation and well- imbalance of yin and yang. The practice includes herbal being. and nutritional therapy, restorative physical exercises, Naturopathic Medicine meditation, acupuncture, and remedial massage. Alternative medical system based on the belief that there is a healing power in the body that establishes, maintains, and restores health. Practitioners work with the Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 25

China in 604 BC; his philosophy is set forth in the Tao Te Ching. Taoist teaching centers on A person influenced by the importance of finding the tao or “way.” This involves living in harmony with the natural Taoist thought is likely to world, experiencing the oneness in all things and living by the golden mean or chung-yung, approach life, illness, and avoiding extremes. Taoism advocates living in harmony with the seasons, with the phases of even death with acceptance and stoicism that the moon and the rhythms of day and night. Life is considered a cycle of birth, death, and might be misunderstood. reincarnation. A person influenced by Taoist thought is likely to approach life, illness, and even death with acceptance and stoicism that might be misunderstood. When an individual sees himself or herself as involved in an ongoing natural process, the idea of surgical interventions and lifesaving measures makes less sense than to one who has no confidence in anything other than his or her immediate existence. Complementary and Alternative

Medicine Complementary and al- The National Center for Complementary and Alternative Medicine (NCCAM), part of ternative medicine is a the National Institutes of Health, is the U.S. government’s lead agency for scientific re- group of diverse medical search on complementary and alternative medicine, referred to on the organization’s Web and health care systems, site as CAM. Many of the patients California health care providers see, both native-born practices, and products and immigrants, will be using complementary and/or alternative medicine. In the following not considered part of country profiles some of these practices are discussed under the heading “traditional prac- conventional medicine. tices,” but because the use of these methods is becoming so widespread throughout our culture, health care professionals should be aware of some salient points. The following information, taken from http://nccam.nih.gov, the Web URL of the NCCAM Clearing- house, is in the public domain and may be freely copied. Definitions Complementary and alternative medicine is a group of diverse medical and health care systems, practices, and products not currently considered part of conventional medicine. Conventional medicine, also called Western or mainstream medicine, is that practiced by those with M.D. (medical doctor) or D.O. (doctor of osteopathy) degrees and by their allied Complementary medicine refers to practices health professionals including physical therapists, registered nurses, and psychologists. Prac- used together with con- tices and products once considered CAM, such as the use of vitamin therapy for macular ventional medicine. Alter- degeneration and the prevention of birth defects, are now part of conventional medicine. native medicine is used Complementary medicine refers to practices used together with conventional medicine, in place of conventional such as the use of meditation to lessen chronic pain. Alternative medicine is used in place of medicine. conventional medicine, such as the use of shark cartilage in place of chemotherapy or radiation to treat cancer. Integrative medicine combines mainstream medical therapies and CAM therapies for which high-quality scientific evidence of safety and effectiveness exists. Types of Complementary and Alternative Medicine 1. ALTERNATIVE MEDICAL SYSTEMS are complete systems of theory and practice that often have evolved apart from and earlier than the conventional U.S. medical approach. Western alternative medical systems include homeopathic medicine and naturopathic medicine; non-Western systems include traditional Chinese medicine and Ayurveda, a system developed in India. 2. MIND-BODY INTERVENTIONS comprise a variety of techniques designed to enhance the mind’s capacity to affect bodily function and symptoms. Some techniques previously considered CAM are now part of mainstream medicine (e.g., patient support groups, ○○○○○○○○○○○○○○○○○○○○○○○○ 26 ○○○○○ Respecting Differences, Celebrating Diversity:

Alternative Medical Sys- cognitive-behavioral therapy). Mind-body techniques still considered CAM include tems are complete sys- meditation, prayer, mental healing, and therapies that use creative outlets such as art, music, or dance. tems of theory and prac- 3. BIOLOGICALLY BASED THERAPIES use substances found in nature such as herbs, foods, tice that often have and vitamins. Examples include dietary supplements, herbal products, and the use of evolved apart from and natural but scientifically unproven therapies, such as shark cartilage as a cancer cure. earlier than the conven- 4. MANIPULATIVE AND BODY-BASED METHODS include chiropractic or osteopathic tional U.S. medical ap- manipulation and massage. proach. Western alterna- 5. ENERGY THERAPIES involve the use of energy fields and are divided into: (1) Biofield tive medical systems in- therapies, such as Qi gong and Reiki, that manipulate biofields by applying pressure clude homeopathic and/or manipulating the body by placing the hands in, or through, the fields of energy believed to surround and penetrate the body. (2) Bioelectromagnetic-based medicine and naturo- therapies involve the unconventional use of electromagnetic fields, such as pulsed pathic medicine; non- fields, magnetic fields, or alternating-current or direct-current fields. Western systems include The glossary on page 24 outlines some of the more common complementary and alterna- traditional Chinese medi- tive medical practices with which health professionals may come in contact as they work cine and Ayurveda, a sys- with both foreign-born and native-born patients. tem developed in India. Working with Students A 2003 report by The Urban Institute, U.S. Immigration—Trends and Implications for Schools, Children of immigrants pointed out that the children of immigrants now account for one in five of all children in now make up one in five grades K through 12, with 10.5 million students in that group. A quarter of these students of all children in grades were born in other countries, making them first-generation, but three-quarters were born in K through 12—10.5 mil- the United States, second-generation. The authors project that by 2015 the children of lion students. immigrants will constitute 30 percent of the nation’s school population. Immigrant children make up a larger share of the secondary than of the elementary school population, 6.4 percent as opposed to 3.8 percent. Five percent of all students in U.S. schools are limited English proficient or English language learners. Nearly half of first- generation Mexican immigrant K–12 students are limited English proficient. Of these, 30 percent have been here for ten years or more, 48 percent for five to nine years, and 21 percent for less than five years. The authors of the study found that a substantially smaller share of English language learners in high schools receive language instruction than those in elementary school. The Urban Institute projects that some 14 million immigrants will enter the United States between 2000 and 2010.

In the spring of 2004 Immigrants and English Language Learners in there were 1,598,535 En- California Schools glish language learners in The California Department of Education reports that in the spring of 2004 there were California public schools, about one-fourth of all 1,598,535 English language learners in California public schools, about one-fourth of all students. students. The countries profiled in the major portion of this handbook were selected on the basis of both the numbers of immigrants from each country identified in the 2000 census and the number of English language learners in our public schools. The largest number of English language learners—1,359,792 (85 percent of the total)—speak Spanish, followed by Vietnamese (2.2%), Hmong (1.5%), Cantonese (1.4%), Filipino (1.3%), Korean (1.1%), Mandarin (0.7%), Armenian (0.7%), Khmer (0.6%), Punjabi (0.6%), Russian (0.5%), Ara- bic (0.5%), Farsi (0.4%), Japanese (0.3%), Lao (0.3%), and Hindi (0.3%). Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 27

In his January/February 2004 newsletter, California Superintendent of Public Instruc- “California has the largest tion Jack O’Connell focused on diversity, highlighting schools with successful programs and most diverse student and providing resources for teachers and administrators. He stated: “California has the population of any state in largest and most diverse student population of any state in our nation. As educators of over our nation. As educators 6.1 million children, we have the privilege and responsibility to ensure that all students of over 6.1 million children, we have the privi- have an equal opportunity to be successful. . . . Diversity presents us with a unique oppor- lege and responsibility to tunity to interact and learn from one another.” In 2003, 14 percent of California schools ensure that all students had Latino enrollments of 80 percent or higher. have an equal opportunity to be successful. . . . Latinos in California High Schools Diversity presents us with a unique opportunity to Some 46 percent of the nearly 6.3 million children enrolled in California public elementary interact and learn from and secondary schools in 2003–2004 were Latino, making them the largest segment of the one another.” state’s student population. Non-Hispanic whites accounted for 32.5 percent of the enroll- Jack O’Connell ment, with African-American students at 8.1 percent and Asian students making up 8 California Superintendent of Public Instruction percent of all students that year. A recent discussion of differences within and between Spanish-speaking student groups is found in a December 2004 Los Angeles Times article focusing on Montebello High School, whose student body is 93 percent Latino and 70 percent low-income. About 28 percent of the students are limited English proficient; an additional 46 percent grew up speaking Some 46 percent of the Spanish but are now considered proficient in English. nearly 6.3 million chil- The author states: “As at many schools in California, students here are delicately split— dren enrolled in Califor- in classes, sports and clubs, at social events and at lunch—between those who seem more nia public elementary and secondary schools in Americanized and those who feel more connected to their Latino immigrant roots.” The 2003–2004 were Latino, campus has an informal but noticeable border between an area called TJ, for Tijuana, and making them the largest Senior Park. Students on the TJ side come from homes where Spanish is spoken; they are segment of the state’s involved primarily in soccer, folklorico dance, and Spanish club. Latino students on the student population. Non- Senior Park side of the border are immersed in traditional high school culture, including Hispanic Whites ac- football, basketball, and drill teams. Their families have often been in California for several counted for 32.5 percent generations, and some of them do not know Spanish. The writer notes that students who of the enrollment, with have moved into regular classes at Montebello seem to be doing better on the California African-American stu- High School Exit Exam than their English-only counterparts. dents at 8.1 percent and Asian students making up To assist teachers who teach large numbers of Latino students, page 29 provides ex- 8 percent of all students cerpts from a slang dictionary found on the PBS Web site in conjunction with the “Ameri- that year. can Family” series segment on a Latino family in East Los Angeles. What’s in a Name? People of Mexican, Central American, and South American descent in this country are referred to by a variety of inclusive names—Hispanic, Latino/a, Chicano/a—in addition to being called Mexican, Mexican-American, Salvadoran, Guatemalan, etc. Prior to about 1930, the term Mexican was most widely used. When the first generation of the children of refugees from the Mexican Revolution came of age in the 1930s, the term “Mexican-Ameri- can” came into use. During the Civil Rights Movement of the 1960s, some children of Mexican-Ameri- cans rejected the dominant culture and decided to refer to themselves by the formerly derogatory term “Chicano.” According to the East Los Angeles segment on the PBS series ○○○○○○○○○○○○○○○○○○○○○○○○ 28 ○○○○○ Respecting Differences, Celebrating Diversity:

The term “Hispanic” is an “American Family,” some who used this label, which means “a pro-active approach to self- English word that was in- respect and dignity,”emerged as leaders in the Mexican-American community and took a troduced at the time of confrontational approach to social justice. In 1968, for example, more than 30,000 East the 1970 census when L.A. students walked out of five high schools to protest inequities in their education, ulti- U.S. government officials mately winning concessions from the school board. were looking for a generic The term “Hispanic” is an English word that was introduced at the time of the 1970 term for people from the census when U.S. government officials were looking for a generic term for people from the Spanish-speaking countries of Latin America. Spanish-speaking countries of Latin America. “Latino” is a Spanish term preferred by many “Latino” is a Spanish term from these countries who feel that differences between national groups are better repre- preferred by many from sented by that term. The teacher or health care professional working with Spanish-speaking these countries who feel students or clients would be wise to look for cues as to preference. Otto Santa Ana, a profes- it better represents the sor at UCLA, suggests (optimistically, and with tongue in cheek) that in the future we all differences between na- call ourselves “Americanos,” as that would cover all the Americas, both north and south. tional groups. Culturally Competent Teaching As stressed in the earlier section on providing culturally competent health care, teachers working in diverse classrooms—and that would appear to include most California public school teachers—will have a better chance of establishing successful working relationships Teachers can support di- with their ethnic and language “minority” students when they make an effort and take the versity in instruction by time to learn about their students’ cultural background. In the useful book Educational accepting and valuing dif- Interventions for Refugee Children, the authors emphasize the need for teachers to support ferences, accommodat- diversity in instruction by accepting and valuing differences, accommodating different learning different learning ing styles, and understanding and building on the cultural background of their students. In styles, and understanding a state with as many different immigrant and refugee groups as California, this can pose a and building on the cul- huge challenge. In the newsletter mentioned above, Superintendent O’Connell states: tural background of their students. Through the study of the many complex forces that influence young people, we can begin to understand the lives of the students who compose our multicultural society. . . . It is essential that students prepare for an international workforce by understanding and appreciating other cultures.

Analysis of the relationship among student achievement, student culture, and educators’ attitudes and expectations prompted this conclusion by Robert Peña:

[I]t is equally important to understand the relationship between minority and majority cultures, and to understand the interplay of these in both the school and community. This means that educational leaders and school practitioners become knowledgeable of minority cultural traditions, and that these individuals become more reflective in their thinking about Both minority and non- culture. minority students learn University of Michigan researcher Patricia Gurin conducted several extensive studies better in settings where that showed that both minority and non-minority students learn better in settings where they interact with others different from them- they interact with others different from themselves. She found that white students with the selves. most experience with racial diversity both in and outside of school demonstrated: ■ increased scores on a test used to measure complex thinking ■ more motivation to achieve ■ greater intellectual self-confidence and engagement ■ the highest level of interest in graduate degrees ■ greater understanding that group differences are compatible with societal unity ■ higher level of motivation to understand the perspectives of others Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○29

SPANISH SLANG abuson ...... person who takes advantage glacos ...... eye glasses agarrado ...... stingy, cheap huachate ...... watch out agringado ...... assimilated to white middle class huelga ...... workers’ strike a la brava ...... impulsive huevos ...... to be brave; see pelotas alalba ...... far-out, way cool huiri huiri ...... gossip alambre ...... Mexico/US border fence huisa...... girl, girlfriend alambrista ...... illegal alien from Mexico jale ...... a job amolado ...... messed up, screwed up jefe ...... the boss, the wife anda bravo ...... angry, pissed off lana ...... money andale ...... hurry up, get to it linea ...... U.S.-Mexican border Anglo, gringo ...... a white American lobo ...... woman chaser arguendero ...... gossiper loco ...... crazy dude arrastrado ...... lazy, no-good lonche ...... lunch a tona madre ...... far-out, unbelievable marqueta ...... market or store Ay te huacho ...... catch you later masa ...... dough baby, flor ...... hottie female, beautiful woman menso ...... stupid person barrio ...... Latin neighborhood neto ...... the truth borlote ...... a fight, noisy argument nieve...... snow, ice cream bote, tambo ...... jail panchanga ...... big party, blow-out fiesta bracero ...... day laborer padelante ...... pregnant cabezon ...... stubborn, thick-headed palabra ...... word, the truth! cacahuate ...... nut case, crazy person pelotas ...... balls cama ...... friend perica ...... radio carnal ...... brother or sister, close relative perro ...... cruel person carrucha ...... car, low-rider profe ...... teacher causa ...... political cause rata ...... rat, fink con safos ...... free Raza, La ...... the family, clan, community coyote ...... smuggler of illegal aliens rola ...... music, tunes crudo ...... rude, cruel safado ...... crazy cuacha ...... ignorant person salsa ...... hot stuff cuate ...... friend, dude scuadro ...... square, not cool cuera ...... girlfriend sieta ...... chair cuico, quico ...... cop sincho ...... of course, absolutely chafa ...... worthless sirol ...... yeah chale ...... no way sista ...... sister chamaca ...... young girl songa ...... song chamacon ...... young man sonsa ...... silly chanza ...... joke sopitas ...... easy chavala ...... girlfriend suave ...... for sure, right on Chicano ...... Mexican American tejano ...... Chicano from Texas chihuahua ...... wow! Dude! tenis, zapos ...... shoes chispa...... smart, aware tequete ...... ticket chocho ...... candies, sweet stuff T.J...... Tijuana cholo ...... low-rider; gang member totacho ...... Chicano slang chupasa ...... cheater trapos ...... clothes, threads entrale ...... go for it troca ...... truck ese...... dude vale, vato...... a guy, a dude fachoso ...... slob varo ...... dollar fregado ...... tease vista...... the movies fresco ...... cool, kewl (adapted from http://www.pbs.org/americanfamily/ gasofa...... gas eastla.html) ○○○○○○○○○○○○○○○○○○○○○○○○ 30 ○○○○○ Respecting Differences, Celebrating Diversity:

■ “From urban areas in Cali- higher levels of citizenship ■ greater likelihood of having friends, neighbors, and co-workers from diverse racial fornia to factory towns in and ethnic backgrounds after graduation rural Iowa, I heard the same message over and Eileen Kugler, researching her book Debunking the Middle-Class Myth: Why Diverse over. Those directly con- Schools Are Good for All Kids, found: “From urban areas in California to factory towns in rural nected to well-run diverse Iowa, I heard the same message over and over. Those directly connected to well-run diverse schools find that students schools find that students of every background benefit both academically and socially.” of every background ben- A year-long ethnographic study by Susan Katz of the University of San Francisco of efit both academically eight Latino immigrant students in an urban Northern California middle school revealed and socially.” that the students identified teacher discrimination against them as Latinos as the main Eileen Kugler reason they took little interest in school. Katz suggests that the teachers themselves were trying to reach the immigrant students but were hampered by such institutional problems as tracking and high teacher turnover that kept them from establishing caring relationships. Perhaps the best resource for the classroom teacher on working effectively with students from a variety of cultures is a publication from the University of Washington, Diver- sity within Unity: Essential Principles for Teaching and Learning in a Multicultural Society. This is available on the Web at http://depts.washington.edu/coe/programs/ci/pubs/ “Cultural, ethnic, and lan- DiversityUnity.pdf. The book presents the work of experts at the Center for Multicultural guage diversity provide Education at the university, along with the Common Destiny Alliance at the University of the nation and the schools with rich oppor- Maryland, who developed 12 essential principles for teacher learning, student learning, tunities to incorporate intergroup relations, and school governance, organization, and equity. The authors state: diverse perspectives, is- An important goal of the schools should be to forge a common nation and destiny from the sues, and characteristics tremendous ethnic, cultural, and language diversity. To forge a common destiny, educators into the nation and the must respect and build upon the cultural strengths and characteristics that students from schools in order to diverse groups bring to school. At the same time, educators must help all students acquire strengthen both.” the knowledge, skills, and values needed to become participating citizens of the common- Diversity within Unity wealth. Cultural, ethnic, and language diversity provide the nation and the schools with rich opportunities to incorporate diverse perspectives, issues, and characteristics into the nation and the schools in order to strengthen both (5).

Teacher and student learning, intergroup relations, and assessment principles are discussed here as they relate to working with high school health careers students. Teacher Learning “Effective teachers for a Principle 1: Professional development programs should help teachers understand the complex char- multicultural society acteristics of ethnic groups within U.S. society and the ways in which race, ethnicity, language, and contextualize instruction social class interact to influence student behavior. The authors point out that most teachers by first understanding how their own teaching come to their diverse classrooms unprepared for the challenge of providing what Banks calls styles and preferences an “equity pedagogy” that provides all students with equal opportunities for academic and may hinder the learning social success. This creates a significant gap between teachers and their ethnically diverse of students who have dif- students. They emphasize that teachers need to be aware of the impact of gender, social ferent learning styles and class, religion, region of origin, generation, and extent of urbanization on the behavior of preferences.” students from different cultures. They state: Diversity within Unity Effective teachers for a multicultural society contextualize instruction by first understanding how their own teaching styles and preferences may hinder the learning of students who have different learning styles and preferences. . . . Rather than relying on . . . generalized notions of ethnic groups that can be misleading, effective teachers use knowledge of their students’ culture and ethnicity as a framework for inquiry. They also use culturally responsive activities, resources, and strategies to organize and implement instruction (7). Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 31

Student Learning Principle 2: Schools should ensure that all students have equitable opportunities to learn and to meet high standards. The authors enumerate the most important learning opportunities as: (1) teacher quality, (2) a safe and orderly learning environment, (3) time actively engaged in learning, (4) student-teacher ratio, (5) rigor of the curriculum, (6) grouping practices that avoid tracking and rigid forms of student assignment based on past performance, (7) so- phistication and currency of learning resources and information technology used by students, and (8) access to extra-curricular activities. Health careers education classes appear to meet most of these criteria admirably, focusing as they do on hands-on learning in small classes using current health care technology, grouping students by interest rather than ability, and active student participation in Health Occupations Students of America (HOSA). Principle 3: The curriculum should help students understand that knowledge is socially constructed and reflects researchers’ personal experiences as well as the social, political, and economic contexts in which they live and work. This relates primarily to the teaching of history, in which often the “Schools should provide dominant group is portrayed as good and noble and everyone else appears in a negative all students with oppor- light. The authors point out that teaching students different interpretations of history will tunities to participate in help them develop empathy for differing points of view and the ability to think critically extra- and co-curricular about information. activities that develop knowledge, skills, and at- Principle 4: Schools should provide all students with opportunities to participate in extra- and co- titudes that increase aca- curricular activities that develop knowledge, skills, and attitudes that increase academic achieve- demic achievement and ment and foster positive interracial relationships. Career and technical education of all kinds, foster positive interracial and especially health careers education through Health Occupations Students of America relationships.” (HOSA), does an admirable job of fulfilling this principle. Diversity within Unity Intergroup Relations Principle 6: Students should learn about stereotyping and other related biases that have negative effects on racial and ethnic relations. Principle 7: Students should learn about the values shared by virtually all cultural groups (e.g., justice, equality, freedom, peace, compassion, and charity). Principle 8: Teachers should help students acquire the social skills needed to interact effectively with students from other racial, ethnic, cultural, and language groups. This is another instance in which HOSA makes a significant contribution to the education of health careers students, as they learn such social and workplace skills as getting along with others, working with diversity, and conflict resolution. The Model Curriculum Standards for the Health Science and Medical Technology Industry Sector include standards on understanding and respecting cultural differences (7.5, 7.6, 9.5). Assessment Principle 12: Teachers should use multiple culturally sensitive techniques to assess complex cognitive and social skills. The authors emphasize the importance of using a variety of assessments to enable students with different learning styles to demonstrate mastery. They suggest such techniques as observations, performance behaviors, portfolios, and problem-solving that are frequently part of the health careers education classroom. An exhaustive and helpful research publication by the National Academy of Sciences, Improving Schooling for Language-Minority Children, suggests the importance of giving language-learners extensive opportunities to interact with native speakers. One researcher ○○○○○○○○○○○○○○○○○○○○○○○○ 32 ○○○○○ Respecting Differences, Celebrating Diversity:

Successful programs profound that successful programs provide opportunities for contact between monolingual En- vide opportunities for glish speakers and English language learners during instruction in core content, in electives, contact between mono- and in alternative activities such as projects—all of which can be accomplished quite easily lingual English speakers within the framework of a health careers education program. Another researcher found that and English language while all learners benefit from this kind of interaction, Hispanic students benefit more than learners during instruc- most. As with native English-speaking students, parental involvement in the student’s school tion in core content, in program was found by several researchers to be beneficial. electives, and in alternative activities such as projects. Improving Schooling Conclusion for Language-Minority An excellent new resource, Beyond “Bilingual” Education, recognizes the challenges Califor- Children nia teachers and administrators face as they attempt to help immigrant students benefit from public education when they lack health care and other social services—all in a climate of reduced budgets and required accountability measures that dilute teacher energy and effectiveness. The book looks at English language learners and recent immigrant students in Los Angeles, San Diego, San Francisco, Long Beach, and Fresno. The authors state:

Teaching language is only one important aspect of educating immigrants effectively. In order to reap the benefits of the opportunities provided by immigrant students, states and The process of under- the federal government need to become more attuned to the wide range of challenges facing standing and communi- recent immigrants and provide programs and services that help schools integrate them eco- cating with students and nomically and socially. clients who speak a dif- Public school teachers and health care providers are key factors in the equation for ferent language, practice establishing a state and national culture in which people from around the world can live a different religion, and together in mutual respect and harmony. We have much to learn from one another. The eat different foods than we do is not easy, but it process of understanding and communicating with students and clients who speak a differ- is worth the effort. ent language, practice a different religion, and eat different foods than we do is not easy, but it is worth the effort. Indeed, if we do not make the effort our jobs as teachers and health care providers will be more difficult, and our students and clients will suffer. In her excellent resource Caring for Patients from Different Cultures: Case Students from American Hospitals, Geri-Ann Galanti puts our mission succintly:

Treat the patient/[student] as a whole person with psychological and spiritual needs as well as physical/[educational] ones. See [them] as members of a family unit, not [simply] as individuals. Do not assume that patients/[students] or co-workers will view the world the same way that you do; they may have different values and different ways of looking at things. “Do not make assump- Do not make assumptions and do respect differences. Recognize that other people’s views tions and do respect dif- are just as valid as yours (146). ferences. Recognize that other people’s views are The country profiles on the following pages are intended to introduce health care pro- just as valid as yours.” viders and educators to the cultures from which the largest numbers of California immi- Geri-Ann Galanti grants and English language learners come. Every effort has been made to provide accurate, up-to-date information while keeping the profiles brief. Statistics in the “Quick Facts” sections have for the most part been taken from the April 2005 on-line version of the CIA World Factbook. The task has been challenging, as sources vary even on information as basic as country area and dates of important historic events. That said, educators and health care providers should be able to broaden their knowledge of students and clients from other cultures by studying these materials, keeping in mind the key concept of individual differences. May increased harmony and mutual understanding result. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○33 Resources and References Immigration, Education August, Diane, and Kenji Hakuta. 1998. Educating Language-Minority Children. Commission on Behavioral Social Sci- ences and Education. http://www.nap.edu/openbook/0309064147/html/R1.html (4 Feb. 2004). ———. 1997. Improving Schooling for Language-Minority Children: A Research Agenda. Commission on Behavioral Social Sciences and Education. http://www.nap.edu/openbook/0309054974/html/R1.html (4 Oct. 2003). Banks, James A., et al. 2001. Diversity within Unity: Essential Principles for Teaching and Learning in a Multicultural Society. Center for Multicultural Education, College of Education, University of Washington, Seattle. http:// depts.washington.edu/coe/programs/ci/pubs/DiversityUnity.pdf. (10 Feb. 2005). Benitez, Tomas. 2004. “About the Family. East L.A.: Past and Present.” American Family. http://www.pbs.org/americanfamily/ eastla.html (20 Feb. 2005). Boyd, Fenice, et al., eds. 2003. Multicultural and Multilingual Literacy and Language: Contexts and Practices. New York: Guilford Press. California Department of Education, Educational Demographics Unit. Enrollment in California Public Schools. http:// data1.cde.ca.gov/dataquest (20 Feb. 2005). ———. English Learners in California Public Schools. http://data1.cde.ca.gov.dataquest./aspGraph2.asp?Level=State (19 Feb. 2005). ———. Statewide English Learners by Language and Grade. http://data1.cde.ca.gov.dataquest (19 Feb. 2005). ———. Statewide Fluent-English-Proficient by Language and Grade. http://data1.cde.ca.gov.dataquest (19 Feb. 2005). Capps, Randy, and Jeffrey Passel. 2003. The New Neighbors: A Users’ Guide to Data on Immigrants in U.S. Communities. The Urban Institute. http://www.urban org/url.cfm?ID=310844 (15 Feb. 2005). Eck, Diana. 2002. A New Religious America: Managing Religious Diversity in a Democracy: Challenges and Prospects for the 21st Century. International Conference on Religious Pluralism in Democratic Societies. http:// www.usembassymalaysia.org.my/eck.html (28 Mar. 2004). Fix, Michael, and Jeffrey Passel. 2003. U.S. Immigration: Trends and Implications for Schools. Immigration Studies Program, The Urban Institute. http://www.urban.org/url.cfm?ID=410654 (18 Feb. 2005). Gershberg, Alec, et al. 2004. Beyond “Bilingual” Education: New Immigrants and Public School Policies in California. Washing- ton, DC: The Urban Institute. Hamilton, Richard, and Dennis Moore. 2004. Educational Interventions for Reguee Children: Theoretical Perspectives and Implementing Best Practice. http://www.tcrecord.org/PrintContent.asp?ContentID=11405 (19 Nov. 2004). Hayasaki, Erika. 2004. “Cultural Divide on Campus.” Los Angeles Times. 3 Dec. http://www.latimes.com/news/ (3 Dec. 2004). Ibarra, Ignacio, and Jeffry Scott. 2000. “Lure of the North: ‘I Had to Come.’” Arizona Daily Star. 29 Oct. http:// www.azstarnet.com/journey/day1.html (27 Mar. 2003). Katz, Susan R. 1999. Teaching in Tensions: Latino Immigrant Youth, Their Teachers, and the Structures of Schooling. Teachers College Record 100: 809–840. Kugler, Eileen. 2003. “The Evidence Is In: Diversity Helps Students.” Washington Post. 9 Oct. http:// www.washingtonpost.com/ac2/wp-dyn/A63524-2003Oct8?language=printer (9 Oct. 2003). Marech, Rona. 2005. “Immigrants’ Kids Found to Make Gains: Income, Education, Job Status Higher, Census Data Show.” San Francisco Chronicle. 22 Feb. http://www.sfgate.com (23 Feb. 2005). Martinez, Ruben. 2004. “At the Crossroads: Latinos in the New Millennium.” American Family. http://www.pbs.org/ americanfamily/latino1.html (20 Feb. 2005). National Council of La Raza. 2003. Hispanic Education in California, Fact Sheet. http://www.nclr.org (20 Feb. 2005). National Immigration Forum. 2003. A, B, Cs of U.S. Immigration. http://immigrationforum.org (28 Mar. 2004). O’Connell, Jack. 2004. High School: A Newsletter for California Educational Leaders. Jan/Feb, Vol. 3, No. 1. California De- partment of Education. http://www.cde.ca.gov/re/pn/nl/documents/janfeb2004.doc (7 Jan 2005). Peña, Robert. Cultural Differences and the Construction of Meaning: Implications for the Leadership and Organizational Context of Schools. Education Policy Analysis Archives. 8 Apr. 1997. http://epaa.asu.edu/epaa/v5n10.html (4 Oct. 2003). Rodriguez, Clara. 2004. “What It Means to Be Latino.” American Family. http://www.pbs.org/americanfamily/latino3.html (20 Feb. 2005). Rumbaut, Ruben. 1996. The New Californians: Assessing the Educational Progress of Children of Immigrants. http:// www.ucop.edu/cprc/rumbaut.html (4 Oct. 2003). ○○○○○○○○

34 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Resources and References, cont.

Santa Ana, Otto. 2004. “Is There Such a Thing as Latino Identity?” American Family. http://www.pbs.org/americanfamily/ latino2.html (20 Feb. 2005). Schulte, Brigid. 2004. “Teaching Teachers How to Connect with Urban Students.” Washington Post. 26 Jul. http:// www.washingtonpost.com/ac2/wp-dyn/A13886-2004Jul25?language=printer (26 Jul. 2004).

Culturally Competent Care American Medical Student Association. Cultural Competency in Medicine. http://www.amsa.org/programs/gpit/cultural/ cfm (7 Oct. 2004). American Public Health Association. Latin America: Health Culture Sketch. http://www.apha.org/ppp/red/laintro.htm (14 Feb. 2005). Anderson, Barbara. 2003. “Language Hinders Health-Care Service.” The Fresno Bee. 1 Aug. http://news.ncmonline.com (14 Feb. 2004). Association of Community Organizations for Reform Now (ACORN). 2004. Speaking the Language of Care: Language Barriers to Hospital Access in America’s Cities. http://www.acorn.org/fileadmin/Additional_Accomplishments/ National_report.pdf (10 Oct. 2004). Association of Asian Pacific Community Health Organizations. http://www.aapcho.org. Athat, Shahid. Information for Health Care Providers When Dealing with a Muslim Patient. Islamic Medical Association of North America. http://www.islam-usa.com/e40.htm (7 Oct. 2004). Betancourt, Joseph, et al. 2002. Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. The Commonwealth Fund. http://www.cmwf.org (10 Oct. 2004). California Department of Health Services. http://www.dhs.ca.gov. California Healthcare Interpreting Association. http://www.chia. California Pan-Ethnic Health Network. http://www.cpehn.org. California Primary Care Association. 2002. Providing Health Care to Limited English Proficient Patients: A Manual of Prom- ising Practices. http://www.cpca.org (24 Feb. 2005). Campinha-Bacote, Josepha. 2003. “Many Faces: Addressing Diversity in Health Care.” Online Journal of Issues in Nursing. Vol 8, No. 1. http://nursingworld.org/ojin/topic20/tpc20_2.htm (7 Oct. 2004). Chen, Alice. 2003. “Beware of the Know-It-All-Interpreter.” New California Media. 1 Oct. http://news.ncmonline.com Collins, Karen, et al. 2002. Diverse Communities, Common Concerns: Assessing Health Care Quality for Minority Americans. The Commonwealth Fund. http://www.cmwf.org (20 Apr. 2004). Center for International Rehabilitation Research Information and Exchange (CIRRIE). The Rehabilitation Provider’s Guide to Cultures of the Foreign-Born. http://cirrie.buffalo.edu/mseries.html. Duhigg, Charles. 2005. “A Spiritual Treatment?” Los Angeles Times. 28. Feb. http://www.latimes.com/features/health (28 Feb. 2005). Fadiman, Anne. 1997. The Spirit Catches You and You Fall Down. New York: Farrar, Strauss, and Giroux. Galanti, Geri-Ann. 1997. Caring for Patients from Different Cultures: Case Studies from American Hospitals, 2nd Ed. Philadel- phia: University of Pennsylvania Press. ———. Cultural Diversity in Healthcare Web site. http://ggalanti.com. Grantmakers in Health. 2003. In the Right Words: Addressing Language and Culture in Providing Health Care. Issue Brief No. 18. http://www.gih.org (23 Feb. 2005). Habel, Maureen. 2003. Putting Patient Teaching into Practice. Nurse Week Continuing Education Course. http:// www.cyberchalk.com/nurse/courses/nurseweek/nw0650/course.htm (16 Feb. 2004). Harvard School of Public Health. Health Literacy Studies. http://www.hsph.harvard.edu/healthliteracy. Healthfinder. http://www.healthfinder.gov. Henry J. Kaiser Family Foundation. 2003. Compendium of Cultural Competence Initiatives in Health Care. http://www.kff.org (7 Jan. 2005). Islamic Council of Queensland, Australia. 1996. Health Care Providers Handbook on Muslim Patients. http:// www.health.qld.gov.au/multicultural/pdf/islamgde.pdf (24 Feb. 2005). Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 35

Resources and References, cont.

Jezewski, Mary Ann, and Paula Sotnik. 2001. Culture Brokering: Providing Culturally Competent Rehabilitation Services to Foreign-Born Persons. Center for International Rehabilitation Research Information and Exchange (CIRRIE). http:// cirrie.buffalo.edu. Kagawa-Singer, Marjorie, and Shaheen Kassim-Lakha. 2003. “A Strategy to Reduce Cross-cultural Miscommunication and Increase the Likelihood of Improving Health Outcomes.” Academic Medicine 78:577–587. http:// www.academicmedicine.org/cgi/content/full/78/6/577 (8 Jan. 2004). Kemp, Charles. Background on Refugees. http://www3.baylor.edu/~Charles_Kemp/backgroundonrefugees.htm (14 Feb. 2005). ———. Mexican and Mexican-Americans: Health Beliefs and Practices. http://www3.baylor.edu/~Charles_Kemp/ hispanic_health.htm (21 Apr. 2004). ———. Refugee Health. http://www3.baylor.edu/~Charles_Kemp/refugee_health_problems.htm (14 Feb. 2005). ———. Religion and Refugees. http://www3.baylor.edu/~Charles_Kemp/religion_and_refugees.htm (14 Feb. 2005). Koenig, Barbara A., and Jan Gates-Williams. 1995. “Understanding Cultural Difference in Caring for Dying Patients.” Western Journal of Medicine, 163:244–249. http://ethnomed.org. (3 Mar. 2005). Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. Meadows, Michelle. 2000. “Moving Toward Consensus on Cultural Competency in Health Care.” Closing the Gap. January. Office of Minority Health, U. S. Department of Health and Human Services. http://www.omhrc.gov (21 Feb. 2005). Miller, Donald, et al. 2001. Immigrant Religion in the City of the Angels. Center for Religion and Civic Culture, University of Southern California. Morales, Leo S., et al. 2003. Improving Patient Satisfaction Surveys to Assess Cultural Competence in Health Care. California HealthCare Foundation. http://www.chcf.org. Murray-Garcia, Jann. 2002. Multicultural Health 2002: An Annotated Bibliography, 2nd Ed. The California Endowment. http://www.calendow.org (21 Feb. 2005). National Alliance for Hispanic Health. 2001. A Primer for Cultural Proficiency: Towards Quality Health Services for Hispanics. http://www.hispanichealth.org/pdf/primer/pdf (21 Feb. 2005). National Center for Complementary and Alternative Medicine. What Is Complementary and Alternative Medicine (CAM)? http://nccam.nih.gov (23 Feb. 2005). National Center for Cultural Competence. http://gucchd.georgetown.edu/nccc. National Council on Interpreting in Health Care. nttp://www.ncihc.org. Office of Minority Health Resource Center. http://www.omhrc.gov. Pew Hispanic Center/Kaiser Family Foundation. 2002. 2002 National Survey of Latinos. http://www.pewhispanic.org/site/ docs/pdf.LatinoSurveyReportFinal.pdf (23 Feb. 2005). Provider’s Guide to Quality and Culture. http://www.msh.org/programs/providerrs_guide.html. Pryor, Carol, et al. 2002. What a Difference an Interpreter Can Make: Health Care Experiences of Uninsured with Limited English Proficiency. The Access Project. http://www.accessproject.org (25 Feb. 2005). Resources for Cross Cultural Health Care. http://www.diversityrx.org. Ross, Houkje. 2001. “Office of Minority Health Publishes Final Standards for Cultural and Linguistic Competence.” Closing the Gap. Feb/Mar. Office of Minority Health, U. S. Department of Health and Human Services. http:// www.omhrc.gov (21 Feb. 2005). Transcultural Nursing. http://www.culturediversity.org. University of Michigan Health System Program for Multicultural Health. http://www.med.umich.edu/multicultural/. U.S. Department of Health and Human Services, Health Resources and Services Administration. 2001. Cultural Compe- tence Works: Using Cultural Competence to Improve the Quality of Health Care for Diverse Populations and Add Value to Managed Care Arrangements. http://www.hrsa.gov/financeMC/ftp/cultural-competence.pdf (24 Feb. 2005). Vedantam, Shankar. 2005. “Patients’ Diversity Is Often Discounted.” Washington Post. 26 June. http:// www.washingtonpost.com (26 Jun. 2005). ○○○○○○○○

36 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Resources and References, cont.

Other Resources Center for Applied Linguistics: http://www.cal.org Excellent resources on language and culture, immigrant education, refugees; includes link to Creating Access: Language and Academic Programs for Secondary School Newcomers.

Center for Cross-Cultural Health: http://www.crosshealth.com Minnesota Department of Health Web site with good information on integrating the role of culture in improving health. Includes sources for health materials in various languages.

CIRRIE: Center for International Rehabilitation Research Information and Exchange http://cirrie.buffalo.edu Excellent resources for understanding other cultures and providing culturally competent health care.

Combined Health Information Database, National Institutes of Health: http://chid.nih.gov Source for listings of health materials in many Asian languages.

Commonwealth Fund: http://cmwf.org An excellent Web site with resources on health care for minorities and the underserved.

Cross Cultural Health Care Program: http://www.xculture.org Seattle organization provides profiles of ethnic communities, resources for caregivers.

CulturedMed: http://www.sunyit.edu/library/html/culturedmed State University of New York Institute of Technology Web site that promotes culturally competent health care for refugees and immigrants.

Diversity Rx: http://www.diversityrx.org Excellent resources for providing culturally competent health care.

EthnoMed: http://ethnomed.org Site developed by University of Washington Harborview Medical Center provides medical and cultural information on immigrant and refugee groups in the Seattle area; includes patient education materials in various languages.

Manager’s Electronic Resource Center: http://erc.msh.org Comprehensive information from Management Sciences for Health on working with health-care clients from other cultures, including profiles of many different cultures focusing on health concerns, etc. Includes The Provider’s Guide to Quality & Culture. Exceptional resource.

Nursing World: http://nursingworld.org. Includes many resources on diversity.

World Education: http://www.worlded.org Guide to culture, health, and literacy for health care practitioners working with patients with limited English skills. In- cludes links to health education materials and Web sites.

Latin America Mexico El Salvador Guatemala ○○○○○○○○

38 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 39 Mexico

Census Figures (2000) United States Residents Born in Mexico: 9,177,487 (29.5%) United States Residents of Mexican Descent: 25,287,619 (2003 American Community Survey) California Residents Born in Mexico: 3,928,701 (44.3%) California Residents of Mexican Descent: 9,885,974 (2003 American Community Survey) Quick Facts Country Area: 756,066 sq. miles (nearly three times the size of Texas) Population: 106,202,903 Median Age: 24.93 years Population Growth Rate: 1.17% Life Expectancy at Birth: 75.19 years Below Poverty Line: 40% Literacy Rate: 92.2% Currency: Mexican peso (MXN) Population Groups: Mestizo 60%, Amerindian 30%, White 9%, Other 1% Languages: Spanish, Amerindian (Natl, Maya, Mixtec, Otom, Tzeltal, Tzotzil, other) Religion: Roman Catholic 88%, Protestant 6%, Other 6% Government: United Mexican States, federal republic; 31 states, 1 federal district; president elected to six-year term; General Congress consists of Senate and Chamber of Deputies; capital is Mexico City Climate: tropical to desert depending upon location Natural Hazards: tsunamis, volcanoes, earthquakes, hurricanes Natural Resources: petroleum, silver, copper, gold, lead, zinc, natural gas, timber Arable Land: 13% Agricultural Products: corn, wheat, soybeans, rice, beans, cotton, coffee, fruit, tomatoes; beef, poultry, dairy products; wood products Exports: fruit, vegetables, coffee, cotton; manufactured goods, oil and oil products, silver Industries: food and beverages, tobacco, chemicals, iron and steel, petroleum, mining, textiles, clothing, motor vehicles, consumer durables, tourism Labor Force: agriculture 18%, industry 24%, services 58% ○○○○○○○○

40 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Mexico, cont. Brief History Our neighbor to the south has a long and proud history, dating to at least 9000 BC when maize, or corn, was first grown in the Tehuacan Valley in the current-day Puebla region of Mexico. Other early peoples include the Olmecs (1800 BC), Zapotecs (300 BC), Maya (250 AD), Toltecs (600 AD), and Aztecs (1325 AD). Spanish explorers conquered the Aztecs in 1521 and ruled Mexico for 300 years. The Mexican empire at that time included what is now California, Arizona, New Mexico, Texas, Colorado, Utah, parts of Wyoming, and most of Central America. Texas declared its independence from Mexico following the Battle of the Alamo in 1836. In 1845, the U.S. Congress voted to annex Texas, leading to the Mexican-American War. Under terms of the Treaty of Guadalupe in 1848, Mexico gave nearly half its territory, what is now Texas, California, Utah, Colorado, and most of Arizona and New Mexico, to the United States. In 1864, the French under Napolean conquered Mexico City and installed Austrian Archduke Maximilian as emperor. The French withdrew in 1867; Maximilian was executed, and Benito Juarez became president. Dictator Porfirio Diaz ruled Mexico from 1878 to 1911. In 1910, a 10-year revolution started under the leadership of land reformer Emiliano Zapata, for whom the present-day Zapatista revolutionaries are named. Diaz was overthrown in 1911; new president Francisco Madero introduced land reform. In 1916, U.S. forces crossed the border in search of the notorious bandit Francisco “Pancho” Villa. The National Revolutionary Party took control of Mexico in 1934, nationalizing oil and instituting land reform. The 1968 summer Olympic Games were held in Mexico City; during that time, hundreds of students were killed in demonstrations. An earthquake in Mexico City in 1985 killed at least 10,000 people. Carlos Salinas de Gortari was elected president in a controversial election in 1988; he signed NAFTA and privatized many industries. In 1994 Zapatista National Liberation Army rebels, working for the rights of indigenous peoples in Chiapas, were brutally suppressed by government troops. Vicente Fox of the National Action Party was elected president in 2000. Current problems include the displacement of farmers and the introduction of genetically modified corn, and a downturn in maquiladora profitability with resulting unemployment as multinational corporations move factories to countries where labor is even cheaper. Housing, Family, Work, Traditions Housing: Lack of adequate housing is an ongoing problem in Mexico, with perhaps one-third of the adult population living in substandard housing. In 1990, nearly 80 percent of Mexican households had access to running water (not necessarily within a house), an improvement over 70 percent in 1980. In some rural areas, people construct shelter of anything available—leaves, cardboard, tin, whatever comes to hand. One-room wooden and adobe huts with dirt floors are common. While less than 20 percent of houses overall had dirt floors in 1990, the figure was more than 50 percent for families in Oaxaca. Habitat for Humanity has constructed more than 12,000 houses in Mexico, using local materials where possible; a 2004 Jimmy Carter building project built 150 homes of autoclaved aerated concrete blocks in five days in Puebla and Veracruz. In large cities, thousands live in shanty towns surrounding the city, and an estimated 40,000 children are on the streets, often involved with alcohol, prostitution, stealing, drugs, or violent crime. Family: Traditionally, Mexicans emphasize the family, la familia, over the individual and include the immediate and extended families in important decisions, with the father or eldest male being the final authority. The traditional role of the male, machismo, indicates the male’s responsibility for the family’s welfare and honor. Marianismo, a traditional descriptor of the female role, indicates women’s spiritual superiority and ability to suffer. Children are protected and taught to be obedient and treat their elders with respect, respeto. Respeto dictates appropriate behavior between individuals based on age, gender, social position, economic status, and authority. In the rural areas, traditional family structures tend to persevere; city families look more like their U.S. counterparts. Mexican individuals generally have the last names of both their mother’s and father’s families, with the father’s family name first. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 41

Mexico, cont.

Employment: The largest percentage of Mexican workers are employed in the service sector. Industry employs the next largest group. Urban residents generally have a six-day work week, with Sunday the only day off. UNICEF estimated that in 1996 some 3.5 million children between the ages of 12 and 17 were part of the labor force. Small-scale farmers have suffered since the implementation of NAFTA in 1994, as their unsubsidized crops cannot compete with cheap, government-subsidized produce from the United States. According to Migration Information Source, “In the last several decades, neither Mexican job creation nor labor demand in the United States have been able to absorb the large and growing cohorts of Mexican workers . . . . Even the growth of the maquiladora (export- oriented factory) sector along the border, which accounted for a record 1.3 million jobs in 2001, has not been able to provide enough job opportunities to Mexico’s growing labor force.” According to an article in the May 9, 2005 Los Angeles Times, between 40 and 50 percent of Mexico’s workforce is engaged in the informal sector, unregistered businesses that provide cheap goods and services for low-income people but pay no employment taxes. Since the election of President Vicente Fox in 2000, this underground economy has been the only source of job growth; the number of street vendors has grown by 40 percent to more than 1.6 million. One vendor explained: “It’s all up to me. There aren’t any jobs, and even if there were, no one would hire someone like me with no education.” Recreation: Soccer is the most popular sport, but Mexicans also enjoy baseball and football as well as rodeos and bullfighting. Mexico City has the world’s largest bullfighting arena. Foods and Eating Habits Dietary Practices: Some Mexican Americans adhere to traditional hot/cold beliefs about keeping the body’s four humors (blood, phlegm, yellow bile, black bile) in balance using qualities of heat, cold, moisture, and dryness. Illnesses considered cold are treated with hot foods and vice versa. No dietary taboos. Everyday Diet: Food is an important part of Mexican daily life as well as its festivals and celebrations. The main meal of the day, comida, is eaten between two and four in the afternoon. Most people eat this meal at home, but cities have restaurants that serve comida, which starts with a soup course, sopa aguada, followed by the sopa seca, a pasta or rice dish. The main course might be something like meat or chicken guisado (stew) or chiles rellenos, and this would be followed by beans. Beans and tortillas (preferably corn) are staples. Dessert is light, something like flan or fruit. Popular Foods: Most Californians are very familiar with a wide variety of Mexican foods, given our large Mexican population. Mexican cuisine is based on corn, a crop native to the area. Corn kernels are softened in water and lime, ground, and made into tortillas and tamales. Communal preparation and sharing of tamales is a strong Mexican tradition. Chiles are used both fresh and dried, ranging in hotness from mild to volcanic. Beans are another staple, often served refried or refritos. Tomatoes and tomatillos are mainstays for salsa and sauces. Fruits, including mango, papaya, pineapple, and coconut, are eaten fresh and in various dishes. Nopales, prickly pear cactus paddles, are served as a vegetable or in desserts. Squash blossoms, flores de calabaza, and pepitas, pumpkin seeds, are used in many dishes. Caldo de pollo, chicken soup, is a favorite in times of illness. Many regions are noted for special dishes. Puebla, two hours south of Mexico City, is the birthplace of mole sauce, a combination of chocolate, chiles, and spices served over turkey or chicken. Camotes, a sweet potato dessert, is a local delight. In Yucatan, cuisine is not as hot as in some other regions, depending more on fruits. Pibil, a sauce made of achiote (red annatto seeds),oranges, pepper, garlic, and cumin, is used on pork or chicken baked in banana leaves. Coastal Veracruz is noted for its fish dishes and unusual fruits. Beverages: Beverages include agua de Jamaica, agua fresca, agua de horchata (made with rice flour, vanilla, and sugar), pulque, mezcal, tequila, chocolate, and coffee. Herbal teas are used for medicinal purposes. ○○○○○○○○

42 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Mexico, cont.

Education Status: Nine years of education are required, and the national average is nearly eight years. President Vicente Fox made education his top priority when elected. The nation’s education system is widely acknowledged to be deeply corrupt. There are vast differences in opportunity between urban and rural areas, racial and economic disparities, and funding often depends on political pressure and bribes. Many people blame a powerful national teachers’ union for resisting changes in teacher training and curriculum. According to an article in Education Week, many of the students whose families emigrate from Mexico to the United States come from the southern states where education is poor. An Urban Institute study found that more than 1 million school-age children in this country were born in Mexico, accounting for about 36 percent of all school-age immigrants to the United States. Primary School: Students attend primary school for six years. Schools in cities and rural areas vary widely in resources and teacher qualifications. In 1995, the government reported an overall primary school completion rate of 62 percent. There are still areas where schools do not offer all six primary grades. Some city schools have morning sessions primarily for middle-class children, and afternoon sessions for poorer children, many of whom work in the mornings to help support their families, and who receive an inferior education. Some rural children are sent to cities to work in exchange for room and board and the opportunity to attend better schools. In the 1999–2000 school year, 14,766,000 students were enrolled in primary schools. Migration and the need for children to be employed are two factors behind poor school attendance and graduation rates. Secondary School: Following graduation from primary school, students attend the Secundaria for grades 7 through 9. Many students attend secondary school through a world-renowned program, Telesecundaria, that broadcasts courses by government-owned satellite from Mexico City to schools throughout the country and in other Latin American countries. More than 3,000 schools are linked to a new network via the Internet. The program reaches one-third of Mexico’s secondary school students. In the 1999–2000 school year, some 5,209,000 students were enrolled in Mexico’s secondary schools. High School: Students who attend Preparatoria have a choice between a college-preparatory course and technical training. In November of 2003, about 66 percent of 15-year-olds in Mexico were attending school, and Mexico is making slow progress toward improving its high school graduation rate, which was 60 percent in 2002. Higher Education: Each state in Mexico has at least one public university, some with campuses in several cities. In addition, there are private universities, technological schools, and teacher-training institutes. The National Autonomous University of Mexico City has more than 350,000 students. Religion Roman Catholicism: In the 2000 census conducted by the National Institute of Statistics, Geography, and Computa- tion, close to 88 percent of Mexicans suveyed identified themselves as Roman Catholics. There are some 11,000 Catholic churches in the country, served by an estimated 14,000 priests and nuns as well as 90,000 laypersons. About 55 percent of the population reported attending religious services at least once a week; 19 percent said they attended once a month, and about 20 percent attended less than once a month. Catholicism was introduced to Mexico by missionaries who arrived with the Spanish. Many holidays and celebrations revolve around the faith, including Semana Santa, the Feast of Our Lady of Guadalupe, and Las Posadas. Protestantism: Estimates of the size of various Protestant groups in Mexico vary considerably. In the 2000 census, respondents identified themselves as roughly 4.5 percent Pentecostal and Protestant Evangelical, Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 43

Mexico, cont.

with mainline Protestants, Jehovah’s Witnesses, Mormons, and Seventh-Day Adventists also represented. Church organizations generally claim much larger numbers. About 3.5 percent of respondents claimed to have no religion. Of nearly 6,000 religious associations registered with the federal government, about 53 percent are Protestant evangelical and 47 percent are non-Protestant Christian. The Protestant population is found primarily in the southern part of the country, with the state of Chiapas claiming a non-Catholic population of about 36 percent. The states of Tabasco, Campeche, and Quintana Roo have large Protestant populations. Other: Mexico has small Jewish and Muslim populations, and indigenous religious practices are followed in many places. In Chiapas, where a Catholic/Mayan traditional religion forms the basis for daily life and celebration, tensions between non-native Protestant evangelicals and indigenous residents has led to harassment and expulsion from communities. Health and Health Care Health Status: As might be expected in a nation where more than half the people live on less than $2 per day, malnutrition, unsanitary living conditions, and lack of access to health care contribute to a less- than-optimal health profile. Health care availability varies widely from urban to rural areas and within cities depending on income level and employment status. Infectious, parasitic, and respiratory illnesses accounted for nearly 70 percent of deaths in 1940; this figure had dropped to 20 percent by 1990, but such diseases as pneumonia and influenza still pose grave threats and are among the top 20 causes of death, along with nutritional deficiencies, measles, and anemia. Traditional Practices: Mexicans may attribute illness to an imbalance between the individual and the environment; balance may be restored by such things as correcting the balance of “hot” and “cold,” which are intrinsic properties of substances and conditions. “Cold” conditions include menstrual cramps, pneumonia, and colic; “hot” conditions include pregnancy, hypertension, and indigestion. Health care workers might hear Mexican patients referring to any of a number of folk illnesses or conditions, including mal de ojo, the “evil eye,” which may affect infants or women. Home remedies are popular and include teas made from various herbs, spices, and/or fruits. Female relatives or neighbors are often consulted, as are the verbero (herbalist), sobador (massage therapist), or partera (midwife). The curandero/a can assist with both physical and spiritual healing. Curanderismo, a combination of Aztec, Spanish, spirtualistic, homeopathic, and modern medicine, is used throughout Latin America. Health care facilities in some U.S. cities with large Hispanic populations are cooperating with curanderos to facilitate optimal care for Hispanic clients. Another traditional healing system followed in Mexico is cantero or brujería, a system of healing magic that originated in Africa. Common folk remedies used by Mexicans include ajo (garlic) for hyptertension or as an anti- biotic; damiana as an aphrodisiac or for chickenpox; gobernadora (chaparral) as a poultice for arthritis or a tea for cancer and tuberculosis; manzanilla (chamomile) for nausea and colic; salvia (sage) for diabetes and to prevent hair loss; and uña de gato for stimulating the immune system. An article from the Feb. 7, 2005 Los Angeles Times discusses the large number—some 500 in Southern California—of botánicas, herbal medicine shops, now catering to the Latinos who make up nearly 45 percent of the city’s population. Organizations of traditional doctors have been formed in Chiapas and nationwide to work on regulating medical practice with the goal of favoring the use of traditional medicine and protecting places where medicinal plants are found and grown. Medical System: Formal-sector workers and their families (about 50 percent of the population in 1995) receive health care through the nation’s social security program. In 1995 there were 121 doctors per 100,000 persons for those covered by social security. Others receive health care from various government ○○○○○○○○

44 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Mexico, cont.

agencies, with fewer resources than those covered by social security. Overall, there were 147,618 physicians in Mexico in 1997. Public health care is generally considered inferior to that provided by private physicians and hospitals. In 1997, there were 4,506 hospitals in Mexico, 1,539 of them public. Mexico City is the principle center for specialized medical care, but many Mexicans who can afford to do so travel outside the country for treatment and surgery. Common antibiotics and other drugs available only by prescription in the United States are sold over the counter in Mexico; many U.S. citizens cross the border to purchase medications and for medical and dental treatment. Tips for Health Care Providers Refer to the section on Working with Latino/Hispanic Clients (pp. 17–18) for general guidelines to follow in working with patients from Mexico. The following information may also be useful. Attitudes: Many Mexican Americans use both traditional practices and conventional Western medicine. Male physicians are generally accepted provided they show respect for modesty and privacy. Most sensitive health information is kept within the family. Clients may be more comfortable disclosing information to health care providers of the same gender. Health care providers, especially physicians, who fail to show respect may be seen as racist or classist. A study conducted in Los Angeles in 2000 found that many Latinos did not use available public health services due to language and transportation problems and perceived cultural insensitivity, as well as fear of deportation. Family Authority: The father or oldest male traditionally is the highest authority. Important medical decisions may require consultations involving the entire family. Health care providers should determine who is the person in charge and be sure to include that individual in decision-making. Addressing Clients: Clients should be addressed in a formal manner, using usted rather than tu if speaking in Spanish, especially in the case of elders and women. Nonverbal Behavior: Touching by strangers is often considered inappropriate or seen as disrespectful and can be stressful. Therapeutic touch is an integral part of traditional healing. Handshaking is considered polite and is generally welcome. Verbal Exchange: Health care providers should give clear explanations of medical conditions and options. Clients may ask for the provider’s opinion on choices. Hospitalization: Family members are traditionally quite involved in care and may see hospital regulations as an impediment to their role. Stoicism is common when dealing with pain, especially among men. Some Mexican American patients may refuse foods based on the idea of hot foods being used to treat cold illnesses and vice versa. Health care workers should be sensitive to the client’s request for such Catholic rites as baptism and the anointing of the sick. Death and Dying: Information about a terminal illness is often handled by a family spokesperson such as the oldest son or daughter, who may wish to shield the patient from knowledge of the gravity of the illness. Dying at home may be preferable. If the patient is Catholic, make sure his or her priest or the hospital chaplain is available for appropriate rites. Wailing is a socially acceptable sign of respect. Relatives or family members may want to assist with the body and will probably request time alone with the body to say farewell. Many Catholic Mexican Americans believe the body must be kept intact for burial and so will resist autopsy and organ donation. Celebrations and Holidays January 1 Año Nuevo, New Year’s Day January 6 Dia de los Santos Reyes, Three Kings’ Day (Epiphany) February 5 Dia de la Constitución, Constitution Day February 14 Dia de la Amistad, Valentine’s Day February 24 Dia de la Bandera, Flag Day Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 45

Mexico, cont.

February/March Carnaval (five-day celebration; begins the week before Lent—parades, music, dancing, feasting) March 21 Birthday of Benito Juarez March/April Semana Santa, Holy Week, includes Holy Thursday, Good Friday, Easter Sunday May 1 Primero de Mayo: National holiday honoring workers, similar to Labor Day. May 5 Cinco de Mayo: National holiday commemorating Mexican victory over the French in 1862. May 10 Dia de la Madre, Mothers’ Day May 18 Nationalization of Petroleum Industry: Commemorates the nation’s taking over oil producing properties from foreign interests. June 24 San Juan Bautista, feast of St. John the Baptist July 18 Death of Benito Juarez September 15 El Grito de Dólores, Cry of Independence: Marks the day Miguel Hidalgo announced the Mexican revolt against Spain. October 12 Dia de la Raza, Day of the Race November 1 & 2 Dia de los Muertos, Day of the Dead. It is believed that the spirits of the dead return to Earth to visit friends and relatives. November 1 is also called Day of the Little Angels, dedicated to children who have died. The Day of the Dead is observed throughout the country, but traditions vary considerably by region and town, with the celebration being more important and elaborate in the southern, more rural parts of Mexico. Many communities clean and decorate graves with branches and flowers. At the gravesites, family members tell stories about departed family members as they share food enjoyed by the departed. These meals are often elaborate and include a special Pan de Muerto, featuring a plastic skeleton baked into a rich dough, as well as sweets in animal, skeleton, and skull shapes. This is a festive occasion, as the living and the dead eat and drink together. November 20 Dia de la Revolución: Celebrates the Mexican Revolution of 1910. December 12 Feast of Our Lady of Guadalupe, Mexico’s patron saint (also called the Virgin of Guadalupe); Celebrates the three appearances of the Virgin Mary to Juan Diego, a poor Indian, just north of Mexico City in 1531; millions of pilgrims come to the Basilica of Guadalupe. This miracle was recognized by the Vatican in 1745. Celebrations include parades, fireworks, dancing, and feasting. December 16–24 Las Posadas: Festival celebrated with processions that commemorate the journey of Mary and Joseph to Bethlehem. December 24 Nochebuena, Christmas Eve December 25 Navidad, Christmas Day December 31 Vispera de Año Nuevo, New Year’s Eve Mexicans in the United States Fr. Junipero Serra and other Spanish missionaries were the first Mexican presence in what is now California, coming in 1769 to establish the presidio and Catholic mission of San Diego. By 1823, 21 missions were strung along the California coast, roughly one day’s walk apart, between San Diego and Sonoma. Early settlers were primarily farmers and ranchers. Most were of mixed racial background, and they created additional mixtures by marrying native California Indians. Mexicans living in the territories ceded to the United States in 1848 were offered U.S. citizenship with the promise of property rights; some 80,000 accepted the offer and are the ancestors of today’s fourth-, fifth-, and sixth-generation Mexi- can Americans. According to the Migration Information Source, migrants to the United States from Mexico can be divided into three categories: (1) sojourner or circular migrants—authorized and unauthorized migrants, generally young and primarily male with little education, who come to the United States to work, mainly in agriculture, but whose primary residence is in Mexico; (2) settled or permanent migrants—authorized and unauthorized migrants, about equally male and female with higher education levels whose residence is in the United States; and (3) naturalized U.S. citizens born in Mexico—these people form a subgroup of the permanent migrants. Before 1929, movement between Mexico and the United States was relatively easy. Mexicans came to the United ○○○○○○○○

46 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Mexico, cont.

States in the 1800s to work on railroad construction, and they were recruited during World War I. During the Great Depression of 1931 to 1940, an estimated 458,000 Mexican Americans were repatriated and deported back to Mexico. Mexicans began migrating to the United States in large numbers during World War II when the United States asked for Mexican workers, braceros, to contribute to the war effort by providing temporary agricultural labor in this country. From 1942 until the bracero program ended in 1964, an estimated 4.5 million workers came to the United States from Mexico. Mexicans have continued to emigrate to the United States, with about 300,000 per year coming across the border either legally or illegally in the 1990s. The movement is primarily motivated by the need for employment, with Mexicans from both urban and rural areas throughout the country seeking opportunities in the United States. The U.S. Census Bureau estimates that there are more than nine million Mexican immigrants living in this country. Of these, about one in five are naturalized U.S. citizens; more than half are undocumented, not authorized to be in the United States. Establishment of the maquiladora districts in 1965 has brought millions of people from all over Mexico to border towns, but the sheer size of the applicant pool and a recent downturn in the maquiladora industry have increased the number of undocumented individuals crossing into the United States. As of the 2000 census, 32 percent of Californians were Hispanic, accounting for three-fourths of the state’s population growth in the decade between 1990 and 2000. Combined “minority” groups now make up a majority of the state’s population. Hispanics accounted for 12.6 percent (35.6 million people) of the U.S. population in 2000; that figure is expected to grow to 24.4 percent, or 102.6 million people, by 2050. These figures include native Hispanics, people born in the United States of Hispanic origin, and foreign-born Hispanics of whatever citizenship status. In a 2004 interview, a Roman Catholic priest with Mexican and Guatemalan roots serving in East Los Angeles stated:

I think Mexican Americans have a very small social space. Most of the world is either Mexican or American. If you’re Mexican American and you go to Mexico, you’re an American. If you’re in this country, you’re a Mexican. So what you learn to do is hang out with your own kind. . . . There’s a bit of schizophrenia that you learn to negotiate when you’re a U.S.-born Latino, which is quite different from the world of immigrants (U.S. Catholic, 25).

The church often serves as a center for support and socialization, offering education, social programs, health care, a place for celebrating and organizing, and assistance with immigration matters. Quinceañeras, the occasion of a Mexican girl’s 15th birthday and entry into the adult world, is widely celebrated in the United States. Language; Useful Words and Phrases Spanish for Health Care Workers, available at www.health-careers.org, provides words and phrases the health care provider can use with Spanish-speaking patients. Spanish is pronounced much like English. Differences include: “ll” is pronounced “y,” “j” is pronounced “h,” “h” is silent, “ñ” is pronounced “ny.” Unless otherwise indicated by an accent mark, the stress falls on the next to the last syllable if the word ends in a vowel or the letters “n” or “s”, on the last syllable if it ends in a consonant. Good morning. Buenos días. Good afternoon. Buenos tardes. Good night. Buenos noches. Hello. Hola. Goodbye. Adiós. See you later. Hasta la vista. Yes/No Sí/No Thank you. Gracias. You’re welcome. De nada/No hay de que. How are you? ¿Cómo está? I am fine, thank you. And you? Muy bien, gracias. Y usted? What is your name? ¿Cómo se llama? My name is . . . . Me llamo . . . . What happened? ¿Qué pasó? Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 47

Mexico, cont.

Where does it hurt? ¿Dónde le duele? Let me help you. Déjeme ayudarle. Are you cold? ¿Tiene frío? Are you hungry? ¿Tiene hambre? Are you thirsty? ¿Tiene sed? breakfast desayuno lunch almuerzo dinner cena Do you need to go to the bathroom? ¿Necesita ir al baño? Do you want to sit up? ¿Quiere sentarse? I am going to take your temperature. Voy a tomarle la temperatura. References Alba, Francisco. 2002. “Mexico: A Crucial Crossroads.” Migration Information Source. July. http:// www.migrationinformation.org/Profiles (5 Mar. 2004). Althaus, Dudley. 2000. “A People in Want.” Houston Chronicle, 20 Nov. http://www.chron.com/cs/CDA/printstory.mpl/ special/mexnewsun/752137 (24 Mar. 2004). Area Studies, Latin America: Mexico, Basic Facts. http://wrc.lingnet.org/mexicol.htm (21 Mar. 2004). BBC News. Timeline: Mexico. http://newsvote.bbc.co.uk (23 Feb. 2004). Central Intelligence Agency. 2005. “Mexico.” The World Factbook. http://www.cia.gov/cia/publications/factbook/geos/mx.html (8 May 2005). Cevallos, Diego. 2001. Learning through TV and Internet in Mexico. http://www.unesco.org/education/efa/know_sharing/ grassroots_stories/mexico_3.shtml (24 Mar. 2004). Country Profile: Mexico. BBC News. http://newsvote.bbc.co.uk (23 Feb. 2004). Daniel, Rebekah. 2005. “Building Dreams . . . and Houses.” Habitat World. Vol. 22, No. 1. Dickerson, Marla. 2005. “Mexico Runs on Sidewalk Economy.” Los Angeles Times. 9 May. http://www.latimes.com/business/la-fi-vendors (9 May 2005). Ferriss, Susan. 2003. “Mexico Lags in High School Graduation.” Arizona Daily Star. 21 Dec. http://www.azstarnet.com/ dailystar/printDS/3119.php (24 Apr. 2004). Grieco, Elizabeth. 2003. “Foreign-Born Hispanics in the United States.” Migration Information Source. 1 Feb. http:// www.migrationinformation.org (5 Feb. 2004). Habitat for Humanity Mexico. http://www2.habitat.org/intl/countryprofiles.fm (24 Mar. 2004). Kemp, Charles. Mexican and Mexican-Americans: Health Beliefs and Practices. http://www3.baylor.edu/~Charles_Kemp/ hispanic_health.htm (21 Apr. 2004). Lee, Cecilia, ed. 2002. Mexico. Anti-Racism, Multiculturalism and Native Issues Centre, Faculty of Social Work, University of Toronto, Canada. http://www.settlement.org/cp/english/guatemala (29 Feb. 2004). Library of Congress, Federal Research Division. Country Studies: Mexico. http://countrystudies.us/mexico (25 Mar. 2004). Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. Lonely Planet World Guide: Destination Mexico. http://www.lonelyplanet.com/destinations/north_america/mexico (23 Feb. 2004). MacGregor, Hilary. 2005. “Mainstream Medicine Is Beginning to Explore the Aisles of Botanicas.” Los Angeles Times. 7 Feb. http://www.latimes.com/features/ (9 Feb. 2005). Mexico, Country Study and Guide. http://reference.allrefer.com/country-guide-study/mexico/mexico52.html (23 Mar. 2004). “Mexico: A Brief History.” Houston Chronicle, 21 Nov. 2000. http://www.chron.com/cs/CDA/printstory.mpl/special/ mexnewsun/752144 (24 Mar. 2004). Mexico. Encyclopedia of Days. http://www.shagtown.com/days/m2.html (28 Feb. 2004). Mexico: Health and Social Security. http://reference.allrefer.com/country-guide-study/mexico/mexico52.html. ○○○○○○○○

48 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Mexico, cont.

National Park Service. A History of Mexican Americans in California. http://www.cr.nps.gov/history/online_books/5views/ 5views5.htm (24 Mar. 2005). Nigenda, G, et al. 2001. “The Practice of Traditional Medicine in Latin America and the Caribbean” Salud Publica de Mexico 43:41-51. http://www.insp.mx/salud/43/eng/i43_5.pdf (21 Apr. 2004). Resendes, Raymond. Mexican Public Holidays. http://gomexico.about.com/cs/mexico/public_holidays_p.htm (25 Mar. 2004). ———. The Festival of Our Lady of Guadalupe. http://gomexico.about.com/cs/mexico/a/lady of guadalupe_p.htm (25 Mar. 2004). Riebe-Estrella, Fr. Gary, SVD. 2004. “When Worlds Collide: Culture Clashes Coming to a Parish Near You.” U.S. Catholic. December, 23–28. Salvador, Ricardo J. 2003. “What Do Mexicans Celebrate on the Day of the Dead?” Death and Bereavement in the Americas. Death, Value and Meaning Series, Vol. II. John D. Morgan and P. Laungani, eds. Amityville, NY: Baywood. http:// www.public.iastate.edu/~rjsalvad/scmfaq/muertos.html (24 Feb. 2004). Santana, Sandra, and Felipe Santana. 2001. An Introduction to Mexican Culture for Rehabilitation Service Providers. Center for International Rehabilitation Research Information and Exchange. http://cirrie.buffalo.edu/mexico.html (17 Feb. 2005). Seligman, Katherine. 2004. “U.S. to Look a Lot Like Californa by 2050.” San Francisco Chronicle. 18 Mar. http://sfgate.com/ cgi-bin/article.cgi?file=c/a/2004/03/18/MNGTB5MUOG1.DTL&type=printable (18 Mar. 2004). Sosa, Elaine. Mexico. www.sallys-place.com/food/ethnic_cuisine/mexico.htm (25 Feb. 2004). Study Abroad in Mexico. A Brief History. http://spanishabroad.com/mexico/country_guide/mex_history.htm (25 Feb. 2004). ———. Day of the Dead. http://spanishabroad.com/mexico/country_guide/mex_society.htm (25 Feb. 2004). ———. Society and Conduct. http://spanishabroad.com/mexico/country_guide/mex_dotd.htm (25 Feb. 2004). ———. The Culture. http://spanishabroad.com/mexico/country_guide/mex_culture.htm (25 Feb. 2004). ———. Traditional Food. http://spanishabroad.com/mexico/country_guide/mex_food.htm (25 Feb. 2004). Thompson, Ginger. 2001. Globalization Is Killing Mexican Agriculture. http://www.organicconsumers.org/corp/ mexglobalization.cfm (24 Mar. 2004). Turner, Barry, ed. 2002. The Statesman’s Yearbook: the Politics, Cultures and Economies of the World. 2003. New York: Palgrave MacMillan. Vital, Rosario. 2003. “Spanish Being Embraced by Californians of All Backgrounds.” El Observador. 4 Dec. http:// news.ncmonline.com/news/view_article.html (5 Feb. 2004). U.S. Department of State Bureau of Democracy, Human Rights, and Labor. International Religious Freedom Report 2002: Mexico. http://www.state.gov/g/drl/rls/irf/2002 (28 Feb. 2004). Zehr, Mary Ann. 2002. “Educating Mexico.” Education Week, 20 March. http://www.edweek.org/ew/ ew_printstory.cfm?slug=27mexico.h21 (23 Mar. 2004).

Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 49 El Salvador

Census Figures (2000) United States Residents Born in El Salvador: 817,336 (2.6%) California Residents Born in El Salvador: 359,673 (4.1%) Quick Facts Country Area: 8,124 sq. miles (slightly smaller than Massachusetts) Population: 6,704,932; smallest, most densely populated country in Central America Median Age: 21.57 years Population Growth Rate: 1.75% Life Expectancy at Birth: 71.22 years Below Poverty Line: 36.1% Literacy Rate: 80.2% Currency: U.S. dollar (USD) Population Groups: mestizo 90%, Amerindian 1%, White 9% Languages: Spanish (official), Nahua Religion: Roman Catholic 55%, Protestant 22%, Other 23% Government: Republic of El Salvador: capital San Salvador; president serves five-year term; Legisla- tive Assembly popularly elected; country divided into 14 departments; departments divided into districts in which municipalities are governed by elected council, mayor. Climate: tropical; rainy season May–November Natural Hazards: volcanoes, earthquakes, hurricanes Natural Resources: hydropower, geothermal power, petroleum Arable Land: 31.85% Agricultural Products: coffee, sugar, corn, rice, beans, oilseed, cotton, sorghum, shrimp, beef, dairy products Exports: coffee, sugar, shrimp; offshore assembly exports, textiles, chemicals, electricity Industries: food processing, beverages, petroleum, chemicals, fertilizer, textiles, furniture, light metals Labor Force: agriculture 17.1%, industry 17.1%, services 65.8% ○○○○○○○○

50 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

El Salvador, cont. Brief History The Olmec people established settlements in the western part of El Salvador by 2000 BC. In about 1200 AD, the Pipil, descendants of the Toltecs and Aztecs, came to El Salvador—which they called Cuzcatlan, Land of Jewels— from Mexico following the collapse of the Maya empire. The Pipil economy was based on maize (corn), and they had a complex culture including laws and taxation, astronomy, mathematics, hieroglyphic writing, and trade routes extending over two continents. In 1524 the Spanish conquistador Pedro de Alvarado arrived in El Salvador, conquering it for Spain in 1540. Spanish settlers established plantations of cotton, balsam, and indigo and destroyed much of the indigenous culture. Following a revolt organized by Fr. José Matias Delgado, El Salvador gained independence from Spain in 1821, but a few wealthy colonists controlled most of the land. President Gerardo Barrios introduced coffee cultivation in 1859, and it has been a major crop ever since. President Maximiliano Hernandez Martinez ruled as a dictator from 1931 to 1944. In 1932, Augustine Farabundo Martí organized a peasant uprising to protest injustices; 30,000 peasants and Indians were killed, and Martí was executed. The present-day FMLN, Frente Martí Liberación Nacional, is named for him. In 1961, following a coup, the right-wing National Conciliation Party (PCN) gained control of the government, establishing death squads to deal with rising popular unrest and guerilla activity. Civil war broke out in 1979 as peasants rose up to protest 60 years of brutal military rule, pitting the FMLN against the U.S.-backed military and its death squads. At the time, 90 percent of the land was owned by 5 percent of the population, known as the “14 families.” Between 1972 and 1991 some 80,000 Salvadorans were killed. In 1980, human rights campaigner Archbishop Oscar Romero was assassinated while celebrating Mass. Jose Napolean Duarte, the first civilian president since 1931, was elected in 1980. In 1992, the FMLN and the government signed a UN-sponsored peace accord in which the FMLN was recognized as a political party. In 1998, Hurricane Mitch devastated coastal areas; earthquakes in 2001 killed 1,200 Salvadorans and left millions homeless. In March 2004, right-wing ARENA candidate Tony Saca was elected president with 57 percent of the vote. Housing, Family, Work, Traditions Housing: Cities are very crowded as people come from rural areas seeking work. One-third of all Salvador- ans live in the capital, San Salvador. Most live in one-room apartments with communal facilities. Middle class individuals live in row houses or apartments. The few wealthy live in neighborhoods protected by high walls and security systems. The poorest urban residents live in shacks made of cardboard or tin on riverbanks or in ravines. In rural areas, most homes are adobe with dirt floors and thatched roofs. The very poor live in huts made of woven branches covered with mud. Following the devastating earthquakes of 2001, cement blocks and other sturdier materials are being used for homes. Family: Most families include two or three generations living together. Often the grandmother is very important, running the home while other family members work for wages. Adult children usually live with parents until they marry. Older family members tend to be looked up to because of their age and experience. Children are brought up to show respect to their elders. Boys are encouraged to show machismo, toughness, and girls are trained to be modest. Women who never marry continue to live at home until the parents die. Then they may live with a close relative, usually a male. Women may begin living with a partner very young, often having children in their teens. Because so many men were killed in the long civil war, at least 25 percent of households are headed by women. War and high unemployment, especially since the coffee market downturn, have caused the traditional family unit to break down. The father or mother often emigrates to find work and make enough money to allow the family to join them for a better future. This can take up to 15 years and often does not happen. It is estimated that one-third of Salvadorans live abroad, most in the United States. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 51

El Salvador, cont.

Employment: About one-third of Salvadorans support themselves by farming. They may own small plots of land or work on large estates. In the cities, they may work in factories, mostly maquiladoras, producing textiles, clothing, furniture, and other items for export. The country has the highest concentration of manufacturing in Central America. Children may begin working at a very young age to help support their families. Human Rights Watch recently studied Salvadoran children employed as domestic workers. They found that 25 percent of children in domestic service began working between the ages of 9 and 11. Recreation: Town plazas are important gathering spots, especially on Sundays, the one non-work day. Soc- cer is a favorite national sport, with most towns having stadiums and villages having playing fields. Most urban families now have television and cell phones. Foods and Eating Habits Dietary Practices: Some Salvadorans subscribe to the hot-cold theory of illness and treatment by opposing foods. They do not like ice in beverages. No dietary taboos. Everyday Diet: Casamiento, a mixture of rice and beans, and fried plantains form the basic diet of most Salva- dorans. Coffee with tortillas or bread is a common breakfast. Prosperous Salvadorans might eat a breafast of eggs, mashed refried beans, tortillas, fried plantains, and coffee; lunch might be soup, meat, rice, salad, and fruit; dinner would be mashed beans, rice, tortilla, fried plantains, cheese, and coffee (plus meat if affordable). Fast food is becoming very popular. Getting together around the dinner table is an important family tradition. Popular Foods: Many foods and drinks are made of corn. Tamales are very popular. Pupusas are internationally famous and consist of toasted corn or rice tortillas filled with pumpkin flowers, cheese, beans, and/or bacon, eaten with spicy pickled cabbage and special hot sauce. These are often eaten for breakfast. Many people eat them at small restaurants called pupuserias. Pasteles are pockets of corn flour dough stuffed with meat, made into crescent shapes, and deep fried. They are popular at special celebrations. Pasteles de chucho is a dish of fried yucca and beef patties. Mariscada is a fish stew including lobster, crab, shrimp, and other fish. Hojuelas is a corn dish eaten with honey during All Saints’ Day celebrations. Coyoles and torrejas are special sweet foods eaten during Holy Week or Easter. Beverages: Frescos/refrescos or liquados are made of tropical fruits. Horchata is a drink made of roasted rice flour mixed with milk or water and sweet spices. Cebada is made of barley flavored with cinnamon. Atol de elote, sweet corn gruel, and shuco atol, gruel made from dark corn, black beans, and powdered pumpkin seeds, are popular drinks. Coffee and hot chocolate are popular. Beverages are usually served at room temperature. Alcoholic beverages include chicha, prepared with fermented pineapple peel and cashew, and torito and tic-tack, made from sugar cane. Education Status: Many children in rural and high-poverty areas do not have access to schools; nearly one-tenth of them never begin school, and many do not complete primary school. Others cannot afford to attend. Migration interferes with school attendance, and many teenaged children are kept at home to care for younger siblings and assist in housework or in the fields. According to Human Rights Watch, many children in the capital city of San Salvador work as domestics as many as 16 hours each day, and attend special night schools designed for them. Many children work as street vendors; they are often exploited and forced into prostitution. Primary School: The school year in El Salvador runs from February through November. Children attend compulsory primary school, basica, for nine years, from age 7 to 15. Although primary school is free, ○○○○○○○○

52 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

El Salvador, cont.

students must buy uniforms and supplies and may pay an enrollment fee each year. The curriculum is similar to that of the United States. Many private schools are operated by the Ro- man Catholic and other churches. Preschool is offered but not required. Secondary School: Following primary school, students have a choice of three-year courses at two kinds of secondary school, media, one offering a college preparatory degree and the other a technical/vocational degree following three years of coursework. School fees, uniforms, and supplies cost up to $300 per year. Higher Education: Public and private universities and specialized institutions provide higher education. Classes run from February to December and are conducted in Spanish. The government operates universities, technical institutes, and national schools of agriculture and physical education. The University of El Salvador, established in 1841, has schools of law and medicine. Religion Roman Catholicism: About 55 percent of Salvadorans are Roman Catholic. The nation’s celebrations and holidays revolve around Roman Catholic saints and feast days. Most towns have a patron saint who is honored annually. Until the 1930s, the Catholic Church was conservative. During the civil unrest related to longtime repression of the majority by landowners and politicians, the church under Archbishop Luis Chavez Gonzalez began taking an active role in seeking to better the lot of the campesinos. In the late 1960s, following Vatican II, the clergy became more involved in the life of the people. In the late 1970s, some 15,000 lay leaders received training in Bible, liturgy, agriculture, cooperativism, leadership, and health, often in base communities that functioned like extended families. Right-wing groups opposed these efforts. Archbishop Oscar Romero, Chavez’s successor and a champion of the poor, was assassinated on March 24, 1980 while saying Mass. Also in 1980, four U.S. religious women were abducted and killed by national guardsmen. On November 16, 1989, six Jesuit priests and their housekeeper and her daughter were killed at the University of Central America by members of the Salvadoran army. In San Salvador today, there are 53 base communities, with 10 to 60 members each, where Catholics meet twice a week to support one another in faith and life. However, there is much opposition to these communities from the conservative church hierarchy, which views them as overly political. The late Pope John Paul II silenced liberation theologians who sought to bring about social reforms. Protestantism: Protestant missionaries, primarily from the fundamentalist and evangelical denominations and sects, have been active in El Salvador at least since the Central American Mission was established in El Salvador and Guatemala in 1898. Most British and German immigrants were Protestant. Protestantism grew steadily, especially during the economic depression and political repression of the 1930s. Missionaries in the 1970s and 1980s used crusades, door-to-door evangelizing, radio programs, and direct food and health aid to spread their message of personal salvation through faith in Jesus. Their emphasis on putting up with the trials of this life while awaiting a heavenly reward continues to appeal to many people as well as to those in political power. Health and Health Care Health Status: About a quarter of the Salvadoran people have no access to health services, and a third do not have clean drinking water. Many people suffer from chronic malnutrition and illnesses linked to unsanitary conditions. Open sewage is a health threat in cities. During the rainy season, waste materials are washed into the drinking water supply, leading to dysentary, mal de mayo, a leading killer of children under age five. Preventable diseases such as measles are still prevalent, and impure water continues to cause cholera outbreaks. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 53

El Salvador, cont.

Traditional Practices: Brujeria is the Indian tradition of natural healing presided over by curanderos who perform special rituals and/or prescribe natural remedies of herbs and spices. Herbs are used instead of commercial medications among older people, especially in rural areas. Coconut water is used as a diuretic. Mint or chamomile tea is a remedy for stomach ache, and sliced raw tomatoes are used for severe burns. Many Salvadorans use these complementary treatments in addition to consulting physicians. Over-the-counter medications are widely used. The information on traditional practices in the section on Mexico, page 44, applies to El Salvador as well. Medical System: The Ministry of Health operates 30 hospitals as well as clinics in rural areas. Private hospitals are also available. Employees of formal businesses participate in a social security program that provides medical insurance, workers compensation, and disability pensions. Other citizens depend on government-subsidized care. Global Policy Forum reports that many people cannot pay the “voluntary contribution” required for health care services. In 2002, under pressure from the World Bank and the Inter-American Development Bank, the President attempted to allow U.S. multinational HMOs to take over the health system. Mas- sive strikes and demonstrations led to agreements in June 2003 between the government and health care unions that appear to have stopped the government’s attempt at privatization. Tips for Health Care Providers Refer to the section on Working with Latino/Hispanic Clients (pp. 17–18) for general guidelines to follow in working with clients and patients from El Salvador. The following information may also be useful. Attitudes: Traditionally, Salvadorans have held their physicians in great respect, like priests and teachers, and would not question their authority. They believe health is related to the balance of hot and cold, and good health may be associated with the ability to perform their daily tasks. Many Salvadorans will seek help from traditional healers or pharmacists before Western physicians, perhaps due to the cost involved. A study conducted in Los Angeles in 2000 found that many Latinos did not use available public health services due to language and transportation problems and perceived cultural insensitivity, as well as fear of deportation. Family Authority: The father or eldest son is the primary decision-maker. In cases of terminal illness, health care practitioners should inform that individual, who may not want the patient informed. Addressing Clients: Although most Salvadorans understand Spanish and may have some English, others may speak native languages. Address clients in a formal manner. Nonverbal Behavior: Touching between members of the same sex is accepted. Women may be shy and prefer a woman physician. Verbal Exchange: Procedures should be explained carefully; Salvadorans and other Central Americans may have difficulty understanding such concepts as patients’ rights and informed consent. Hospitalization: Salvadorans may be stoic in enduring pain. During childbirth, it is customary for several women to participate in labor and delivery. New mothers are to avoid cold foods and drinks as well as strong emotions. Chicken soup, bananas, and meat are believed to strengthen the mother. Death and Dying: Diagnosis of terminal illness should be given to father or eldest son. Catholics will want a priest to administer the sacraments. Many Salvadorans would prefer to die at home with family. Family members may wish to prepare the body for burial and to stay with the body to say goodbye. Cremation is not common. Organ donation may be accepted if the body is treated respectfully. Celebrations and Holidays January 1 New Year’s Day March/April Holy Week, Semana Santa: Good Friday celebrated with music, processions. ○○○○○○○○

54 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

El Salvador, cont.

May 1 Labor Day May 3 Day of the Cross: This festival is believed to have originated in an Indian festival honoring the rain god and praying for rain before being appropriated by the Spaniards into a celebration honoring the cross. Families decorate crosses in their front yards with flowers, fruits, and paper orna- ments and participate in a ceremonial adoration of the cross. June 17 Dia del Padre, Fathers’ Day June 22 Schoolteachers’ Day June Corpus Christi August 6 La Bajada: Celebrated throughout the capitol, San Salvador, La Bajada, which means “the descent,” honors the nation’s patron saint. It takes its name from the fact that campesinos from the surrounding hills come down to the city to honor the saint. The festival features a statue of El Divino Salvador dressed in purple robes being lowered into a globe representing the world. The statue reemerges dressed in white robes representing the transfiguration. The crowd shouts “Viva El Salvador,” referring to both the savior and the nation. In 2003, a replica of the statue was brought to Mission Dolores in Los Angeles, where nearly 60 percent of the Salvadoran immigrants to the United States live. September 15 Independence Day: Commemorates the declaration of independence of Central America from Spain in 1821. November 2 All Souls’ Day November 5 First Call for Independence Day: Commemorates the 1811 battle for independence from Spain. December 12 Virgen de Guadalupe: To honor the Virgin of Guadalupe, patron saint of Latin America, children dress up in Indian costumes and accompany the Virgin in procession. Christmas Traditional celebrations take place on Christmas Eve; families attend midnight Mass; children receive gifts from El Niño, the baby Jesus. Many families have elaborate nacimientos, nativity scenes. Salvadorans in the United States According to Catherine Elton, writing in The Christian Science Monitor: “More than a quarter of El Salvador’s 6.5 million citizens live in the U.S., and Salvadoran economist Robert Rubio estimates that remittances account for 16 percent of the country’s economy. He likens the flow of remittances to a life-support system for the country’s poor economy.” Elizabeth DiNovella, writing in The Progressive, states: “Most Salvadorans I meet have a family member who is living abroad. Nearly one-third of the population lives outside the country.” More than 2 million Salvadorans live in the United States, about half in California with the majority of those, nearly 1 million, in Los Angeles. About half a million Salvadorans live in the Washington, D.C. area. The Salvadorans send about $2.5 billion back to El Salvador each year, about 15 percent of the country’s gross national product. In March 2001, the United States granted Temporary Protection Status (TPS) to Salvadorans fleeing the devastation of the massive earthquakes of January and February. Some 248,000 Salvadorans took advantage of the opportunity to receive special visas allowing them to live and work in the United States and send money back to family members in El Salvador. On Jan. 6, 2005, the residency and work permits were extended for a second time, until Sept. 9, 2006. An exceptional resource for understanding health care clients and students from El Salvador is the recent book Seeking Community in a Global City: Guatemalans and Salvadorans in Los Angeles. The authors, who have spent many years working with and studying immigrants in Los Angeles, provide an excellent history of the two groups, describing their persecution and dislocation within Latin America, their immigration to the United States, and their adaptation to U.S. culture. Salvadorans were being recruited in 2004 to help the United States fight the war against Iraq. The Washington Post reported: “With the U.S. military unable to meet security needs in Iraq, private U.S. firms are now . . . aggressively recruiting in El Salvador, a member of the U.S.-led military coalition in Iraq, viewing it as an ideal source of guards. The country has low wages, high unemployment and a large pool of men with military or police experience — many of whom were U.S.- trained — from the 12-year civil war that ended in 1992.” Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 55

El Salvador, cont. Language; Useful Words and Phrases Spanish for Health Care Workers, available at www.health-careers.org, provides words and phrases the health care provider can use with Spanish-speaking patients. Spanish is pronounced much like English. Differences include: “ll” is pronounced “y,” “j” is pronounced “h,” “h” is silent, “ñ” is pronounced “ny.” Unless otherwise indicated by an accent mark, the stress falls on the next to the last syllable if the word ends in a vowel or the letters “n” or “s”, on the last syllable if it ends in a consonant. Good morning. Buenos días. Good afternoon. Buenos tardes. Good night. Buenos noches. Hello. Hola. Goodbye. Adiós. See you later. Hasta la vista. Yes/No Sí/No Thank you. Gracias. You’re welcome. De nada/No hay de que. How are you? ¿Cómo está? I am fine, thank you. And you? Muy bien, gracias. Y usted? What is your name? ¿Cómo se llama? My name is . . . . Me llamo . . . . What happened? ¿Qué pasó? Where does it hurt? ¿Dónde le duele? Let me help you. Déjeme ayudarle. Are you cold? ¿Tiene frío? Are you hungry? ¿Tiene hambre? Are you thirsty? ¿Tiene sed? breakfast desayuno lunch almuerzo dinner cena Do you need to go to the bathroom? ¿Necesita ir al baño? Do you want to sit up? ¿Quiere sentarse? I am going to take your temperature. Voy a tomarle la temperatura. References “Abuses against Child Domestic Workers in El Salvador.” 2004. Human Rights Watch, 16:1(B) Jan. http://hrw.org/english/ docs/2004 (25 Feb. 2004). Area Studies, Latin America: El Salvador, Basic Facts. http://wrc.lingnet.org/elsalvad.htm (21 Mar. 2004). At a Glance: El Salvador. UNICEF. http://www.unicef.org/infobycountry/elsalvador/html (23 Feb. 2004). “A People’s Victory: Healthcare Workers Defeat Privatization.” 2003. El Salvador Watch. Jul./Aug. Committee in Solidarity with the People of El Salvador. http://www.cispes.org/english/Newsletter/index.html (24 Feb. 2004). Batres, Eileen Giron. 2001. An Introduction to the Culture of El Salvador for Providers of Disability Services in the U.S. http:/ /www.cirrie.buffalo.edu/elsalvador.htm. (25 Feb. 2004). BBC News. Country Profile: El Salvador. http://newsvote.bbc.co.uk (23 Feb. 2004). Betancur, Belisario, et al. 1993. From Madness to Hope: the 12-Year War in El Salvador: Report of the Commission on the Truth for El Salvador. United States Institute of Peace. http://www.usip.org/library/tc/doc/reports/el_salvador/ tc_es_03151993_toc.html (24 Feb. 2004). Central Intelligence Agency. 2005. “El Salvador.” The World Factbook. http://www.cia.gov/cia/publications/factbook/geos/ es.html (8 May 2005). ○○○○○○○○

56 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

El Salvador, cont.

Chu, Henry. 2005. “In Latin America, a Religious Turf War.” Los Angeles Times. 15 April. http://www.latimes.com/news/ nationworld (15 Apr. 2005). DiNovella, Elizabeth. 2004. “Salvador: From the Bullet to the Ballot.” The Progressive. March: 26–29. El Salvador. Christian Foundation for Children and Aging. http://www.cfcausa.org/countries/ElSalvador/ElSalvador.htm (23 Feb. 2004). El Salvador. Encyclopedia of Days. http://www.shagtown.com/days/elsalvador.html (28 Feb. 2004). “El Salvador Food Fest.” Common Ground Radio. May 13, 2003. http://commongroundradio.org/shows/03/0319.shtml (25 Feb. 2004). Elton, Catherine. 2004. “El Salvador Vote Recalls Cold-War Power Play.” The Christian Science Monitor. 19 Mar. http:// csmonitor.com/2004/0319 (23 Mar. 2004). Embassy of El Salvador in the United States. http://www.elsalvador.org (26 Feb. 2004). Fraser, Barbara, and Paul Jeffrey. 2004. “Base Communities, Once Hope of Church, Now in Disarray.” National Catholic Reporter. 12 Nov.: 12–16. Hamilton, Nora, and Norma S. Chinchilla. 2001. Seeking Community in a Global City: Guatemalans and Salvadorans in Los Angeles. Philadelphia: Temple University Press. Holidays: El Salvador. http://www.holidayfestival.com/ElSalvador.html (29 Feb. 2004). Kellerman, Maureen, and Swarnalatha Vemuri. 2002. El Salvador. Anti-Racism, Multiculturalism and Native Issues Cen- tre, Faculty of Social Work, University of Toronto, Canada. http://www.settlement.org/cp/english/elsalvador (29 Feb. 2004). Library of Congress, Federal Research Division. 1988. Country Studies: El Salvador. http://lcweb2.loc.gov (23 Feb. 2004). Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. Lonely Planet World Guide: Destination El Salvador. http://www.lonelyplanet.com/destinations/central_america/el_salvador (23 Feb. 2004). Luxner, Larry. 2003. “El Salvador’s Ambassador León Both Diplomat, Community Leader.” Washington Diplomat. Sept. http://www.washdiplomat.com/03-09/a6_03_09.html (11 Feb. 2005). Moore, Solomon. 2005. “Salvadorans’ Stay in U.S. to Be Extended.” Los Angeles Times. 7 Jan. http://www.elsalvador.org/ Prensa (11 Feb. 2005). Orleans, Valerie. 2004. “Professor Studies ‘La Bajada’ Among L.A. Salvadorans.” Dateline. California State University, Fullerton. 5 Feb. http://campusapps.fullerton.edu/news/people/2004/print/solano/html (28 Feb. 2004). Pereira-Papenburg, Gloria. 2002. “Fighting the Privatization of Health Care in El Salvador.” Upstream Journal. Nov./Dec. http://www.globalpolicy.org/socecon/bwi-wto/wbank/2002/novdecelsal.htm (24 Feb. 2004). Sullivan, Kevin. 2004. “Poor Salvadorans Chase the ‘Iraqi Dream’: U.S. Security Firms Find Eager Recruits Among Former Soldiers, Police Officers.” Washington Post. 9 Dec.: A24 (11 Feb. 2005). Turner, Barry, ed. 2003. The Statesman’s Yearbook: the Politics, Cultures and Economies of the World. 2003. New York: Palgrave MacMillan. U.S. Department of State. 2005. United States Extends Temporary Protected Status for Salvadorans. 6 Jan. http:// usinfo.state.gov/wh/Archive/2005/Jan/07-910002.html (11 Feb. 2005).

Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 57 Guatemala

Census Figures (2000) United States Residents Born in Guatemala: 480,665(1.5%) California Residents Born in Guatemala: 211,458 (2.4%) Quick Facts Country Area: 42,042 sq. miles (slightly smaller than Tennessee) Population: 14,655,189 Median Age: 18.47 years Population Growth Rate: 2.57% Life Expectancy at Birth: 65.14 years Below Poverty Line: 75% Literacy Rate: 70.6% Currency: quetzal (GDQ), U.S. dollar (USD) Population Groups: Mestizo/Ladino, approximately 55%; Amerindian or predominantly Amerindian, approximately 43%; Whites and Others 2% Languages: Spanish 60%, Amerindian Languages (23)–40% Religion: Roman Catholic, Protestant, Indigenous Mayan Government: Republic of Guatemala, a democratic republic: president serves five-year term; one-house Congress, members elected for five-year terms; country divided into 22 departments; Guatemala City is the capital. Climate: tropical; rainy season May–October Natural Hazards: volcanoes, earthquakes, hurricanes Natural Resources: petroleum, nickel, rare woods, fish, chicle, hydropower Arable Land: 12.5% Agricultural Products: sugarcane, corn, bananas, coffee, beans, cardamom, cattle, sheep, pigs, chickens Exports: coffee, sugar, bananas, fruits, vegetables, cardamom, meat; apparel, petroleum, electricity Industries: sugar, textiles and clothing, furniture, chemicals, petroleum, metals, rubber, tourism Labor Force: agriculture 50%, services 35%, industry 15% ○○○○○○○○

58 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Guatemala, cont. Brief History Fishing and farming villages on the Pacific coast of Guatemala go back at least as far as 2000 BC. By 250 AD, the Maya were building great temple cities in the highlands. In 1523, Spanish conquistador Pedro de Alvarado conquered the Maya, paving the way for Spanish colonization. Guatemala gained its independence in 1821. Exploitation of indigenous peoples continued, however, as governments encouraged foreign investment, even giving communally owned land to investors and allowing them to use 25 percent of the male population to work the plantations. Those who objected were massacred. Conservative dictator Rafael Carrera ruled from 1844 to 1865. In 1873, liberal Justo Rufino Barrios became president; he modernized the country and introduced coffee as a cash crop. Juan Jose Arevalo became president in 1944 following the overthrow of repressive president Jorge Ubico. Arevalo introduced democratic reforms such as land redistribution and social security. Colonel Jacobo Arbenz Guzman continued these reforms when he was elected in 1951. When he began expropriating foreign-owned land, the U.S. CIA, acting to protect the vast holdings of United Fruit Company, backed a coup that brought Colonel Carlos Castillo to power in 1953. Castillo was assassinated in 1963. Democratic rule was restored in 1966 with the election of Cesar Mendez. In 1970, the military candidate, Carlos Arena, was elected. His efforts to eliminate anti-government elements resulted in the death of 50,000 or more people in the coming decade. An earthquake in 1976 killed 27,000 people and left more than a million homeless. In 1981, death squads and the military killed 11,000 people in response to guerilla activities. By 1989, some 100,000 people had been killed and 40,000 were among the missing. Rigoberto Menchu, Mayan civil rights activist, received the Nobel Peace Prize in 1992 for her efforts on behalf of her people. In 1996, President Alvaro Arzu signed peace accords with the guerillas, ending 36 years of civil war in which an estimated 200,000 people died, including those killed in 626 massacres in Mayan villages. Conservative businessman Oscar Berger was elected president in 2003. Housing, Family, Work, Traditions Housing: Recent estimates suggest that more than half of Guatemalans, especially indigenous peoples, live in inadequate housing. Forced evictions of residents from squatter settlements and a shortage of 1.5 million houses mean many homeless people, including 5,000 children, live in the streets of the capital, Guatemala City. The city nearly doubled in population between 1955 and 1995 and is now home to more than 3 million residents, about 75 percent of whom live in poverty. A clean water supply is one of the city’s critical problems. Squatters receive no city services, and most obtain water from public taps or privately owned water trucks. Rural houses might be adobe enclosures for sleeping with a packed earth floor and a tin or thatched roof, surrounded by a larger room that serves as a kitchen and all-purpose room. Family: Most families consist of parents and their unmarried children, with perhaps a married son or daughter and family as well as elderly relatives and godparents, padrinos, who are an important part of the family. Women tend to marry young and have large families. Guatemala has one of the highest fertility rates in Latin America. At the current growth rate, the population will double every 22 years. In rural areas, common-law marriages are frequent, and Mayan marriage rituals differ from those of the Roman Catholic church. As Guatemalans adopt more North American values, family structures are changing. Indigenous Peoples: Guatemala has the highest proportion of indigenous people of any Central American nation, with Mayan groups or indigenas, who follow traditional customs and speak one of the 23 officially recognized dialects. They far outnumber ladinos, those who follow a more Westernized lifestyle and speak Spanish. The various linguistic groups tend to cluster in separate areas. The largest groups are the Kiche, Mam, Kaqchikel, and Q’eqchi. Traditional Textiles: Guatemalan textiles are famous around the world. Mayan women have woven the fabric on backstrap looms for two centuries. They wear beautiful blouses called huipiles, some with designs more than a thousand years old. According to The Center for Maya Textiles, “The huipil is the ultimate Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 59

Guatemala, cont.

expression of native weaving artistry, proclaiming the wearer’s identity as a woman and individual within her community.” Each Mayan village has its distinctive pattern. The Spanish conquerors and later the army used those patterns as a means of identifying specific Mayan groups. Traditional skirts, called cortes, are made of fabric woven by men on foot treadle looms. Employment: Most rural families labor on plantations of the small percentage of people who own the majority of land. They may have their own livestock and garden plots for growing beans, rice, and corn. In the cities, many women work as live-in domestics and in maquiladoras supplying U.S. and South Korean corporations, facing discrimination and exploitative working hours and conditions. A non- profit group, the Commission for the Verification of Codes of Conduct, is now working with international companies doing business in Guatemala to monitor and improve working conditions and labor practices both in factories and in coffee and banana fields. Foods and Eating Habits Dietary Practices: No dietary taboos. Everyday Diet: Some indigenous people in Guatemala and Mexico refer to themselves as Corn People. Corn originated in this area in the teocinte plant. This staple of life is endangered by the introduction of genetically modified seed, a serious threat to a crop that forms the backbone of the country’s agriculture, markets, and social life. Rural Guatemalans eat mainly black beans and corn prepared in various ways, including fried bean paste, beans and rice mixtures, and corn tortillas. Those who live in houses in the cities probably begin the day with coffee, porridge or beans, eggs, and perhaps fried plantains. The large midday meal might begin with soup and be followed by meat, rice, vegetables, and salad. Guatemalans enjoy many tropical fruits, including bananas (which may be eaten with chocolate sauce, honey-cinnamon syrup, or orange juice and whipped cream), mangoes, mameys, pitahayas, and jocotes. Popular Foods: Arroz con pollo chapina is a chicken and rice dish that includes onions, garlic, tomatoes, peppers, and seasonal vegetables. Jocon combines chicken and a green sauce made from squash seeds, chiles, tomatillos, scallions, sesame seeds, and cilantro. Tamales and chile rellenos are also popular. Pepian is a beef stew with vegetables and a sauce of roasted seeds and peppers. Subanik is a dish combining chicken, pork, and beef accompanied with rice and guacamole. Fiambre, cured pork, is a traditional food eaten on All Saints’ Day. Bunuelos, fried dumplings with honey, and flans, rice cakes, rice custards, honey crisps, and sugared figs are popular desserts. Beverages: Coffee and champurrado, chocolate coffee, are popular beverages, as is fruit juice. Alcoholic drinks include locally made beer, wine, rum, and rompopo, a punch made from milk, egg yolks, and rum. Education Status: The school year in Guatemala runs from January to October. Education is compulsory through grade six. All schools teach a curriculum established by the Ministry of Education. Public schools are free, but students must buy textbooks and uniforms. Some students attend in the morning, others in the afternoon. Children from wealthier families attend the many private schools, both religious and secular, found in Guatemala. School attendance varies widely depending on location and economics. Many families cannot afford fees for books and uniforms; others prefer to teach their children agricultural skills. In rural areas, children often work in the fields or as household laborers to help support their families. Recent figures show that about 33 percent of children attend preschool and 82 percent attend primary grades. Half the children who start primary school in urban areas complete it, compared with one-fifth of children in rural areas, where about 60 percent of school-age children live. Only 58 percent of all municipalities have secondary schools. ○○○○○○○○

60 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Guatemala, cont.

Elementary School: Schooling begins at age four with pre-kindergarten, followed by kindergarten, primary grades, and six elementary grades. Secondary School: During the five years of secondary school, students may begin and even complete career training. For several careers, including secretary, elementary school teacher, and accountant, high school training is sufficient. Other careers require three to six years of university training. Higher Education: The University of San Carlos was founded in 1681. The only public university, it has campuses in nine locations in addition to the capital, Guatemala City. There are six private universities special- izing in various fields of study. Religion Roman Catholicism: According to the International Religious Freedom Report of 2002, the percentage of Roman Catholics in Guatemala has declined to perhaps 50 to 60 percent, with the remainder of the population identified as Protestant. Most sources put the Roman Catholic population at over 80 percent. Church attendance is reported to be high among evangelical Protestants and lower among Catholics. Catholicism was established in Guatemala by Dominican friars who made the faith understandable to the Mayan people. The church has incorporated indigenous Mayan beliefs and practices that do not conflict directly with church teachings, which makes Catholicism in Guate- mala distinct. Protestantism: The largest Protestant groups are the Assembly of God, the Church of God of the Complete Gospel, and the Prince of Peace Church; mainline denominations such as Presbyterian, Baptist, Lutheran, and Episcopalian are also represented. Evangelical Protestant churches, now claiming some 25 percent of the population as members, generally do not tolerate indigenous beliefs and tend to be conservative in their political outlook, focusing on the believer’s personal realtionship with Jesus Christ and on individual success and prosperity rather than social justice. Mayan Religion: Indigenous peoples outnumber ladinos, but they are looked down upon and their religious practices are regarded as witchcraft or devil worship by many, particularly those in the evangelical Protestant community. Mayan spiritual leaders report that about half the population practices some kind of indigenous spiritual ritual, with only about 10 percent doing so openly. Traditional prayer men, called brujas, ajkunes, and chuchkujawes, are believed to have powers related to planting crops, healing the sick, foretelling the future, and bringing back lost objects. They conduct their rituals in caves or houses, using offerings of liquor and incense. Mayan religion was based on synchronizing human activities with the orderly cycles of nature. The Maya developed several calendar systems for various aspects of their activities, reaching a calculation accuracy of one day off every 6,000 years. Mayan calendars served as astronomical almanacs controlling behavior and religious ceremonies. The Maya worshipped many gods and envisioned the universe as having multiple layers both above and below the earth. They believed their rulers were descendants of the gods. Health and Health Care Health Status: Nearly half the population of Guatemala has no access to health services. There is no national health insurance. Rural residents are subject to malaria, typhus, dysentary, and other diseases ag- gravated by unclean water and poor nutrition. Agricultural chemicals cause problems for planta- tion workers. Traditional Practices: Many Guatemalans have little access to modern medicine and depend on traditional healers, curanderos or yerbaristes, for herbal remedies. Some also use a zahorin, a healer who cures illness using charms and prayers. Many indigenous peoples believe that plants have spirits linked with Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 61

Guatemala, cont.

their healing powers. Mayan healers often administer their herbs based on magically important numbers, and they may classify herbs as male or female and use them in pairs. Therapeutic baths are often used. Some Indians believe illness is caused by the evil eye, and they make special efforts to protect women and children from strangers. Medical System: In cities and towns, state-run hospitals and clinics are available. A full range of medical care is available in Guatemala City, but medical care outside the city is limited. Guatemala’s public hospitals have experienced serious shortages of basic medicines and equipment. Tips for Health Care Providers Refer to the section on Working with Latino/Hispanic Clients (pp. 17–18) for general guidelines to follow in working with clients and patients from Guatemala. The following information may also be useful. Attitudes: Many Guatemalans, especially the Maya, have little if any experience with Western medicine. They may view illness as a disruption in the hot-cold balance. A study conducted in Los Angeles in 2000 found that many Latinos did not use available public health services due to language and transportation problems and perceived cultural insensitivity, as well as fear of deportation. Family Authority: The father or eldest son is the primary decision-maker. In cases of terminal illness, health care practitioners should inform that individual, who may not want the patient informed. Addressing Clients: In the case of Guatemalans who are Maya or members of other indigenous peoples, communication may be difficult. Address clients in a formal manner. Physical Contact: Touching between members of the same sex is accepted. Women may prefer a woman physician. Verbal Exchange: Procedures should be explained carefully. Central Americans, especially indigenous peoples, may have difficulty understanding such concepts as patients’ rights and informed consent. Hospitalization: Particularly for indigenous peoples, hospitalization may be very frightening if they are isolated from family members and traditional support systems. Death and Dying: Diagnosis of terminal illness should be given to father or eldest son. Catholics will want a priest to administer the sacraments. Celebrations and Holidays January 1 New Year’s Day January 6 Epiphany February/March Carnaval, celebrated before Lent begins: People dress in costumes and masks, break open painted eggs filled with confetti. March/April Holy Week, Semana Santa; Streets are decorated with flowers and colored sawdust for processions where images of Jesus and the Virgin Mary are carried through the streets. Easter Day Celebrated with processions and special foods May 1 Labor Day May 2–3 Day of the Cross June 30 Army Day: Celebrates revolt for agrarian reform in 1871. July 21–26 Rabin Ajau, a traditional Qeqchi Maya festival September 15 Independence Day October 12 Indigenous Peoples Day October 20 Revolution of 1944 Day: Celebrates overthrow of Jorge Ubico. November 1 All Saints’ Day: Guatemalans place food, drinks, pine needles, and flowers on graves of family members and friends; giant kites flown in some cemeteries. Families often eat dinner at the graves and offer food to the dead. December 7 Devil-Burning Day: People search their houses for things that can be thrown away; these are burned in front of the house to purify it for Christmas. ○○○○○○○○

62 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Guatemala, cont.

December 8 Feast of the Immaculate Conception December 12 Feast of the Virgin of Guadalupe December 24–25 Christmas Eve festivities include eating tamales and setting off fireworks. December 28 Day of the Innocents Guatemalans in the United States According to the Immigration and Naturalization Service (INS), Guatemala ranks third behind Mexico and El Salvador as a source of illegal immigrants into the United States. This means that the 2002 census figure showing some 480,000-plus native-born Guatemalans living in the United States is probably conservative. The INS reported that in 1996 there were 165,000 Guatemalans living illegally in this country; over the period 1992–1996, the average annual growth rate of illigal immigration from Guatemala was 12,000. In 1998, 5,821 Guatemalans sought assylum in the United States, with an approval rate of 8.7 percent. Guatemalans who do not have legal status tend not to use the health care system for fear of being deported. An exceptional resource for understanding health care clients and students from Guatemala is the recent book Seeking Community in a Global City: Guatemalans and Salvadorans in Los Angeles. The authors, who have spent many years working with and studying immigrants in Los Angeles, provide an excellent history of the two groups, describing their persecution and dislocation within Latin America, their immigration to the United States, and their adaptation to U.S. culture in Los Angeles. Although until recently most immigrants from Mexico and Central American have settled on the West Coast, increasing numbers of Latinos are being recruited to work in meat packing plants in the Midwest, Northeast, and South. An award-winning 1997 series by Marcus Stern in the San Diego Union-Tribune reported on the system that allows illegal immigrants to find work in such places as Case Farms, a poultry plant in the North Carolina foothills where most of the workers at that time were illegal immigrants from Guatemala:

Alberto, like many Case Farms workers, is from the rural Guatemalan town of Huehuetenango. During the 1980s it was the site of nightmarish political violence. The killings ended years ago, but the poverty endures. Today, children living in the thatched-roof huts of Huehuetenango eat better because of the paychecks distributed on the factory floor at Case Farms. Like the other Guatemalan workers, Alberto earns about $54 a day, far more than the $3 he said he’d earn in Guatemala. But the illegal workers pay dearly for this opportunity. Entering the United States through its ‘back door’ is undignified, inhumane and fraught with danger. Once here, they remain vulnerable to exploitation. Language; Useful Words and Phrases Spanish for Health Care Workers, available at www.health-careers.org, provides words and phrases the health care provider can use with Spanish-speaking patients. Spanish is pronounced much like English. Differences include: “ll” is pronounced “y,” “j” is pronounced “h,” “h” is silent, “ñ” is pronounced “ny.” Unless otherwise indicated by an accent mark, the stress falls on the next to the last syllable if the word ends in a vowel or the letters “n” or “s”, on the last syllable if it ends in a consonant. Good morning. Buenos días. Good afternoon. Buenos tardes. Good night. Buenos noches. Hello. Hola. Goodbye. Adiós. See you later. Hasta la vista. Yes/No Sí/No Thank you. Gracias. You’re welcome. De nada/No hay de que. How are you? ¿Cómo está? I am fine, thank you. And you? Muy bien, gracias. Y usted? Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 63

Guatemala, cont.

What is your name? ¿Cómo se llama? My name is . . . . Me llamo . . . . What happened? ¿Qué pasó? Where does it hurt? ¿Dónde le duele? Let me help you. Déjeme ayudarle. Are you cold? ¿Tiene frío? Are you hungry? ¿Tiene hambre? Are you thirsty? ¿Tiene sed? breakfast/lunch/dinner desayuno/almuerzo/cena Do you need to go to the bathroom? ¿Necesita ir al baño? Do you want to sit up? ¿Quiere sentarse? I am going to take your temperature. Voy a tomarle la temperatura. References Area Studies, Latin America: Guatemala, Basic Facts. http://wrc.lingnet.org/guatemal.htm (21 Mar. 2004). BBC News. Timeline: Guatemala. http://newsvote.bbc.co.uk (23 Feb. 2004). Center for Maya Textiles. http://nimpot.com/ (24 Feb. 2004). Central Intelligence Agency. 2005. The World Factbook: Guatemala. http://www.cia.gov/cia/publications/factbook/geos/gt.html (5 May 2005). Chu, Henry. 2005. “In Latin America, a Religious Turf War.” Los Angeles Times. 15 April. http://www.latimes.com/news/ nationworld (15 Apr. 2005). Country Profile: Guatemala. BBC News. http://newsvote.bbc.co.uk (23 Feb. 2004). Embassy of Guatemala to the United States. Culture and Education. http://www.guatemala-embassy.org/culture.asp (23 Feb. 2004). General Information on Guatemala. http://www.guatemalaweb.com/2/generalinfo.htm (21 Mar. 2004). Global Ministries of Latin America and the Caribbean. Christian Action of Guatemala. http://www.globalministries.org/ lac/spo8.htm (21 Mar. 2004). Guatemala, A War Called Peace: A Visual Journey with Peace Brigades International. http://www.peacebrigades.org/ guatemala/cap-piet04.html (21 Mar. 2004). Guatemala. Encyclopedia of Days. http://www.shagtown.com/days/guatemala.html (28 Feb. 2004). Guatemala: General Information. http://centralamerica.com/guatemala/guatemalainfo.htm (23 Feb. 2004). Guatemala: Meals near the Mayans. Food Network. http://www.foodnetwork.com/food/ck_gc_guatemala/text (21 Mar. 2004). Hamilton, Nora, and Norma S. Chinchilla. 2001. Seeking Community in a Global City: Guatemalans and Salvadorans in Los Angeles. Philadelphia: Temple University Press. Icu, Hugo. 2000. “Health Care Reform in Guatemala.” People’s Health Assembly, Dec. http://phmovement.org/pha2000/ stories/icu.html (24 Feb. 2004). Ling, Carlos. 2002. “Letter from Guatemala.” Oxfam Connections, Sept. http://www.caa.org.au/publications/connections/ september_2002/letterfromguatemala.html (24 Feb. 2004). Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. Lonely Planet World Guide: Destination Guatemala. http://www.lonelyplanet.com/destinations/central_america/guatemala (23 Feb. 2004). Morgenstern, Kat. 1998. “Central America’s Traditional Plant Medicine.” May. http://www.planeta.com/planeta/98/ 0598central.htm. (24 Feb. 2004). The National Folk Festival and the Arts. http://www.salvonet.com/ed/index/shtml (24 Feb. 2004) Our Living Maya Culture. http://www.quetzalnet.com/QuetzalNET/MayaCulture.html (23 Feb. 2004). ○○○○○○○○

64 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Guatemala, cont.

“Overview of Human Rights Issues in Guatemala.” 2003. Human Rights Watch, Dec. http://hrw.org/english/docs/2004/01/ 21/guatem6985_txt.htm (25 Feb. 2004). Oxfam. 2002. “Fair Trade vs Free Trade in Mesoamerica.” Oxfam Connections, Sept. http://www.caa.org.au/publications/ connections/september_2002/fairtradevsfreetrade.html (24 Feb. 2004). Peace Corps. “Food, Friends, and Fun: Holidays in Guatemala.” Peace Corps Kids World. http://www.peacecorps.gov/kids/ like/guat-celebration2.html (21 Mar. 2004). Stern, Marcus. 1997. “Jobs Magnet.” San Diego Union-Tribune. 2 Nov. http://www.cis.org/katz1998.html (27 Mar. 2004). Turner, Barry, ed. 2002. The Statesman’s Yearbook: the Politics, Cultures and Economies of the World. 2003. New York: Palgrave MacMillan. UNICEF. At a Glance: Guatemala. http://www.unicef.org/infobycountry/guatemala/html (23 Feb. 2004). U.S. Department of State Bureau of Democracy, Human Rights, and Labor. 2002. International Religious Freedom Report 2002: Guatemala. http://www.state.gov/g/drl/rls/irf/2002 (28 Feb. 2004) World Resources Institute Education Center: Sustainable Communities. Water Provision: Guatemala City, Guatemala. http://www.wri.org/enved/suscom-guatemala.html (19 Mar. 2004) Williams, E., and S. Vemuri. 2002. Guatemala. Anti-Racism, Multiculturalism and Native Issues Centre, Faculty of Social Work, University of Toronto, Canada. http://www.settlement.org/cp/english/guatemala (8 May 2005).

Eastern Asia China South Korea Japan ○○○○○○○○

66 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 67 China

Census Figures (2000) United States Residents Born in China: 988,857 (3.2%); Hong Kong 203,580 (0.7%); Taiwan 326,215 (1.0%) California Residents Born in China: 327,611 (3.7%); Hong Kong 91,101 (1.0%); Taiwan 151,775 (1.7%) Quick Facts Country Area: 3,696,100 sq. miles (comparable in size to the United States) Population: 1,306,313,812 Median Age: 32.6 years Population Growth Rate: 0.58% Life Expectancy at Birth: 72.27 years Below Poverty Line: 10% Literacy Rate: 90.9% Currency: yuan(CNY), also referred to as the renminbi (RMB) Population Groups: Han Chinese 91.9%; Zhuang, Uygur, Hui, Yi, Tibetan, Miao, Manchu, Mongol, Buyi, Ko- rean, and other groups 8.1% ; China has 55 ethnic minority groups Languages: Seven major language groups: Standard Chinese or Mandarin (Putonghua, based on the Beijing dialect) spoken by more than 70%, Yue (Cantonese), Wu (Shanghaiese), Minbei (Fuzhou), Minnan (Hokkien-Taiwanese), Xiang, Gan, Hakka dialects, minority languages Religion: Officially atheist; Taoist, Buddhist 8%, Muslim 1.4%, Christian 3%–4% Government: People’s Republic of China: communist state; capital Beijing; country divided into 23 provinces, 5 autonomous regions, and 4 municipalities; Taiwan considered a province; Hong Kong and Macau considered special administrative regions Climate: extremely diverse: tropical in south to subarctic in north Natural Hazards: frequent typhoons (about five per year along southern and eastern coasts), damaging floods, tsunamis, earthquakes, droughts, land subsidence Natural Resources: coal, iron ore, petroleum, natural gas, mercury, tin, tungsten, antimony, manganese, molybdenum, vanadium, magnetite, aluminum, lead, zinc, uranium, hydropower potential Arable Land: 15.4% Agricultural Products: rice, wheat, potatoes, sorghum, peanuts, tea, millet, barley, cotton, oilseed, pork, fish Exports: machinery/equipment, textiles/clothing, footwear, toys/sporting goods, mineral fuels Industries: iron and steel, coal, machine building, armaments, textiles and apparel, petroleum, cement, chemical fertilizers, footwear, toys, food processing, automobiles, consumer electronics, telecommunications Labor Force: agriculture 49%, industry 22%, services 29% ○○○○○○○○

68 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

China, cont. Brief History Creating a brief history of one of the world’s four oldest civilizations is a difficult task. China’s written history alone extends for more than 4,000 years. From about 5000 to 1900 BC Neolithic Chinese lived in settlements along the Yellow River. The Shang Dynasty ruled China from 1900 to 1050 BC from its capital in Luoyang. During this period, the Chinese perfected bronze casting and developed a written language. The Western Zhou Dynasty, 1050 to 770 BC, is noted for the concept of the Mandate of Heaven. During the Eastern Zhou Dynasty, also known as the Spring and Autumn Period, 770 to 475 BC, Confucius set forth his code of ethics and Sun Tzu wrote The Art of War, still used today. From 475 to 221 BC., the Warring States period, Lao Tsu developed Taoism. During the Qin Dynasty, 221 to 207 BC, Emperor Qin conquered all the other kingdoms for a united China and began building the Great Wall. He banned all non-military books and built the recently discovered tombs with the terra cotta warriors. The Western Han Dynasty, 207 BC to 9 AD, established the traditional Chinese state with Mandarin civil service. The population of China at that time was 58 million. Buddhism was introduced during the Eastern Han Dynasty, 25 to 220, and paper was invented. The Tang Dynasty, 618 to 906, was a golden age of peace, music, dance, and poetry. The Ming Dynasty, 1368 to 1644, was established when the Mongols were overthrown by native Chinese. During this time the Chinese explored India and East Africa, welcomed Jesuits to their court, and developed blue and white ceramics. The Qing Dynasty was established by invading Manchus in 1644; it lasted until 1911 when a revolution inspired by Sun Yat-sen established the Chinese Republic. During this period opium became a prime commodity as western traders set up shop in Guangzhou; Hong Kong was ceded to Britain in 1842 as a result of the first Opium War, 1838–40. It was returned to China on July 1, 1997, as a Special Administrative Region. The period 1911 until 1949 was a time of civil unrest, foreign exploitation by capitalists and missionaries, invasion and occupation by Japan. In the 1920s SunYat-sen organized the Chinese Nationalist People’s Party. Chiang Kai-shek, his successor, was unable to resume power following World War II, and the Chinese Communist Party, having survived the Long March across China, organized under Mao Zedong and took power. Chiang Kai-shek and many of his supporters fled to Taiwan. Under Mao’s Great Leap Forward, people were forced to move to agricultural communes and required to produce quotas of crops often not suited for their bioregions. Intellectuals and those suspected of harboring dissident views were sent to camps for re-education. Tens of millions of Chinese people died, many of starvation, during Mao’s regime. The Cultural Revolution pitted one faction of communist leadership against another, destroyed many cultural artifacts, and included the radical youth organization the Red Guard. Mao’s successor, Deng Xiao Ping, established an Open Door Policy in 1979 that introduced market-oriented reforms and decentralized economic decision-making. On May 4, 1989, some 100,000 students and workers peacfully marched in Beijing to demand democratic reforms and protest government corruption. The government declared martial law on May 20. The situation came to a head in Tiananmen Square on June 3 and 4, when the People’s Liberation Army violently confronted peaceful demonstratorrs and killed between 400 and 2,600 people, depending on which source one reads. About 10,000 people were injured. In 1998, following Deng’s death, Jiang Zemin was re-elected president and Zhu Rongji was selected as premier. Housing, Family, Work, Traditions Housing: Housing in Chinese cities is likely to be scarce and crowded. Traditionally, Chinese live in extended families, but the size of urban living units makes this difficult. Rural houses are larger, and several generations may live together and contribute to the family. A minimum standard of living was established nationwide in 1993; it consists of very general principles and leaves implementation up to local governments, as standards of living vary tremendously from city to city, rural to urban area, and east to west throughout this vast country. Family: In an attempt to control population growth, the Chinese government in 1979 enacted the one- child-per-family policy. Urban families are allowed to have one child; rural families can have two children. Families can pay substantial fines to have additional children. Some couples are opting Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 69

China, cont.

not to have children in order to enjoy a higher standard of living. Abortion and infanticide of female children have been inevitable results of this policy, which has nevertheless been very successful in urban areas. The family remains the fundamental and most important unit of Chinese society; Confucian philosophy advocates sacrificing individual needs for the common good. Re- spect for elders and filial piety are still important values to most Chinese. Children are raised to be obedient and to control emotions and impulses. In urban areas, women have virtually the same standing as men, working outside the home and being treated as equal partners in the marriage. Employment: About half of all Chinese work in the agriculture sector, even though only 15 percent of the land is suitable for growing crops. Under the communist system, farmers are required to produce a certain amount for the state; they can use or sell in the open market whatever they produce beyond that. Gender discrimination in wages has been illegal for more than 50 years. About 90 percent of Chinese women work outside the home; children are cared for in day-care centers. As the Chinese economy is becoming more westernized, it is difficult to characterize the work environment accurately. According to the CIA World Factbook, the government has struggled to (a) sustain adequate jobs growth for tens of millions of workers laid off from state-owned enterprises, migrants, and new entrants to the work force; (b) reduce corruption and other economic crimes; and (c) keep afloat the large state-owned enterprises, many of which had been shielded from competition by subsidies and had been losing the ability to pay full wages and pensions. From 80 to 120 million surplus rural workers are adrift between the villages and the cities, many subsisting through part-time, low-paying jobs. According to a Chinese government white paper reported in an April 2004 article in Xinhua, the government needed to find jobs for about 14 million people. The country has a large working- age population with a relatively low level of education. In 2003, some 8 million city dwellers were registered as jobless. From 1990 to 2003, employment in rural sectors declined by about 8 percent, and the number of Chinese employed in state-owned entities decreased by 34.7 million. Nearly half of the newly employed in urban areas during the period worked in individual and private economic entities. A March 30, 2005 article in the International Herald Tribune described a labor shortage in Guangdong Province, on the southern coast of China, where 70 percent of 329 manufacturing companies, most of which depend heavily on migrant labor, reported ongoing difficulty in recruiting workers. According to the writer, peasants appear to be unwilling to travel thousands of miles to endure poor working conditions for meagre wages—as low as 500 yuan or $60 a month. Sports: The 2008 Summer Olympic Games will be held in Beijing. The Chinese are avid participants and spectators in a variety of sports, with table tennis, basketball, and soccer being among the most popular. Mahjong, a game of skill played with tiles, is popular, as are tiaoqi, Chinese checkers, and xian gi, chess. Karaoke has spread to China from Japan. Chinese movement arts such as tai chi and qi gong are popular around the world. Foods and Eating Habits Dietary Practices: Food is seen as an important part of maintaining the balance of yin (cold) and yang (hot) in the body. Hot foods are generally those high in protein, fat, and calories; they include meats, eggs, sugar, and alcoholic beverages. Cold foods include fruits, most vegetables, soy products, and cold drinks. Hot foods are avoided when a person has a hot illness and vice versa. Dairy products are not part of the usual Chinese diet. Everyday Diet: More than 2,000 years ago, the Chinese were printing cookbooks and developing sophisticated cooking techniques. Chinese food is stir-fried, baked, steamed, roasted, cooked in every way imag- inable. Rice and noodles are the staples of the Chinese diet, along with cooked vegetable and meat ○○○○○○○○

70 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

China, cont.

dishes, called cai. The Mandarin word fan means both “rice” and “food.” The Chinese generally eat three meals a day, provided they can afford to do so. The poorest peasants eat simple grain foods with salty pickles adding flavor. Dinner is the main family meal. Pork is the best-loved meat throughout the country. Chinese cuisine is generally divided into four major types or schools according to region. In the northern part of the country, where Beijing is located, garlic, scallions, leeks, and chiles are widely used. Mutton and pork are the preferred meats, with mutton especially popular in the Muslim northwest. Poultry and seafood are rarely used. Salt and oil are liberally used, as is fat, especially pork fat, which adds calories that help during the long winters. Preserved vegetables, similar to Korean kimchee, are popular. Wheat products such as pancakes, steamed buns, noodles of all kinds, and dumplings are more commonly eaten than rice. Eastern Chinese cuisine, found in the cities of Shanghai and Hangzhou and the surrounding provinces, is noted for sweet dishes. Sugar, wines, and vinegars are used to create sweet tastes and subtle flavors. Fish and shellfish from the Yangtze River and the ocean are abundant; soups and soupy dishes are popular. Foreign contact has brought European influences to the cooking of this region. Western Chinese cooking combines a wealth of spices with pork, beef, poultry, and many fruits and vegetables. Bean dishes such as dou fu (tofu) are popular. The heat index of western cuisine rivals that of Thai or Mexican food, with abundant use of hot chiles. The Sichuan/Szechuan school of cooking is perhaps the most popular and best known of this region, although Hunan- style food is also notable. The Szechuan style food served in American restaurants outside the Chinatowns where large immigrant populations live bears only a faint resemblance to the real thing. The cuisine of southern China, centered on Guangdong province and its capital, Guangzhou (Canton), is probably the best known in California and widely considered the best in China. The mild climate makes Guangdong the world’s premier rice-growing region and yields abundant culinary resources; cuisine emphasizes the freshest ingredients and a light cooking touch. Popular Foods: Jaizoi, dumplings filled with meat or vegetables and dipped in black vinegar sauce, are a popular northern dish traditional at Lunar New Year celebrations. Tang yuan, boiled sweet sticky-rice dumplings with various fillings, are eaten at Lantern Festival, the conclusion of the Lunar New Year celebration.Steamed buns, called mantou or baozi, are eaten for breakfast in the north along with zhou, rice porridge. One of the best-known dishes is Peking/Beijing duck, with the classic meal consisting of three courses in which nearly every part of the duck is consumed—first the skin wrapped in pancakes, then stir-fried duck meat, and finally a soup made of the bones. Ma po dou fu, a classic Sichuan dish, consists of soft tofu cubes in a numbing-spicy sauce of ground pork and red chiles. Yue bing, moon cakes, are round cakes with sweet fillings eaten during the Moon Festival. Beverages: Tea is the best-known and most popular drink, with many varieties, but the Chinese have been drinking it for only about 1,400 years. They first produced alcoholic beverages more than 3,400 years ago. Chinese teas come in all colors and flavors. Green teas are perhaps most popular, with Dragon Well tea from Hangzhou province considered the finest tea produced in China. Chinese wine (jiu) is made from fermented rice and other grains, and spirits are also grain-based. A strong sorghum liquor called bai jiu is especially popular in the northern part of the country. Education Status: Education is a high priority for the Chinese government. The Ministry of Education is implementing a plan for nine years of compulsory education nationwide, mandated in 1986 along with standardization of exams and free education. About 91 percent of children have access to primary education. Local governments are mainly responsible for primary education, with central and provincial governments in charge of higher education. Non-governmental agencies are increas- Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 71

China, cont.

ingly involved in education financing. The educational system comprises basic education, occupational education, common higher education, and adult education. Most schools are not entirely free, requiring a variety of fees—for uniforms, meals, classes such as art and music, etc.—that put a heavy burden on many families. In rural areas, the people often have to pay the teacher’s salary and keep up the facilities. An April 1, 2005 article in China Daily notes that the average Chinese family spends up to 50 percent of its income raising a child. Competition for good schools is very high, and many families pressure their only child to excel in school and outside activities. Primary School: During six years of primary school education, students study Chinese language, mathematics, moral education, and other subjects and participate in sports and other activities. Foreign languages are available in the senior year. Students take an exam after sixth grade to determine which junior middle school they will attend. Children attend kindergarten for three years before primary school; according to a March 2005 article this may cost more than $3,000 in Guangzhou. Junior Middle School: Three years are required, the equivalent of our grades 7 through 9, with a curriculum including chemistry, physics, biology, history, geography, and foreign languages. Physical education is encouraged. Senior Middle School: Entrance is by competitive examination taken at the end of ninth grade. The program lasts for three years, the equivalent of our grades 10 through 12. Curriculum includes English, math, science, Chinese literature, history, politics, and sports. Other Education: Occupational education comprises mid-level professional schools, polytechnic schools, occupational middle schools, and short-term occupational and technical training programs. Common higher education includes junior college programs lasting two to three years, four-year bachelor’s programs, two- to three-year master’s programs, and three-year doctoral programs. Adult education includes literacy programs and all levels of education for adults. To enter a university, students must pass a national college entrance exam held the first 10 days of July; students select either the humanities exam or the science/engineering exam and apply for institutions and departments in order of preference. Examination results, plus investigation into social behavior and moral character, determine admission. Less than 50 percent of students are accepted. Religion Status: The Chinese Constitution provides freedom of religious belief, but the government tries to restrict religious practice to government-sanctioned organizations and registered places of worship. It seeks to prevent the rise of groups that might constitute sources of authority outside the government and the Chinese Communist Party. Harsh measures have been taken against groups perceived to threaten the government, but overall membership in religious organizations is growing. A 2002 government white paper stated that there were 200 million religious adherents in China, with more than 100,000 sites for religious activity. The degree of repression varies from region to region, with officials in some areas encouraging Western religious groups to get involved in social service projects. The five officially recognized religions are Buddhism, Islam, Taoism, Catholi- cism, and Protestantism. Traditional folk religions involving the worship of local gods, heroes, and ancestors are widely practiced. Falun Gong, a blend of Taoism, Buddhism, the exercise discipline qi gong, and the teachings of Li Hongzhi, is considered a cult; members have been arrested and imprisoned. Buddhism: In 2002, approximately 8 percent of the population was Buddhist. The more than 100 million members are primarily from the dominant Han ethnic group. According to government figures, there are some 16,000 Buddhist temples and monasteries and more than 320,000 monks and nuns in China. Nearly all Chinese Buddhists are adherents of the Mahayana school. ○○○○○○○○

72 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

China, cont.

Confucianism: Confucianism is not technically a religion, but rather a philosophy of life that, along with Taoism, forms the underpinnings of Chinese culture. Cufucianism, which developed in the sixth century BC, stressed the concept of filial piety and reinforced the Chinese tradition of ancestor worship. Confucianism is a strong force for social harmony in that it prescribes clearly defined roles and responsibilities for every person in society. Taoism: Although officially recognized as a religion, Taoism is a philosophy that developed slightly before Confucianism, about 600 BC. Taoism has no deity, only the tao, or way. The Tao Te Ching, read widely throughout the world, focuses on the importance of living in harmony with the nature of the universe in order to avoid suffering. While there are no official figures on Taoist adherents, the Chinese government in 1997 reported more than 1,000 temples and 10,000 monks and nuns. The Taoist principle of feng shui (wind-water), widely practiced in China and becoming popular in the West, dictates the placement of buildings and objects to ensure harmony with nature. Christianity: Both Catholic and Protestant churches are officially registered with the Chinese government. Christianity was introduced in 1246 by a Franciscan. The unofficial Vatican-affiliated Catholic Church claims as many as 10 million members. The registered Catholic Church has about 5,000 churches, according to the Chinese government. The Vatican is working to unify these groups. The government reports as many as 15 million registered Protestants with more than 12,000 churches. Foreign sources say that about 30 million Chinese worship in independent house churches. Islam: Government figures put Muslim believers at 20 million, with 35,000 places of worship and more than 45,000 imams nationwide. Health and Health Care Health Status: A survey of 16 cities with populations larger than 1 milliion reported in 2004 revealed that up to 75 percent of urban Chinese are in poor health. This was blamed on poor working habits, inadequate government funding, poor disease prevention, and lack of health education. In the days when most industry was owned by the state, workers were organized into work groups that provided for most of their needs, including health care. Job-based medical insurance is increasingly rare; an article from China Daily of April 2, 2005, reported that nearly 45 percent of urban residents and 79 percent of rural residents had no medical insurance. Traditional Practices: Traditional Chinese Medicine (TCM) has been practiced for more than 3,000 years and is based on the concept of balanced qi (“chee”) or vital energy that is believed to flow throughout the body and regulate a person’s spiritual, emotional, mental, and physical balance. Qi is influenced by the complementary forces of yin (negative energy) and yang (positive energy). Disease results from disturbance in the flow of qi resulting in an imbalance of yin and yang. The practice includes herbal and nutritional therapy, restorative physical exercises, meditation, acupuncture, and remedial massage. Herbal treatments and teas, made from a selection of more than 5,000 different plants, have been used for thousands of years. The goal of TCM is to restore balance through acupuncture and the use of compounds. Many Chinese use both traditional and Western medicine, and pharmacies often dispense both Western and traditional Chinese medicines. Medical System: Premier Wen Jiabao reiterated the government’s intention of improving the public health system at the National People’s Congress held in March 2005. China does not have an affordable system to serve the uninsured; 60 percent of medical expenses are paid by consumers. Many people— nearly 50 percent according to a recent survey—would not go to a hospital even when ill. In 2002, the central government began building a voluntary cooperative medical system in rural areas, to be funded with contributions from individuals, collectives, and government. Pilot programs are underway in 310 of China’s 2,000 counties. Wuhan, the capital city of Hubei Province in central China, opened Huimin Hospital in 2005 to serve the poor and disabled. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 73

China, cont. Tips for Health Care Providers An article in the Los Angeles Times of February 11, 2005, described two hospitals in Southern California that have been reorganized to better meet the needs of Chinese American patients. Garfield Medical Center in Monterey Park and Whittier Hospital Medical Center in Whittier are implementing policies and procedures to make these patients more comfortable, incorporating the latest medical technology with the preferences and needs of their Chinese American clients. Attitudes: In the Chinese culture, family members are expected to care for their sick members. Thus family members may play an important role in the interaction between a health care professional and Chinese American client. Medical professionals are advised not to schedule appointments during the Lunar New Year celebration season. A 1997 survey of Chinese and Chinese Americans in San Francisco found that half took Chinese herbal remedies, and that they tend not to take advantage of preventive care measures. Family Authority: The oldest male of the family is generally the final authority. Males are generally more respected than females in the Chinese culture. Addressing Clients: Because there are so many Chinese dialects, the health care provider should determine which dialect the client speaks in order to find an appropriate interpreter, if one is needed. Educated immigrants probably know Mandarin or Cantonese and perhaps a local dialect. Immigrants from Taiwan may speak only Taiwanese dialects. Address older persons by Mr. or Mrs. and their family name. Mainland Chinese women keep their own family name when they marry. Nonverbal Behavior: Chinese traditionally bow slightly or nod politely when greeting another person; handshakes may be acceptable. Eye contact with authority figures is generally avoided. Direct eye contact may be seen as an intimidation tactic. Chinese people, especially women, are very modest. They do not like physical contact with people they do not know. Smiling may indicate embarrassment or shy- ness rather than a positive reaction. Verbal Exchange: In order to save face, a Chinese client may not want to disclose personal information. The client may appear to agree to a procedure when he or she does not really understand it. Chinese language depends a great deal on tone for meaning. Even when speaking English, Chinese Americans may seem to be very loud and abrupt. Practitioners must take care to ensure that patients understand procedures and medications and to verify this understanding and the patient’s willingness to com- ply with treatment protocols. Hospitalization: Family members may want to be involved in patient care. Staff at the Garfield Medical Center in Los Angeles report having to watch for family members trying to sneak in acupuncturists or herbal remedies without the knowledge of the staff, which does try to incorporate complementary medicine when appropriate. Patients may refuse foods due to yin-yang/hot-cold beliefs. When appropriate following dietary consultation, family members may bring requested foods or even herbal preparations. Water and other beverages should be served without ice. Some patients may prefer acupressure or acupuncture to pain medication. Chinese may resist surgery due to the belief in the importance of keeping the body intact so the soul will have a place to live when making future visits to Earth. Death and Dying: Diagnosis of terminal illness should be given to the eldest male family member, who may not want to share it with the patient. Chinese may not want to discuss a terminal illness, and they may be reluctant to complain. According to several sources, among Chinese more than many other cultures it may be common for relatives not to reveal a terminal diagnosis and for the patient to pretend that he/she does not know what is happening. Some Chinese prefer to die in a hospital because dying at home may bring bad luck, while others might believe the spirit could be lost if a person dies in a hospital. At the time of death, family members may want to prepare the body for burial. Organ donation and autopsy may be resisted because of a belief in the importance of keeping the body intact. ○○○○○○○○

74 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

China, cont. Celebrations and Holidays January 1 New Year’s Day: Employees get a paid day off; people celebrate with parties, family visits. February/March Lunar/Chinese New Year or Spring Festival: First day of the first lunar month of the year; most important festival in China and much of East and Southeast Asia. Families clean their homes thoroughly to rid them of bad luck and make way for good luck in the new year. Doors and windows are decorated with paper cutouts and posters expressing hopes for happiness, long life, wealth, etc. Incense is burned to honor the ancestors. Families gather to feast on new year’s eve, then they play games and await fireworks at midnight. On new year’s morning, children receive hong boa, gifts of money wrapped in red paper. The day and following days are spent visiting relatives and neighbors, and exchanging gifts. February Lantern Festival: This takes place on the 15th day of the first lunar month and marks the conclusion of the new year season. Celebrations include lantern exhibits, lion and dragon dances; people eat tang yuan, boiled sticky-rice dumplings filled with beans and sweets, a symbol of family re- union, unity, affection, and happiness. March 8 International Women’s Day April 1 Tree Planting Day; began in 1970s with campaign for a “green nation.” April Qingming Festival/Festival of Pure Brightness: 12th day of the 3rd lunar month, usually around April 4 or 5; activities include cleaning ancestors’ graves, holding memorial ceremonies, making offerings to pay respects to the dead, and flying kites. May 1 International Labor Day May 4 Youth Day: Marks first mass student movement in 1919. June 1 Children’s Day: Celebrates children; more important with “one child” policy. July 1 Birthday of Chinese Communist Party, 1921 August 1 Army Day: Marks beginning of Red Army (later the People’s Liberation Army) in 1927 uprising against the Nationalists. Summer Dragon Boat Festival: Commemorates Chu Yuan, a poet and statesman who drowned himself in 277 BC to protest government corruption; colorful dragon boat races attract many spectators. September 1 Teacher’s Day: Started in the 1980s to reverse anti-intellectualism of the Cultural Revolution. October 1 National Day: Anniversary of founding of People’s Republic of China, 1949. Fall Mid-Autumn/Moon Festival: Celebrated on the 15th day of the 8th month, a day to celebrate the harvest, remember the 14th-century uprising against Mongol rule, and feast on yue bing, moon cakes, small round cakes with various sweet fillings, under the brightest moon of the year. Chinese in the United States The first large numbers of Chinese came to the United States in the 1840s looking for work; many found work with railroads or providing services for mining towns in the West. The Chinese Exclusion Act of 1882 put an end to Chinese immigration until 1924, when the National Origins Quota Act provided American citizens of Chinese ancestry could work in the United States, but that wives and families could not live here. In 1930 the law was ammended to allow wives of Chinese merchants and Chinese women married to American citizens before 1924 to immigrate. At this time, groups of American-born Chinese began to gather in Chinatowns. Early Chinese immigrants faced rampant discrimination, including special taxes, racial violence, and loss of property. In 1943, repeal of the Chinese Exclusion Act enabled more Chinese families to reunite and paved the way for Chinese men to return to China to find wives and then bring them to the United States. The National Origins Quota Act was repealed in 1965, replaced by an Immigration Act that assigned an annual quote of 20,000 immigrant visas to every country outside the Western Hemisphere. Most Chinese arriving under the provisions of this legislation came as families and settled in the areas of major cities where Chinatowns had been established. Prior to 1978, when the United States normalized relations Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 75

China, cont.

with mainland China, Taiwanese made up the largest part of these immigrants. At that time, both Taiwan and mainland China had the right to 20,000 immigrants per year. Hong Kong was allowed to send 600, later increased to 5,000, each year. Following the Tiananmen Square incident in 1989, the United States granted special permament residency status to many Chinese students and visiting scholars. Between 1990 and 2000, the number of foreign-born from China in the United States increased by 87 percent; the United States is home to about 1 million foreign-born from China, the fourth-largest immigrant group in the nation. The total number of those who identified themselves as Chinese during that period increased by 66.2 percent in the United States and by 48.5 percent in California. Los Angeles County has the largest population of Chinese in the United States, about 300,000, with some 35,000 who consider themselves full Taiwanese and want nothing to do with mainland China. The city of San Francisco was home to 160,113 Chinese as of Census 2000. In the year 2000, California received 26 percent of immigrants to the United States, including the majority of those born in Taiwan and 30 percent of those born in China. An article in the April 3, 2005 Los Angeles Times discussed the ongoing friction between mainland Chinese and Tai- wanese in Los Angeles County. Many in Taiwan, the island nation formerly known as Formosa 100 miles from the mainland, want the country to be recognized as a sovereign nation. Feelings were running especially high following recent enactment of an anti-secession law by China, which carries the threat of military force in the event that Taiwan tries to become permanently independent. Taiwanese in Los Angeles County who support independence, organized into a chapter of the Formosan Association for Public Affairs, find themselves alienated from the larger Chinese community. Chinese American women have the highest suicide rate of any ethnic group, according to a 2003 report by Pacific News Service. Among Asian women in the United States, suicide is 2.5 to 3 times more common than among Caucasian women, and appears to be higher among immigrants, possibly in part because of the absence of a social support system, and also because people from many cultures are afraid or ashamed of seeking help for psychological problems. Language; Useful Words and Phrases All Chinese languages and dialects use the same characters, which express word meanings rather than sounds. There are some 60,000 characters; only about 8,000 are commonly used, and a knowledge of at least 4,000 is needed to be able to read a Chinese newspaper. Basic literacy requires knowledge of about 2,000 characters. Spoken Mandarin has four tones—five if you count the “neutral” tone—and pronouncing the tone just right is very important. Written characters don’t reveal their initials and finals, nor do they indicate which tones they are to be pronounced in. Tones also have nothing to do with parts of speech or any other variable. Each character’s “assigned” tone is simply learned when you study or “acquire” Chi- nese. For example, simply by saying “ma” in the four different tones one can say “Did your mother scold the horse?” The first tone is high and level. The second tone starts at a medium pitch and rises. The third tone starts low, dips to the bottom, and then rises. The fourth tone starts at the top, then falls sharply and strongly to the bottom. Finally, there is the neutral, flat tone with no emphasis. China has been streamlining the system of writing characters since 1956, and many characters have been simplified. The official system for writing Chinese words phonetically using Latin script, officially adopted in 1979, is called pinyin, a system developed in China beginning in the 1950s to help fight illiteracy. Replacement of other Chinese-English romanization systems such as Wade-Giles and Yale with pinyin, adopted by the U.S. government for all Chinese names and places, is the reason we now know the country’s capital as Beijing rather than Peking, for example. About 70 percent of Chinese speak Mandarin (Putonghua), the national language, one of seven major languages and more than 50 ethnic languages and dialects. Cantonese is spoken in Macau and Hong Kong and by many Chinese immigrants. The following Mandarin phrases may be helpful to health care professionals working with Chinese clients. Good morning. Cao shang hao (pronounced tsow shawng how). Good afternoon. Xia wu hao. Good evening. Wan shang hao. Hello. Ni hao (knee how). Goodbye. Zai jian. See you later. Zao jian. ○○○○○○○○

76 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

China, cont.

Yes/No Shi/Bu Please Qing (prounounced cheeng). Thank you. Xie xie (sheeuh sheeuh). You’re welcome. Huan ying. How are you? Ni hao ma? Fine/Good Hao. Excuse me. Dui bu qi. What is your name? Ni gui xing? I’m pleased to meet you. Hen gaoxing renshi ni. Do you speak English? Ni hui shuo yingwen ma? Do you speak Chinese? Ni hui shuo zhongwen ma? Happy New Year! Xin nian kuai le! References Brief History of China. http://www.eastgreetswesttravel.com/ChinaWindows/history.html (30 Mar. 2005). Central Intelligence Agency. 2005. The World Factbook: China. http://www.cia.gov/cia/publications/factbook/geos/ch.html (8 May 2005). Chin, Falice. 2005. “Chinese Education System Needs an Overhaul.” Calgary Herald. 24 Mar. http://www.canada.com (1 Apr. 2005). China Education. http://www.index-china.com/index-english/education-s.htm (1 Apr. 2005). “China Faces Prominent Employment Problem.” 2004. Xinhua. 26 Apr. http://english.people.com.cn/ 200404.26.print20040426_141526.shtml (30 Mar. 2005). China Online. http://chineseculture.about.com (30 Mar. 2005). Chinese Outpost. Mandarin Chinese Pronunciation. http://www.chinese-outpost.comn/language/pronunciation/ (4 April 2005). “China Quickens Medical Insurance Reform.” 2001. People’s Daily. 15 Aug. http://www.china.org.cn/english/MATERIAL/ 17542.htm (30 Mar. 2005). “China’s City Dwellers in Poor Health.” 2004. Xinhua. 20 Sept. http://english.people.com.cn/200409/20/ print20040920_157647.html (2 Apr. 2005). Chin, Elizabeth, et al. 2002. China. Anti-Racism, Multiculturalism and Native Issues Centre, Faculty of Social Work, University of Toronto, Canada. http://www.settlement.org/cp/english/china (29 Mar. 2005). CountryReports.China—General Overview. http://www.countreports.org/expandedprofile.asp?countryid=51& countryname=China (3 Apr. 2005). ———. China—In Their Language. http://www.countreports.org/greetings.asp?countryid=51& countryname=China (3 Apr. 2005). Education in China. http://www.travelchinaguide.com/intro/education/ (1 Apr. 2005). Fuller, Thomas. 2005. “The Workplace: Seeking Unskilled Workers.” International Herald Tribune. 30 Mar. http:// www.truthout.org/issues_05/printer_033105LB.shtml (1 Apr. 2005). Grieco, Elizabeth. 2004. “The Foreign Born from China in the United States.” Migration Information Source. http:// www.migrationinformation.org/USfocus/print.cfm?ID-190 (5 Feb. 2004). International Labor Organization. 2004. “China Employment Forum Concludes with Focus on Decent Work for All.” Press Release. 30 Apr. (30 Mar. 2005). Kemp, Charles. Chinese Culture, Health, Refugees, Immigrants. http://www3.baylor.edu/~Charles_Kemp/chinese.htm (14 Feb. 2005). Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 77

China, cont.

Liu, Gloria Zhang. 2001. Chinese Culture and Disability: Information for U.S. Service Providers. Buffalo, NY: State University of New York, Buffalo, Center for International Rehabilitation Research Information and Exchange (CIRRIE). http:/ /cirrie.buffalo.edu (23 Mar. 2005). Minimum Standard of Living System in China: An Interview. 2001. China.org. http://www.china.org.cn/english/2001/ Aug/17444.htm (30 Mar. 2005). Pierson, David. 2005. “Reaching Out to Asian Patients.” Los Angeles Times. 11 Feb. http://www.latimes.com/news/local/ (11 Feb. 2005). ———. 2005. “Split Over Taiwan’s Future.” Los Angeles Times. 3 Apr. http://www.latimes.com/news/local/ (3 Apr. 2005). “Public Health System Needs Overhaul.” 2005. China Daily. 2 Feb. http://www.chinadaily.com.cn/english/doc/2005-04/ 02/content_430420.htm (2 Apr. 2005). Stohler, Jason. 2005. Chinese Education System. Telephone Interview. 1 Apr. Taerea, Denis M. 2003. “The Problem of Health Care in Asian Communities.” APA News and Review. 7 May. (14 Feb. 2004). Timmons, Rachel.Ethnic Cuisine: China. Sally’s Place. http://sallys-place.com/food/ethnic_cuisine/china.htm (31 Mar. 2005). U.S. Department of State Bureau of Democracy, Human Rights, and Labor. 2002. “International Religious Freedom Re- port 2002: China.” http://www.state.gov/g/drl/rls/irf/2002/13870pf.htm (28 Feb. 2004). Vongs, Pueng. 2003. “Hiding the Pain: Suicides High Among Asian Immigrant Women.” Pacific News Service. 22 Dec. (14 Feb. 2004). Wikipedia. “Tiananmen Square Protests of 1989.” http://en.wikipedia.org/wiki/Tiananmen_Square_protests_of_1989 (30 Mar. 2005). WuChin, Yuan. 2005. “Parents Pay Too Much for Education.” China Daily. 1 Apr. http://www.chinadaily.com.cn/english/ doc/2005-04/01/content_430102.htm (1 Apr. 2005). Xiaoping, Yang. 2002. Survey Lists Top 10 Issues of Concern to Urban Citizens. http://www.china.org.cn/english/2002/ Feb/26986.htm (30 Mar. 2005).

○○○○○○○○

78 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 79 South Korea

Census Figures (2000) United States Residents Born in Korea: 864,125 (2.8%) California Residents Born in Korea: 268,452 (3.0%) Quick Facts Country Area: 38,023 sq. miles (slightly larger than Indiana) Population: 48,422,644 Median Age: 34.51 years Population Growth Rate: 0.38% Life Expectancy at Birth: 75.82 years Below Poverty Line: 4% Literacy Rate: 97.9% Currency: South Korean won (KRW) Population Groups: homogeneous (except for about 20,000 Chinese) Languages: Korean, English widely taught in junior high and high school Religion: No affiliation 46%, Christian 26%, Buddhist 26%, Confucianist 1%, Other 1% Government: Republic of Korea; country divided into 9 provinces and 7 metropolitan cities, Seoul is capital Climate: temperate, with rainfall heavier in summer than winter Natural Hazards: occasional typhoons, high winds, floods; low-level seismic activity common in southwest Natural Resources: coal, tungsten, graphite, molybdenum, lead, hydropower potential Arable Land: 17.18% Agricultural Products: rice, root crops, barley, vegetables, fruit; cattle, pigs, chickens, milk, eggs; fish Exports: semiconductors, wireless telecommunications equipment, motor vehicles, computers, steel, ships, petrochemicals Industries: electronics, telecommunications, automobile production, chemicals, shipbuilding, steel Labor Force: agriculture 8%, industry 19%, services 73% ○○○○○○○○

80 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

South Korea, cont. Brief History Archaeological discoveries indicate that the Korean peninsula may have been inhabited for 40,000 years. The Korean people are the descendants of tribes that migrated into the peninsula from central Asia, Manchuria, Siberia, and other areas. The first political state emerged in what is now North Korea more than 5,000 years ago. Written history goes back to the Three Kingdoms period, 57 BC to 668 AD. The Koryo Dynasty (from which the name “Korea” comes) which ruled from 918 to 1392 was noted for its beautiful blue and green celadon pottery with incised designs. Korea was under Chinese control beginning in 1392, but Korean state structures continued. The Choson Dynasty ruled from 1392 to 1910, when Japan imposed colonial rule; this ended at the conclusion of World War II in 1945. That marked the beginning of internal conflicts that led to the establishment in 1948 of the People’s Republic of Korea in the north, backed by communist China and Russia, and the Republic of Korea in the south, supported by the United States. In 1950 North Korea attacked South Korea, triggering the Korean War that ended with an armistice in 1953 that made the 38th Parallel demilitarized zone, or DMZ, the border between the two nations. United Nations forces from 16 nations joined the war to defend South Korea. Following the war, it took nearly 10 years for South Korea to become a stable and economically prosperous nation. In 1987, South Korean voters elected Roh Tae-woo to the presidency, ending 26 years of military dictatorships. South Korea today is a democracy with a GDP per capita 18 times North Korea’s and equal to the lesser economies of the European Union. This success through the late 1980s was achieved by a system of close government/business ties, including directed credit, import restrictions, sponsorship of specific industries, and a strong labor effort. The government promoted the import of raw materials and technology at the expense of consumer goods and encouraged savings and investment over consumption. In June 2000, a historic first North-South summit took place between the South’s President Kim Tae-chung and the North’s leader Kim Jong Il. North Korea remains isolated from the rest of the world, its people impoverished and unable to move freely about the country or to emigrate to other countries. Housing, Family, Work, Traditions Housing: A typical Korean house is made of wood and clay; roofing materials are straw or tiles. According to one source, most Korean houses have inner yards and back yards with terraces. Temperatures fluctuate between very hot in summer and very cold in winter, so houses are well insulated. Heat- ing is usually by means of flues beneath the floors of the house which are connected to a wood- burning stove or other heat source. A traditional Korean home is L- or U-shaped and has one story separated by sliding doors into three to five rooms. Rooms may be multi-functional. A table may be brought out to create a dining room and later put away when mattresses are spread out to create a bedroom. People sit on the floor on cushions and eat off low tables. In the 1990s, a middle-class family in Seoul would have lived in a small apartment with a hallway, a small bedroom with bunkbeds for the children, a small room with mats and dressers that served as a family room during the day and a sleeping room for the parents at night, as well as a larger room divided into a dining area, a small kitchen area, and a living room. Economic development, increasing population density in urban areas, and escalating land prices have made home ownership difficult for lower-income Koreans. Family: The traditional Korean family developed during the Choson period with influence from Chinese Confucianism. Two or three generations might live together under one roof, with strict kinship relations in which relatives are identified by titles given to their positions within the family. Con- fucianism holds harmony and order in high regard and prescribes strict roles for husband and wife in the marriage relationship. The father is head of the family, to be succeeded by the oldest son, who is responsible for caring for the parents in their old age. What is called the direct family is more common, comprising a married couple, their children, and perhaps the husband’s parents. The belief in filial piety or duty is strong—children treat parents with respect, care for them when Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 81

South Korea, cont.

they are old, give them a proper burial, and remember them with rituals after death. Women are treated as less important than men except for their importance in providing male heirs to ensure continuation of the family. Children are often indulged until they go to school, when they are expected to behave and not bring shame on their families. Expression of feelings may be discouraged, and silence is valued. Employment: Until recently, the South Korean work-week included Saturday mornings; South Koreans were noted for having the longest work-week of any nation—up to 60 hours a week for the average worker, and as much as 84 hours for unskilled laborers. In 1986, the average Korean worked 54.7 hours each week; this was necessary due to low wages. The largest percentage of Koreans are employed in the service sector, followed by industry. In the work environment, the individual’s identity is related to his or her position in the organization. Koreans tend to use job titles rather than first names in addressing co-workers or superiors. The sex trade is a continuing problem for the South Korean government, as it faces U.S. pressure to combat trafficking in women and girls. Traditions: Koreans are a homogeneous people; according to their mythology, all Koreans are descended from a common ancestor. Korean society is rigidly ordered based on age or station. People may address one another as “brother” or “sister,” “aunt” or “uncle” even if they are not related. Friendship is a close relationship within the same age group. The concept of kibun, loosely translated as “state of mind,” is important in relating to Korean people. In interpersonal relationships, each participant is responsible for assessing the other’s kibun and acting so as not to upset it. Korean people generally do not participate in small talk and are comfortable with long periods of silence. The traditional Korean costume for both men and women is called the hanbok. For men, it consists of trousers with a jacket and perhaps a vest and over-jacket. The woman’s hanbok consists of a long, loose skirt with a long-sleeved top. Foods and Eating Habits Dietary Practices: Many Koreans hold to the hot-cold theory of balance that requires certain foods to be eaten to treat various illnesses and conditions. Koreans generally do not like iced beverages; many are lactose intolerant and avoid milk products. No dietary taboos as such. Everyday Diet: Rice and vegetables are the staples of the Korean diet. Meals are generally eaten in silence, as it is not considered appropriate to speak while dining, especially in the presence of an elder. A typical meal includes rice (pap), generally steamed, some kind of soup (kuk), and vegetable side dishes (banchan). Koreans eat rice with a spoon. In contrast to custom in China and Japan, lifting the rice bowl to the mouth is not considered good manners. Vegetables are usually eaten raw. Kimchee is served at most meals. This well-known Korean condiment is made of vegetables including cabbage, radishes, cucumber, and various leaves and roots fermented with ginger, garlic, green onion and red pepper, or other spices. Bean curd, called tubu in Korean, is a source of protein. Breakfast is the most important meal of the day. Popular seasonings include garlic, ginger, pepper, soy sauce, green onion, sesame oil, bean paste, red pepper paste, and pickled fish. Salty seasonings and the use of many preserved foods means that many Koreans eat high amounts of sodium, which contributes to such health problems as high blood pressure and diabetes. Ginseng is widely used in foods for its healing properties. Popular Foods: In addition to kimchee, popular foods include a variety of rice cakes (p’yon), skewered boiled beef (chok), slices of dried meat (yukp’o), cold bean soup (k’ongguk), cold noodles (naengmyon), and half- moon shaped rice cakes (songp’yon). A special rice dumpling soup with beef broth, tkokkuk, is eaten to celebrate the Lunar New Year. According to Korean tradition, eating this soup marks the individual’s being one year older and is a means of setting out on a new year marked with health and strength. ○○○○○○○○

82 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

South Korea, cont.

Beverages: Koreans may drink a hot or cold tea made by boiling roasted corn or barley and straining the liquid. Wines and grain alcohol are produced from rice, barley, white, millet, and beans. Wines are made from a wide variety of fruits and flowers, including cherry, strawberry, pine tree, azalea, and chrysanthemum. A punch made with honey, dried persimmons, pine nuts, and cinnamon (sujonggwa) is popular, as is a sweet rice drink, shik’ye, that is served as a special dessert. Education Status: South Korea has one of the highest literacy rates in the world—nearly 98 percent. The country is homogeneous, so virtually everyone speaks Korean. English is widely taught in schools because of the country’s close relationship to the United States. In recent years, Chinese has been increasingly popular as the South Koreans rediscover their ancient ties to China and the importance of China as a trading partner. The Korean school system is organized in a 6-3-3-4 ladder pattern, with six grades of elementary school, three grades each of middle and high school, and four years of higher education. Elementary School: While kindergarten is not included in the formal educational structure, in 1997 there were more than 9,000 kindergartens in the country enrolling more than 27 percent of children ages 3 to 5. The Ministry of Education is working to increase availability. Elementary education was made free and compulsory for children ages 6 to 11 in 1953. The basic curricula consists of moral education, Korean language, social studies, arithmetic, natural science, physical education, music, fine arts, and practical arts. Secondary School: Middle school enrollment has been steadily growing as more children ages 12 to 14 attend grades 7 to 9. In 1997, nearly all students continued on after graduating from elementary school. Prior to 1969, students were required to pass an entrance exam to advance to middle school. Since that time, admission has been through a lottery system by zones in an attempt to ease distinctions between schools of differing quality. Curricula includes 11 required subjects, electives, and extracurricular activities. Elective subjects include technical and vocational courses. High school education provides advanced general and specific training based on middle school work. It is not free and is based at least partly on an entrance examination but may also include middle school activities records. Small specialized schools for subjects such as music, math, and science are being established. Private high schools can select students by whatever methods they choose and decide on appropriate tuition. Higher Education: Higher education institutions include four-year colleges and universities, junior colleges, universities and colleges of education, and miscellaneous colleges such as seminaries. About 80 percent are private, but all are supervised by the Ministry of Education. Bachelor’s degrees are offered in 26 areas of study. Junior vocational colleges work with industry and play a major role in graduating mid-level technicians and preparing graduates for certification in many areas. Religion Status: The most recent estimate shows that 46 percent of Koreans have no religious affiliation, and that about identical percentages practice Christianity and Buddhism: 26 percent. Relations among various religions groups are generally peaceful. Christianity: Among practicing Christians, Protestants outnumber Roman Catholics about three to one. Some 83 Protestant denominations are active in South Korea, and 17 Protestant missionary groups operate in the country. Roman Catholics have 15 dioceses and six missionary groups. Christianity was introduced to Korea in the 18th century by Jesuit missionaries. Koreans in the United States find support in Korean congregations of many denominations. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 83

South Korea, cont.

Buddhism: Most Korean Buddhists are members of the Mahayana (greater vehicle) school also practiced in China, Japan, and Vietnam. Confucianism: Confucianism was the official Korean religion from the 14th to the 20th centuries, and it is a powerful underpinning for Korean social order. More a philosophy than a religion, Confucianism emphasizes devotion to parents, family, and friends, and the worship of ancestors. Peace, harmony, justice, and ethical living are central tenets of Confucianism. The influence of Confucianism is seen throughout Korean social life, particularly in the rules governing human relationships and ancestor worship. From the Three Kingdoms through the Choson period, Buddhist and Confu- cian thinkers left a legacy of refined philosophical works as well as beautiful, practical examples of their search for human ideals. Shamanism: Korean folk beliefs, including shamanism, the country’s oldest religion, still exist in many diverse forms and have a strong influence on everyday life. Religious surveys typically fail to include the shamanist population, so the exact number of practicing shamanists is unknown. According to the Korean Embassy, shamanist rituals still take place and there are well over 50,000 fee-paying members of shamanist organizations throughout the country. Other: Some Koreans are adherents of Taoism. Muslims, Jehovah’s Witnesses, Mormons, and members of such organizations as the Jesus Morning Star Church and the All People’s Holiness Church are part of the Korean religious landscape. Health and Health Care Health Status: Because of the high sodium content of traditional Korean diets, high blood pressure, diabetes, and other conditions are common. Koreans generally eat a diet low in fat and processed food and high in vegetables, which contributes to their longevity. Alcoholism is a significant problem, especially in the business community; the country has the highest alcohol consumption rate in the world. Traditional Practices: Many traditional practices are used and accepted in South Korea. Acupuncture and herbal remedies are popular, and ginseng is widely used. Illness is sometimes seen as the result of a disruption of the body’s balance. Illnesses seen as “hot” or “cold” are treated by opposing forces to restore balance. Thus a cold would be treated with hot bean sprout soup laced with garlic, hot spices, and dried anchovies to clear congestion. Koreans may also be concerned about kior chi force, the life force of the body, which may be diminished by such things as blood withdrawal, sweating, and sex. Like other Asian cultures, Koreans may use cupping techniques as well as moxibustion, the burning of a soft material at specified spots corresponding to internal energy channels. Those who practice shamanism may use a practice known as hanyak to heal both body and soul. This involves the use of herbal medicine to create personal harmony. Medical System: In July 2000 South Korea completed a five-year restructuring of its health care system, merging many private insurance companies into one national provider, the National Health Insurance Cor- poration, that serves all citizens. Employers deduct a small amount from the employee’s wages to cover costs. Each family has a health insurance card, and dental care is covered as well. Many U.S. prescription medications are available over the counter in South Korea. Tips for Health Care Providers Attitudes: Koreans view physicians as powerful and trustworthy members of society. Many traditional practices are used and accepted in South Korea. Illness is sometimes seen as the result of a disruption of the body’s balance. Koreans who are Buddhists view illness as a natural part of life to be accepted. Contraception is widely used in South Korea to limit family size to two children. Abortion is legal and accepted. ○○○○○○○○

84 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

South Korea, cont.

Family Authority: Decisions are becoming more family-focused, but a husband, father, or eldest son may be the final authority. One of them or the eldest daughter may act as spokesperson for the client. Addressing Clients: Show respect, especially to elders. Do not address an older person by his or her first name. When handing something to an elderly person, use both hands. Nonverbal Exchange: Touching among strangers is considered disrespectful except for medical examination purposes. As in many Asian cultures, pointing the sole of the foot toward another person is considered rude. Verbal Exchange: Provide teaching instruction in as many ways as necessary to insure understanding. Emphasize prevention, particularly the reduction of sodium in the daily diet. Hospitalization: When hospitalization is needed, be aware that in Korea patients are generally not hospitalized for long periods but are cared for at home by relatives. Allow the family to share in patient care as appropriate. Korean patients may be seen as overly dramatic in expressing pain, which may make pain assessment difficult. They often do not like to use pain medication for fear of addiction or complications. The Korean expression for “much pain” is ah-poom nida; the term chegesso or chegetta, which literally means “I could die,” may be used for dramatic effect in describing pain. Religious Practices: Most South Korean immigrants are Christian and would follow Christian religious practices such as requesting a minister or priest. Shamanism is still a strong force, and it is not uncommon for several religious traditions to be intermingled. Spiritual healers may be used. Death and Dying: Be careful in discussing terminal illness. This is often resisted, although prolonging life is seen as unacceptable and DNR orders are common. Organ donation and transplantation are thought to disturb the body’s integrity. When a patient dies, family and friends may chant, pray, and burn incense. The family will want to spend time with the individual following death, and may request cleansing of the body. Cremation is viewed as destroying the soul or spirit. Celebrations and Holidays January 1 Western New Year: Most Koreans count themselves one year older on this date. January/February Lunar New Year: Celebration varies from January 21 to February 19. Koreans dress in traditional clothing and travel to be with family and to honor the ancestors and older living family members in a ceremony called sebae. Gifts of cash in red envelopes are given to young people for correctly executing a traditional bow in front of elders. A traditional game, Yut-Nori, is played on a board with 29 circles and four sticks. See-sawing is popular, as is kite flying. Special foods include a rice dumpling soup in beef broth, tkokkuk. March 1 Independence Movement Day: Commemorates the beginning of the Samil Independence Movement against the Japanese colonists in 1919; celebrates Korea’s independence from all foreign powers, including the United States. April 5 Arbor Day April/May Buddha’s Birthday May 5 Children’s Day: Parents give gifts to their children and take them on family outings. May 8 Parents’ Day: Children give their parents gifts of carnations and letters of appreciation. July 17 Constitution Day: Celebrates the establishment of the first Korean constitution in 1948 and the establishment of the Republic of Korea shortly thereafter. August 15 Liberation Day: Celebrated as the official end of Japanese colonial rule and the beginning of the modern era; this is the date Japan surrendered to the United States. September/October Ch’usok: Harvest Moon Festival, date varies; one of the most important holidays; Koreans wear traditional clothing and travel to be with family; two to four days off work. October 3 National Foundation Day (Gaecheonjeol Day): Date on which Dangun, the mythical first Ko- rean, founded the Korean nation more than 4,000 years ago. December 25 Christmas Day: Official holiday as many Koreans are Christian. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 85

South Korea, cont. Koreans in the United States Koreans have been migrating to the United States for more than one hundred years. Beginning in 1903, about 8,000 Koreans settled in Hawaii to work on plantations, escaping Japanese control. Korean women came to the United States as “picture brides.” From 1950 to 1965 some 17,000 Koreans came to the United States, most under the War Brides Act of 1947 that allowed Asian wives and children of U.S. military personnel to enter on non-quota status. The 1965 Immigration Act opened the gates to a large influx of immigrants from throughout Asia. The second wave of Korean immigrants was from the middle class, many with college degrees. During the period of 1965 to 1977, many health care professionals emigrated from Korea to the United States. Koreans in the United States are concentrated primarily in Hawaii, California, New York, Illinois, and Texas. Los Angeles County has the largest population of Korean immigrants in the nation, with more than 95,000 Korean residents identified in the 2000 census. More than a quarter of all Koreans in the United States live in the Los Angeles, Orange, San Bernardino, Riverside, and Ventura county area. There are large Korean settlements in Fullerton, Glendale, La Cañada, and Torrance. The Korean population of the United States increased by 53.8 percent from 1990 to 2000; in California, the percentage increase was 44.5. In 1992, the Korean community in Los Angeles suffered devastating losses following four days of rioting in response to the Rodney King verdict. Nearly 2,500 Korean businesses were damaged or destroyed. In the Los Angeles area, Korean Christian church attendance is estimated to be about 80 percent. The naturalization rate for Korean Americans is about 60 percent, and many 1.5 and second-generation Korean Ameri- cans are becoming involved in politics. Among immigrants, about 92 percent are non-English speakers. According to information from the Korean American Coalition Los Angeles–Census Information Center, foreign-born Koreans show the highest percentage of persons with difficulty in English as compared with other Asians. In Los Angeles County, 43 percent of Koreans have difficulty with English. In July 2005 authorities broke up a sex-trafficking ring operating brothels in the San Francisco and Los Angeles areas using women brought to California illegally from poor areas of South Korea. Language; Useful Words and Phrases The Korean spoken language, Han-gul, originated in the 15th century with King Sea Jong and is thought to be the first phonetic alphabet in East Asia. Han-gul was influenced by Chinese, from which half of its vocabulary came, and has similarities to other languages including Japanese and Turkish. The language consists of 14 consonants and 10 vowels. Sentence structure is subject-object-verb, so a Korean word order would be “I breakfast eat” or “She sick is.” Sentences tend to be longer and more complicated in Korean than in English. Despite the fact that there are five major dialects spoken in the northern and southern parts of the peninsula, Korean is relatively homogeneous and people throughout the country can understand one another. Most Americans know the Korean word tae-kwon-do, which literally translates as “leg-to raise- way of life.” Korean names are usually three syllables with the one-syllable last name first. Kim, Park, and Lee are the most common Korean family names. Several Web sites provide Korean words and phrases; the learner can hear words pronounced at http:// www.langintro.com/kintro. The following words and phrases are rendered phonetically. Pronunciation helps include tips that the accent is usually on the first syllable of the word, that “si” is pronounced “shi,” and “l” is pronounced like a combination of “r” and “l.” Good morning/day/night. Ahn yawng hah seh yoh. How are you? Ahn hawng hah seh yoh? Hello. Yaw boh sey yoh. Goodbye. Ahn yawng hee kyeh seh yoh (said when speaker is leaving). Nice to meet you. Mahna beh bahn gahp sum nee dah. Please/Thank you Ship shee yo/Kam sahm nee da You’re welcome. Chawn mahn neh yoh. Yes/No Yeh/Neh/Ah nee yoh ○○○○○○○○

86 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

South Korea, cont. bed Chim dae toilet Pyun so pain A pu food Um sik hungry Bae kop pa rice Pap hot Deu ku wu stomachache Bae a pa cold Choo wu headache Khol a pa References Annual Customs. http://www.asianinfo.org/asianinfo/korea/cel/annual_customs.htm (22 Mar. 2005). Asia-Pacific Connections, Ltd. Korean Holidays. http://www.asia-pacific-connections.com/korean_national_holidays.htm (22 Mar. 2005). ———. Korean Language. http://www.asia-pacific-connections.com/Language.htm (22 Mar. 2005). Central Intelligence Agency. 2005. The World Factbook: South Korea. http://www.cia.gov/cia/publications/factbook/geos/ ks.html (8 May 2005). Education/Literacy in Korea. http://www.asianinfo.org/asianinfo/korea/education.htm (3 Mar. 2005). Eisenberg, J. David. An Introduction to Korean. http://www.langintro.com/kintro/ (28 Feb. 2005). Kemp, Charles. Korean-American Health Care Beliefs and Practices. http://www3.baylor.edu/~Charles_Kemp/korean.htm (14 Feb. 2005). Kim-Rupnow, Weol Soon. 2001. An Introduction to Korean Culture for Rehabilitation Service Providers. Buffalo, NY: State University of New York, Buffalo, Center for International Rehabilitation Research Information and Exchange (CIRRIE). http://cirrie.buffalo.edu (28 Feb. 2005). Korean American Coalition Los Angeles Census Information Center. 2003. “Socio-economic Indicators, Language Use, Linguistically Isolated Language Environment, 2000.” Press release. 18 July. KTNET. Clothing, Food, Housing. http://www.ktnet.co.kr/enghome/culture/living.html (28 Feb. 2005). ———. Family Structure and Relatives. http://www.ktnet.co.kr/enghome/culture/family.html (28 Feb. 2005). Lee, Cecilia, ed. 2002. South Korea. Toronto, Canada: University of Toronto Anti-Racism, Multiculturalism and Native Issues Centre. http://atwork.settlement.org (3 Mar. 2005). Library of Congress. Country Studies: South Korea. http://www.country-studies.com/south-korea.html (1 Mar. 2005). Lin, Sam Chu. 2003. “Scattered But Strong: Korean American Results from the 2000 Census.” Asian Week, 10 Jan. http:// www.asianweek.com/2003_01_10/feature_scattered.html (22 Mar. 2005). Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. Love the Children. Korean Words. http://www.lovethechildren.com/words.html (22 Mar. 2005). Neely, Jane N. 2005. “Local Koreans Mark the Lunar New Year Traditionally.” La Cañada Valley Sun. 3 Feb. http:///www.lacanadaonline.com/articles/2005/02/03/newws/news01.prt (9 Feb. 2005). Purcell, Conor. n.d. “Sex Life Active, Sex Trade Thriving in Korea.” The Seoul Times. http://theseoultimes.com/ST/db/ read.php?idx=260 (1 Mar. 2005). Seoul Searching. Korean Words and Phrases. http://www.seoulsearching.com/language/phrases.html (22 Mar. 2005). Sun Microsystems. 2004. Smart IT Choices Keep a National Health System Humming. Boardroom Minutes. Nov.-Dec. http://www.sun.com/br/1204_ezine/hc_nhic.html (3 Mar. 2005). TravelBlog. About Korean. http://www.travelblog.org/World/korean-language.htm. (22 Mar. 2005). U.S. Department of State. Background Note: South Korea. http://www.state.gov/r/pa/ei/bgn/2800.htm (3 Mar. 2005). ———. International Religious Freedom Report 2002, Republic of Korea. http://www.state.gov/g/drl/rls/irf/2002/13877pf.htm (28 Feb. 2004). Van Derbeken, Jaxon, and Ryan Kim. 2005. “Alleged Sex-Trade Ring Broken Up in Bay Area.” San Francisco Chronicle. 2 July. http://www.sfgate.com (9 Jul. 2005). Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 87 Japan

Census Figures (2000) United States Residents Born in Japan: 347,539 (1.1%) California Residents Born in Japan: 112,212 (1.2%) Quick Facts Country Area: 145,898 sq. miles (slightly smaller than California); Japan comprises four main islands: Hokkaido, Honshu, Shikoku, and Kyushu Population: 127,417,244 Median Age: 42.64 years Population Growth Rate: 0.05% Life Expectancy at Birth: 81.15 years Below Poverty Line: Unknown Literacy Rate: 99% Currency: yen ( JPY) Population Groups: Japanese 99%, Others 1% (Korean, Chinese, Brazilian, Filipino, Other) Languages: Japanese Religion: Shintoism 50.1%, Buddhism 44.3%, New Religions 4.7%, Christianity 0.8% Government: constitutional monarchy with a parliamentary government; capital is Tokyo; country divided into 47 prefectures Climate: varies from tropical in south to cool temperate in north Natural Hazards: many dormant and some active volcanoes; about 1,500 seismic occurrences (mostly tremors) per year; tsunamis; typhoons Natural Resources: negligible mineral resources, fish Arable Land: 12.19% Agricultural Products: rice, sugar beets, vegetables, fruit, pork, poultry, dairy products, eggs, fish Exports: motor vehicles, semiconductors, electrical machinery, chemicals Industries: among world’s largest and most advanced producers of motor vehicles, electronic equipment, machine tools, steel and nonferrous metals, ships, chemicals, textiles, processed foods Labor Force: agriculture 5%, industry 25%, services 70% ○○○○○○○○

88 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Japan, cont. Brief History Japan is thought to have been founded in 660 BC; Jimmu was the first emperor. Early Japanese tribal culture was greatly influenced by both Korea and China. The Yamato clan came to power in the 4th century AD. In the 5th century, historiog- raphers were appointed to keep records. Buddhism came to Japan from Korea about 552; it became the national religion by the 7th century. Nara became the capital in 710; in 794 the capital was moved to Kyoto, where it remained until 1868. In the 9th century, emperors retreated into the background, leaving the affairs of government to their subordinates. The Fujiwara family took power in 858 and kept it for 300 years. Under the greatest Fujiwara leader, Michinaga, Japan’s government changed from centralized to a system where the country was divided into great estates. Near the end of the 12th century, warriors from the Taira and Minamoto clans engaged in a power struggle that ended with the Taira taking control of the country from the Fujiwara in 1160; in 1185 the Minamoto under Yorimoto assumed power. Yorimoto separated the military from the government, establishing a military capital at Kamakura. This was the beginning of the shogunate and the rule of the samurai class as well as the beginning of the Japanese feudal era. Warrior families controlled villages and agriculture, and the influence of the imperial court was undermined by Buddhist monks. In the 16th century, traders from Spain and Portugal reached Japan, and Jesuit missionaries introduced Christianity. A new Buddhist sect, Zen, gained importance. During this time, well-known Japanese practices such as ikebana (flower arranging), the Noh drama, and the tea ceremony were established. In the 17th century, Tokyo became the capital and Japan closed itself off from Western influence, banning European books and missionaries. In 1868 power returned to the emperor in Kyoto; feudal institutions were abolished. The Japanese defeated the Chinese in a war during 1894–95, and in 1904–5 Japan defeated Russia to take power over Korea. In World War I, Japan fought against Germany. In December 1941 Japan bombed Pearl Harbor and entered World War II on the side of Germany. The nuclear bombing of Hiroshima and Nagasaki in 1945 by the United States forced Japan to surrender; the country was occupied by the U.S. military from 1945 to 1952. Since the 1950s, Japan has experienced tremendous economic growth. The constitution was rewritten in 1946; it resembles the U.S. Constitution, but offensive military forces and nuclear weapons are forbidden. The emperor retains his throne, primarily as a symbol of national unity. The Japanese governing body is a prime minister and the National Diet, much like the U.S. Congress. The Liberal Democratic party, actually a very conservative group, is currently in control. Junichiro Koizumi has been prime minister since April 2001. Housing, Family, Work, Traditions Housing: About three-quarters of the Japanese people live in cities. Many have to wait years to find a house or apartment, which are very expensive. Some Japanese families choose to live in the suburbs and must commute several hours each day to jobs in the city. Most people live in modern housing, but traditional Japanese houses can still be found. They are set back from the street and entered through a gate and a garden, then through a sliding door where occupants remove their outdoor shoes. The house is divided into rooms by sliding screens made of wood and rice paper. The Japanese sleep on futons which are placed on the floor and then folded and put away during waking hours. Family: The modern Japanese nuclear family is usually small. The father is head of the family, which is characterized by solidarity and mutual helpfulness. Young people tend to marry in their late 20s or even after, generally living with their parents before marriage because of the severe housing shortage. Men and women meet at work or while studying at a university, perhaps through an arranged meeting or miai. Elderly relatives are often part of the household, as grown children are required to care for their parents. Elders my assist with household chores and childcare if they are able. Tradi- tionally, children have been taught that the group is more important than the individual, and that maintaining harmony is a value. They learn to behave in public by being polite and shy, to respect and obey age and authority, and to carry out the formal behaviors required in polite Japanese society. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 89

Japan, cont.

Work: The Japanese work environment is known to be highly stressful and exhausting, giving rise to the problem of karoshi, death from overwork. This is becoming less common as young people devote more time to leisure pursuits. The 40-hour work week was implemented in 1997. Robots are used extensively in factories to do work such as welding and painting. When the stock market crashed in 1992, the Japanese economy went into a recession from which it continues to recover. This caused considerable stress among workers. Although women make up about 40 percent of the workforce, they are generally paid less than men and hold subordinate positions. Most people have to commute to work, many using the crowded bullet train or shinkansen that travels between major city centers at speeds of over 180 miles per hour. Traditions: Japanese are traditionally quiet and polite; they control their facial expressions and are not given to emotional outbursts. Elders and authority figures, including medical personnel, are treated with respect. They tend not to make direct eye contact, especially with superiors, and touching is not common. During conversation, the Japanese nod their heads to show agreement or concentration; a negative is indicated by holding a hand in front of the face and waving it back and forth sideways. Japanese women traditionally put a hand in front of their mouth when laughing to avoid showing their teeth. When greeting others, Japanese tend to be formal and may use a smile or small bow to acknowledge the other person. The depth of the bow is related to the occasion and the social status of the individuals involved. When bowing, the Japanese keep their feet together and their backs straight; women put their hands on the front of their legs, and men hold their hands at their sides. Handshaking is becoming more common. Saving face is important. The concepts of enryo (self- restraint), gaman (self-control, endurance), and haji (shame) are key to Japanese culture. A well- known Japanese tradition, the tea ceremony (cha no yu) has been observed for 600 years, incorporating special rules of etiquette designed to achieve a feeling of peace. Leisure: Traditional Japanese leisure pursuits include horse racing (and gambling); a single event runs for eight days at ten racing tracks throughout the country. Local horse racing is held at 30 regional tracks throughout the country. Go and shogi are traditional indoor games, and many Japanese enjoy traveling to see cherry blossoms in spring and colored leaves in the fall. Pachinko (pinball) is wildly popular, as is karaoke. According to the Japanese Embassy, “The numbers of those who have become completly preoccupied with and dependent upon pachinko have been on the rise.” Foods and Eating Habits Dietary Practices: Some older Japanese hold beliefs that certain combinations of food may cause illness (e.g., watermelon and crabs). Many Japanese are lactose-intolerant and do not handle alcohol well. During the Lunar New Year celebration, eating certain foods is thought to bring good luck and health for the coming year. Everyday Diet: The Japanese eat three meals a day and may have snacks such as rice cakes between meals. The traditional Japanese diet is low in fat, cholesterol, animal protein, and sugar, but may be high in salt. Rice (gohan) is eaten with most meals, especially dinner. Brown buckwheat noodles, soba, may be eaten instead of rice at times. Other popular noodles are ramen and udon. Fish and soybeans are traditional sources of protein. Soybeans are used in sauces, tofu (beancurd), and miso (soy paste used in soups). Other mainstays of the everyday diet are vegetables and seaweed. Japanese traditionally make an effort to prepare and serve food in a manner that is visually appealing. Many Japanese now eat a Western-style breakfast, but the traditional breakfast is white rice, cooked fish, vegetables, miso soup, and umeboshi (salty pickled plums). Lunch, o-hiru, might be a packed lunch, bento, including rice, vegetables, and umeboshi. Dinner, yu shoku, is when parents and children eat together. Traditionally, the Japanese would say Itadokimasu (I receive) before a meal and Gochiso- sama-deshita (It was a magnificent feast) after a meal. ○○○○○○○○

90 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Japan, cont.

Popular Foods: Japanese food is probably quite familiar to most Californians. Types of Japanese foods and cooking include: Sukiyaki—thinly sliced beef with vegetables, tofu, and vermicelli prepared right at the table; Tempura—prawns, fish, and vegetables dipped in egg batter and deep-fat fried; Sushi—small pieces of raw seafood such as tuna, squid, or prawn placed on a ball of vinegared rice and wrapped in seaweed; may include cucumber, pickled radish, and other ingredients; Sashimi—sliced raw fish eaten with soy sauce; Yakitori—small pieces of chicken and vegetables skewered on bamboo and grilled over hot coals.; Donburi—bowl of rice with a hot entree, like stir-fried vegetables or deep- fried chicken, on top; Yakisoba—fried noodles, possibly with vegetables and meat, stir-fried in a wok and eaten like spaghetti; Ramen—popular and very inexpensive noodle soup, Japanese “fast food.” Wasabi, a fiery green horseradish paste, is a popular accompaniment. Kobe beef is a very expensive delicacy throughout Japan. It comes from cattle that are specially bred and raised to produce very tender meat with a high fat content. Beverages: Japanese rice wine, sake, is consumed both cold and warmed; local breweries produce different varieties. The Japanese drink green tea, without cream or sugar, and coffee is also popular. Education Status: Elementary and junior high school attendance (nine years) is compulsory. Education is funded by the federal government together with local and regional governments. Prior to elementary school, children attend kindergartens and day-care centers. Most schools have three terms each year; the school year begins April 1. Most students attend five days a week, but some have classes on Satur- day mornings. Terms are April through July, September through December, and January through March. Classes are generally large in both primary and secondary education. Most children wear uniforms to school, and Japanese children study harder than students in many Western nations. After school, elementary and junior high students may attend juku, private cram school, where they receive individual help with their schoolwork so that they will do well and be prepared for the high school entrance exam. The severe stress caused by this emphasis on performance has resulted in a pervasive school climate of bullying, violence, and “allergies to school” as early as elementary school. Bullying and violence have been blamed for suicides among schoolchildren across the country. Both parents and the system itself have been blamed for this unhealthy situation. Elementary School: The Ministry of Education defines the curriculum for the six elementary grades, so that all students throughout Japan study the same thing in a grade. Curriculum includes Japanese language, social studies, arithmetic, science, life environmental studies, music, arts and craft, physical education, and homemaking. One hour each week is devoted to moral education and extracurricular activities. Lunch is provided; the students eat in their classrooms. By the end of the sixth grade, children are required to learn a minimum of 1,006 Chinese characters in addition to Japanese. Junior High School: Three years of junior high school are compulsory. The Ministry of Education specifies the subjects to be taught, but teachers have latitude in defining the topics they cover. The standard junior high curriculum requires Japanese language, social studies, mathematics, science, music, fine arts, health and physical education, and industrial arts or homemaking. Students may take electives in foreign language, often English; there are weekly extracurricular activities and an hour of moral education. High School: High school attendance (three years) is not required and can be extremely competitive. Students must pass entrance examinations, and those who want to get into the most highly regarded universities need to be accepted by the better high schools. The curriculum includes Japanese language, geography and history, civics, mathematics, science, health and physical education, art, foreign languages, and home economics. The atmosphere surrounding both high school and college entrance examinations is called, according to the Japanese Embassy, “examination hell.” Most of the exams are multiple choice questions, but some include essays or performance tests. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 91

Japan, cont.

Higher Education: About half the graduates of Japanese high schools attend either a two-year junior college or a four-year university. There are both public and private institutions. Competition for schools considered most prestigious is fierce, as attending a big-name school is thought to increase the graduate’s chances of getting a good job. Many companies recruit from only the top universities. Religion Status: According to the U.S. Department of State’s International Religious Freedom Report of 2002, regular participation in formal religious activities is low, making it difficult to determine numbers for particular groups. The Aum Shinrikyo group, responsible for the sarin gas atttack on the Tokyo subway system in 1995, has been renamed Aleph and is under government surveillance. Shintoism/Shinto: Shintoism, or Shinto, is the indigenous Japanese folk religion that embodies native Japanese religious and philosophical beliefs, in contrast to Buddhism, introduced to Japan in the sixth century. Many Japanese practice both Shinto and Buddhism. Customarily, the Japanese use Shinto rites to celebrate birth and marriage and Buddhist ceremonies for funerals and memorial services. Shinto grew out of respect and awe for nature, all of which was believed to be imbued by supernatural beings or kami. Practitioners erected shrines in sacred places. According to Shinto belief, after death every person, regardless of the quality of his or her earthly life, becomes a kami and continues to participate in the life of the community. Shinto has no official sacred scriptures or fixed dogma. Believers visit shrines as they desire; there are no weekly religious services. Each shrine has several major festivals each year. Practitioners strive for peaceful relations with other religions. Buddhism: Buddhism was introduced to Japan in the sixth century from Korea. Some 28 different schools of Buddhism are recognized under the 1951 Religious Corporation Law; major schools include Jodo Shinshu, Tendai, Shiingon, Joudo, Zen, Nichiren, and Nara. The lay organization Soka Gakkai has more than 8 million members. Christianity: Spanish Jesuit missionaries introduced Christianity to Japan in 1549; it was banned from 1612 until 1873. Japanese Christians are both Roman Catholic and Protestant, with the numbers of Protestant and Catholic churches roughly equal as of 1994. New Religions: All other religions practiced in Japan are grouped in this category. They include the Unification Church of Japan, the Church of Scientology, Jehovah’s Witnesses, and native religions such as Perfect Liberty and Risho Koseikai. Health and Health Care Health Status: The Japanese population is overall much older than that of many neighboring countries; the median age is more than 40. In addition, the birth rate is well below one percent. The Japanese people are generally very healthy and live on average to 81 years of age. It is estimated that about a fourth of the population will be over age 65 by the year 2025. Traditional Practices: One traditional Japanese practice, kampo, is a holistic approach designed to strengthen the body while treating an illness. Kampo practitioners are both medical doctors and pharmacists trained in Eastern medicine. Acupuncture is frequently used, as are shiatsu and amma massage. Sekkotsu therapy is the use of touch to diagnose sprains, fractures, and dislocations, which are then treated with massage. Moxibustion, the burning of small amounts of a plant called mogusa or moxa on the skin to stimulate the immune system and prevent illness, is used in Japan as in many other Asian countries. Japanese may eat rice porridge with pickled vegetables when they are ill and use pickled plums and hot tea to avoid constipation. Medical System: Japan has a comprehensive health care system funded by national and local governments as well as employer and individual contributions. Everyone is covered by the public health insurance plan, ○○○○○○○○

92 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Japan, cont. and private plans are also available. The system includes small neighborhood clinics and large hospitals. Public health centers in urban areas provide health education, immunization, preventive health care, and both prenatal and post-natal care. Some Japanese companies operate hospitals for their employees. Tips for Health Care Providers Attitudes: First-generation Japanese Americans, Isei, may not speak or understand English. The second generation, or Nisei, born and educated in the United States, may still retain Japanese attitudes. Third generation Sansei and fourth generation Yonsei generally reflect U.S. attitudes and culture. Family Authority: The father, eldest son, or eldest daughter is traditionally the family authority. In younger generation families, the mother often has more authority than the son or daughter. Addressing Clients: Greet clients formally by using the last name. Handshakes are common in younger generations. Nonverbal Exchange: Japanese tend to be very modest and prefer caregivers of the same gender. They use little direct eye contact, especially with superiors. Facial expressions are generally controlled, and touching is not common. Older Japanese may nod during conversation; this may not indicate agreement. Verbal Exchange: It is considered polite to speak in a soft voice and avoid expressions of conflict or disagreement. Saving face is important. Japanese Americans, especially older individuals, tend not to ask many questions about medical treatment and leave decisions to health care professionals. Self-disclosure depends on establishing a relationship of trust, and the health care professional may need to ask pointed questions to elicit desired information. Hospitalization: Cleanliness is very important as part of a belief in the need to purify the body to restore health. Daily tub baths before bedtime are generally preferred. Japanese begin by soaping and scrubbing before entering the tub. The bath, or ofuro, is used only for soaking—the most relaxing part of the bathing ritual. Japanese may be very stoic in expressing pain, and older Japanese may refuse medication for fear of addiction. Oral medication may be preferred to injections. Family members may wish to stay with the patient during hospitalization. Visitors will bring gifts of food and flowers, although potted plants are frowned upon because their roots are considered an omen of a long hospitalization. Chrysanthemums and white flowers are generally not given because of their association with death and funerals. Death and Dying: In situations of terminal illness, discuss the situation with family members including spouse and eldest children. They may be hesitant to disclose bad news to the patient. Family and patient may avoid discussing death. DNR is generally decided by the entire family. Terminal patients may prefer to die at home with care from the family. Sick elders are primarily cared for by the eldest son’s family. Placing a parent in a nursing home is a difficult decision that may cause guilt. Japanese Americans who follow Shinto or Buddhist beliefs may have the body cremated. Older Japanes may not agree to organ donation or autopsy due to belief that the body should remain intact. Celebrations and Holidays January 1–3 Shogatsu, New Year: The most important Japanese celebration before which people clean their houses, pay debts, and settle conflicts. The gates of the house are decorated with kadomatsu made of pine branches, bamboo, and straw, and a straw rope called shimenawa hangs at the entrance to the house. These decorations welcome the gods and spirits of ancestors who protect the families living there. Families visit Shinto shrines or Buddhist temples to pray for good health and good fortune in the new year, a tradition called hatsumode. At midnight on New Year’s Eve, bells ring 108 times to drive away the evil spirits of the past year. Red and white foods are eaten, as these are the colors of good fortune, and children receive otoshidama, decorated envelopes of money. Many people write resolutions for the new year. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 93

Japan, cont. January (2nd Monday) Seijin no hi, Adults’ Day: All young people turning 20 during the coming year are honored in a coming-of-age ceremony, after which they are eligible to vote, drink, and smoke. February 11 National Foundation Day March 3 Hina-matsuri, Doll Festival: Families pray for the health and happiness of their daughters and display doll collections with dolls wearing traditional Japanese court attire. Offerings of white sake, rice cakes, and dry rice cake pellets with peach blossoms are made. March 21 Haru no Higan, Vernal Equinox Day: People visit family graves to pay respect to ancestors; Bud- dhist priests perform sutra readings to honor the ancestors. April 29 Green Day begins Golden Week, the beginning of the school year and the time employees begin new jobs. Many people take a holiday of a week or more to enjoy spring travel. May 3 Constitution Day May 5 Children’s Day: Celebrated during Golden Week, traditionally honored boys but now includes girls as well; fun activities and special foods include rice dumplings wrapped in bamboo leaves. July O Bon, Festival of the Dead: Many people take holidays from work for this observance of welcom- ing and consoling the spirits of ancestors; opens with fires and lanterns to guide the spirits home and concludes with fires to see the ancestors back to the spirit world. September 15 Keiro no hi, Respect for the Aged Day: Celebrates the elderly and long life. September 23 Tsukimi, Moon Viewing, Autumn Equinox: Includes custom of making special dumplings to offer to the moon along with samples of crops from the autumn harvest. October 10 Sports Day November 3 Culture Day November 15 Shichigosan, Seven-Five-Three Day: Boys ages 3 and 5 and girls ages 3 and 7 are taken to Shinto shrines wearing traditional costumes to pray for health and safety. The numbers 3, 5, and 7 are considered lucky by the Japanese. Red-and-white candy sticks called chitose-ame (thousand year candy) are sold at the shrine to bring 1,000 years of happiness to the child. Special food includes rice boiled with beans and a saltwater fish. November 23 Labor Day December 23 Emperor’s Birthday Japanese in the United States Immigration to Hawaii and the West Coast of the United States began in the late 19th century, reaching a peak between 1900 and 1910. The National Origins Act of 1924 banned Japanese and other Asians from entering the United States. According to a history Web site prepared by the National Park Service, one of the first groups of settlers from Japan arrived at Gold Hill in El Dorado County in June 1869, bringing mulberry trees, silk cocoons, tea plants, bamboo roots, and other agricultural products. In October 1877 the first Japanese American community organization of record in the United States, the Gospel Society, was established in San Francisco to provide English classes and offer boarding services and a gathering place for Japanese immigrants. In 1890, 2,038 Japanese lived in the United States, more than 1,100 in California. In 1942, after the bombing of Pearl Harbor by Japan and the entry of the United States into World War II, Executive Order 9066 directed the forcible resettling of all persons of Japanese descent living in California, Oregon, and Washington in relocation camps in remote locations. More than 90,000 Californians of Japanese descent, United States citizens and legal permanent residents, were interned in temporary detention camps for two to seven months and then moved to permanent concentration camps where they were held without charges, evidence, or trial. The book Return to Manzanar tells the story of one such camp. Even prior to World War II, discrimination against Asian Americans was a fact of life on the West Coast, with media reinforcing negative stereotypes. Assembly Bill 781, which became law in California in 2004, retroactively issues a high school diploma to any person of Japanese descent whose education was interrupted due to forced removal and incarceration during World War II. Beginning in the 1950s, Japanese were again allowed to immigrate to the United States. ○○○○○○○○

94 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Japan, cont.

Japanese are the only immigrant group to identify themselves by the generation in which they were born. The first- generation Issei maintain a strong sense of Japanese identity. The Nisei are those born and educated in the United States who retain significant vestiges of Japanese culture. Sansei and Yonsei are third- and fourth-generation Japanese Americans. Recent immigrants tend to be well educated and to settle in urban areas with Japanese American communities. In Califor- nia, Japanese are found throughout the state with the largest concentration in Los Angeles. Language; Useful Words and Phrases Written Japanese has three sets of characters. Kanji contains 50,000 Chinese characters for nouns, verbs, and adjectives, but only about 3,000 are used regularly. To show verb tense, another set of characters, hiragana, are added to the kanji. Katagana characters are used to make foreign words pronounceable in Japanese. There are many local dialects, particularly in Kyoto and Osaka, but standard Japanese, based on the language as spoken in Tokyo, is most widely used. Japanese books are read from what we would consider the back to the front, with lines of characters printed vertically and read from right to left. Japanese contains many loan words from other languages, often Chinese but sometimes English and European languages. An interesting note is that the Japanese consider the stomach, not the heart, the center of emotions, so a traditional Japanese person would “open the stomach” for a conversation. As in other cultures, the Japanese have a special manner of speaking, called keijo in Japanese, to indicate honor and respect that includes factors such as age, social status, gender, the owing of a favor—with the result that a simple sentence might be uttered 20 different ways. Names in Japanese, as in most other Asian cultures, begin with the family name followed by the given name. Titles are added after the family name. The word “san” is the equivalent of “Mr” or “Mrs,” and other titles of respect, such as sensei, are often added when the person addressed is a doctor or teacher. The suffix “chan” may be used for a child or close friend. The following words and phrases may be helpful to the health care provider. A number of excellent Web sites provide pronunciation of words to aid those who wish to speak elementary Japanese to their Japanese American patients. One of these is found at http://www2.tokai.or.jp/yuki/greetings.htm. Hello. Konnichiwa. Good morning. Ohayo/Ohayo-gozaimasu (polite). Good afternoon. Konnichiwa. Good evening. Konbanwa. Good night. Oyasumi/Oyasuminasia. Good-bye. Sayonara. How are you? Ogenki desu-ka? I’m fine. Genki-desu. Please. Dozo (used when offering something). Please. Onegai shimasu (used when asking for something). Thank you. Arigato/Arigato gozaimasu (polite). Yes/No. Hai/Iie. OK. Ii-desu/Ii-desu-yo. I understand. Wakari-masita. I don’t understand. Wakari-masen. I know. Wakatte-imasu. I don’t know. Shiri-masen. I think so. Sou omoi-masu. I don’t think so. Sou omoi-masen. Of course. Mochiron-desu. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 95

Japan, cont. References AsianInfo.Org. Eating in Japan. http://www.asianinfo.org/asianinfo/japan/cuisine_sushi.htm (22 Mar. 2005). ———. Japanese Education and Literacy. http://www.asianinfo.org/asianinfo/japan/education_literacy.htm (22 Mar. 2005). ———. Japan’s Family Customs. http://www.asianinfo.org/asianinfo/japan/pro-family_customs.htm (22 Mar. 2005). ———. Japan’s History and Background. http://www.asianinfo.org/asianinfo/japan/pro-history.htm (22 Mar. 2005). ———. Japan’s Religion and Philosophy. http://www.asianinfo.org/asianinfo/japan/pro-religion.htm (22 Mar. 2005). ———. Japan’s Society Celebrations. http://www.asianinfo.org/asianinfo/japan/society_celebrations.htm (22 Mar. 2005). ———. The Language of Japan. http://www.asianinfo.org/asianinfo/japan/japanese_language.htm (22 Mar. 2005). Campsie, Philippa, ed. 2000. Japan. Toronto, Canada: University of Toronto Anti-Racism, Multiculturalism and Native Issues Centre. http://atwork.settlement.org (23 Mar. 2005). Central Intelligence Agency. 2005. The World Factbook: Japan. http://www.cia.gov/cia/publications/factbook/geos/ja.html (8 May 2005). JobMonkey. General Information about Japan. http://www.jobmonkey.com/teaching/asia/html/about_japan.html (25 Mar. 2005). Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. National Park Service. History of Japanese Americans in California: Incarceration of Japanese Americans During World War II. http://www.cr.npt.gov/history/online_books/5views/5views4e.htm (24 Mar. 2005). ———. History of Japanese Americans in California: Immigration. http://www.cr.npt.gov/history/online_books/5views/ 5views4a.htm (24 Mar. 2005). ———. History of Japanese Americans in California: Organizations and Religious Practices. http://www.cr.npt.gov/history/ online_books/5views/5views4c.htm (24 Mar. 2005). “Saint.” 2005. Encyclopaedia Britannica. Encyclopaedia Britannica Premium Service. http://www.britannica.com/eb/ article?tocid+34111 (24 Mar. 2005). U.S. Department of State. International Religious Freedom Report 2002, Japan. http://www.state.gov/g/drl/rls/irf/2002/ 13874pf.htm (28 Feb. 2004). Yuki’s Page. Japanese Words and Phrases. http://www2.tokai.or.jp/yuki/ (24 Mar. 2005).

○○○○○○○○

96 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Southeast Asia Philippines Vietnam Laos Thailand Cambodia ○○○○○○○○

98 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○ 99 Philippines

Census Figures (2000) United States Residents Born in Philippines: 1.4 million (4.4%) California Residents Born in Philippines: 664,935 (7.5%) Quick Facts Country Area: 115,830 sq. miles (7,107 islands, slightly larger than Arizona) Population: 87,857,473 Median Age: 22.27 years Population Growth Rate: 1.84% Life Expectancy at Birth: 69.91 years Below Poverty Line: 40% Literacy Rate: 92.6% Currency: Philippine peso (PHP) Population Groups: Christian Malay 91.5%, Muslim Malay 4%, Chinese 1.5%, Other 3% Languages: Pilipino/Filipino (based on Tagalog) and English official languages, eight major dialects, 76 indigenous languages Religion: Roman Catholic 81%, Protestant 9%, Muslim 5%, Buddhist/Other 5% Government: Republic of the Philippines: president directly elected for six-year term; Senate and House; 15 regions and Metro Manila, 79 provinces, 115 chartered cities Climate: tropical marine; northeast monsoon (Nov. to April); southwest monsoon (May to Oct.) Natural Hazards: volcanoes, earthquakes, typhoons, floods Natural Resources: petroleum, nickel, rare woods, fish, chicle, hydropower Arable Land: 18.95% Agricultural Products: rice, coconuts, corn, sugarcane, bananas, pineapples, mangoes, pork, eggs, beef, fish Exports: coconut products; electronics, clothing, wiring sets, woodcraft and furniture Industries: electronics assembly, textiles, pharmaceuticals, chemicals, wood products, food processing, petroleum refining, fishing Labor Force: agriculture 36%, industry 16%, services 48% ○○○○○○○○

100 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Philippines, cont. Brief History The first inhabitants of what we now call the Philippines, the hunter-gatherer Aeta, arrived on the island of Palawan over a land bridge from mainland Asia as long as 200,000 years ago; stone tool remains date to 30,000 BC. Fossilized human bones on Palawan indicate habitation as long ago as 22,000 BC. In 2500 BC, Austronesians (precursors of the Malay people) arrived by sea from Taiwan. In 1380 AD the Makdum people brought Islam to the Sulu archipelago. Ferdinand Magellan landed on Cebu in 1521 and claimed it for Charles I of Spain; he was killed by a local chief. In 1565 there was a permanent Spanish settlement at Cebu under royal governor Miguel Lopez de Legazpi; Manila was established in 1571; the country was named for King Philip II. The entire country except the Sulu archipelago was soon under Spanish control. The independence movement began in 1886 with publication of an anti-Spanish novel by Jose Rizal, who was executed by the Spanish in 1896 for instigating insurrection. Filipinos fought with the Americans against the Spanish in the Spanish-American War; Filipinos under General Emilio Aguinaldo declared their independence in 1898. Under terms of the Treaty of Paris in 1898 the Philippines, Guam, and Puerto Rico were sold to the United States for $20 million; under Aguinaldo, the Filipinos began guerilla war against the United States. In 1901 the United States captured Aguinaldo; William Howard Taft took over as the first U.S. governor of the Philippines. In 1935 a constitution created the Commonwealth of the Philipines; Manuel Quezon y Molina became the first president. Japan invaded the Philippines in 1941; Quezon established a government in exile. The Philippines became an independent nation in 1946; Manuel Roxas y Acuña was elected president. In 1965 Ferdinand Marcos was elected president; he declared martial law in 1972 and ruled as dictator until 1986 when Corazon Aquino was elected president. Mount Pinatubo erupted on June 15, 1991, destroying U.S. Clark Airbase. Fidel Ramos was elected president in 1992 and U.S. military presence ended. In 1996, the Philippine government granted greater freedom to the southernmost island of Mindanao, formally ending a 24-year struggle by Islamic separatist Moro National Liberation Front for autonomy; turmoil continues in the area. In 1998, former movie star Joseph Estrada was elected president; he was forced to step down in 2000 over corruption charges and was later indicted. Gloria Macapagal-Arroyo assumed the presidency in 2001. A military coup attempt in 2003 failed. Arroyo narrowly defeated film star Fernando Poe, Jr. in the May 2004 presidential election. In July 2005 Arroyo was accused of election fraud and corruption; impeachment charges were dismissed in September, but opposition to Arroyo and political turmoil, including street protests and rumors of a coup, continued. Housing, Family, Work, Traditions Housing: As in many countries, population growth and migration from rural areas to cities has resulted in housing shortages, overcrowding, and slum conditions in parts of the Philippines, especially the capital city of Manila. Most people live in simple houses or apartments, with wealthier people having Western-style houses. In 2002 an estimated 4.2 million Filipino families lacked adequate shelter. Many people in rural areas live on land with no water or sanitation. The basic problem is inequitable distribution of resources, with one percent of the population controlling most of the land and means of production. Nearly half the people are below the poverty line with another third just above it; the middle class comprises only about one-tenth of the population. Family: Traditionally, the father is head of the household and responsible for financial security. Many women work outside the home in addition to running their households, caring for children, and managing finances. Women retain their private property following marriage. Children start learning household chores at a young age and may assist the family financially by selling small items on the streets or at markets. They are raised to respect their elders and to be achievers and make their families proud. Nearly everything revolves around the family, which provides personal, social, and often economic solidarity. Godmothers (comadres) and godfathers (compadres) are important; as many as 10 pairs may be involved in a wedding or baptism. Relatives often live close to one another or together in extended family settings. Older family members make decisions by consensus. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○101

Philippines, cont.

Traditions: Filipinos greet each other by bowing and shaking hands. They try to avoid confrontation and do not make direct critical remarks. Lengthy eye contact is considered rude, and many Filipinos shy away from calling attention to themselves in public. In cases of conflict, a third party may be enlisted to mediate a solution that saves face for those in conflict. Filipinos primarily wear West- ern-style clothing, but on special occasions they may don national costumes: for women, a terno— long dress with flared skirt and butterfly sleeves; for men, slacks and a barong tagalog, an embroidered shirt worn outside the slacks. Employment: About 40 percent of the Philippines workforce is involved in agriculture, forestry, or fishing. Women make up about 35 percent of the labor force. Many Filipino nurses have emigrated to the United States, Canada, and Western Europe and send back remittances that support their families and strengthen the Philippine economy. Recreation: Teenagers in the Philippines form same-sex peer groups or friendship clubs known as barkadas which develop their own slang and spend many hours together. Basketball is the country’s most popular sport. Cockfighting is popular among men. Foods and Eating Habits Dietary Practices: Filipinos who are Muslims do not eat pork or pork products or consume alcohol. Filipinos prefer soft and warm foods when they are ill. They prefer drinks without ice, and do not like cold or acidic foods at breakfast. Some Filipinos may be lactose-intolerant and/or wheat-intolerant. Everyday Diet: Rice is the basic element of the Filipino diet; the Tagalog language has several different words for rice depending on its condition (kanin is rice that is ready to eat, for example). Rice is eaten for every meal in combination with such things as salted or smoked fish and vegetables. It is often seasoned with garlic, vinegar, soy sauce, and patis, a salty liquid made from fish. In some areas, coconut milk, chiles, and/or ginger may be cooked with the rice. Filipinos are noted for combining several meats and/or seafoods in one dish. Fish is abundant and prepared many ways. Popular Foods: Filipino foods reflect the diverse history and settlement of the islands. Salty and sour flavors are very popular. One popular dish, sinigang, is fish lightly boiled in a sour stock with vegetables and fish sauce. The Chinese influence is seen in noodle dishes, called pancit and featured in popular restaurants called panciterias. Popular Chinese dishes include lumpia, the Filipino version of spring rolls, vegetables and meats rolled in edible wrappers; siopao, steamed, filled buns; and siomai, dumplings. The Spanish influence is seen in such dishes as paealla, relleno, and a Filipino version of tamales. Adobo, a Filipino national dish of braised chicken and pork with coconut milk, reflects the Spanish influence. Adobo refers to the spice mixture used in the dish, which in the Philippines most often includes vinegar, garlic, bay leaf, peppercorns, and soy sauce. Meriendas, snacks served mid-morning and mid-afternoon, include rice cakes, buko (coconut flesh), ginataan (fruit cooked in coconut milk), and halo halo (a dessert of layered fruit, gelatin, and caramel custard topped with shaved ice and coconut milk or ice cream). Beverages: Fruit juices, fruit shakes, ginger tea, coconut wine, and sugarcane wine are popular beverages. Filipinos drink lots of water, preferably at room temperature or warmer. Education Status: In 1995 the Philippines ranked after Brunei and Korea as a leader in school enrollment. However, about two-thirds of all children fail to complete primary education; completion rates are high in major cities and low in some outlying areas. Overall, 97 percent of children are enrolled in elementary school and 66 percent in secondary school. There are more than 1,500 Islamic schools in the Philippines, and efforts are under way to integrate them into the national education system. ○○○○○○○○

102 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Philippines, cont.

Primary School: The school year in the Philippines runs from June through March with a Christmas holiday break. School is free and compulsory for children ages 7 through 12. Primary school comprises grades 1 through 6; attendance rate is about 97 percent. The school day generally lasts from 8 a.m. to 5 p.m. Instruction in Grade 1 is in the language spoken in the homes of children in the area. In Grades 2 through 6, instruction is in English. Both English and Filipino are taught along with math, science, history, government, social science, civics, music, and physical education. Children also study home economics, which includes cooking, sewing, gardening, and other subjects. Most children attend public schools, but there are many private schools run by religious orders that charge tuition and often include a year or two of preschool as well as a Grade 7. Less than one percent of the 1.4 million 2004 primary school graduates passed the aptitude test given in June. Secondary School: Four-year high schools are free but not compulsory, with about 66 percent of Filipino children attending. Both academic and vocational high schools are available. Compulsory high school subjects include English, Filipino, science, social studies, mathematics, practical arts, youth development training, and citizen army training. Students take examinations to receive a high school diploma; they must pass the National Secondary Aptitude Test to enter a university. Higher Education: Higher education institutions include both public and private universities and colleges, with 72 percent of students attending private institutions. Students receive a bachelor’s degree after accu- mulating from 120 to 190 credits; some fields, such as teacher education and engineering, require a semester of work experience. Many health-related degrees require a one-year internship. Religion Status: The National Ecumenical Commission fosters interfaith dialogue among Protestant, Catholic, and Islamic groups. Roman Catholic, Protestant, and Islamic representatives work together with the Interfaith Group to support peace in Mindanao. A monthly meeting of Roman Catholic bishops and Muslim leaders works to deepen understanding and further the peace process. Roman Catholicism: Ferdinand Magellan introduced Christianity to the islands comprising the Philippines on his arrival in 1521. The Roman Catholic Church claims about 68 million members. The practice of Catholicism in the Philippines retains strong roots in the animism practiced both before and after Spanish priests converted the natives. Many Filipinos are devoted to the Virgin Mary, and there are cults devoted to the worship of the Child Jesus, with more than 50 icons said to be responsible for miracles. A growing charismatic lay movement, El Shaddai, claims 5 million active members. Protestantism: Presbyterian and Methodist missionaries who came to the Philippines with U.S. soldiers during the Spanish-American War introduced Protestantism. Currently about 9 percent of Filipinos are affiliated with a Protestant denomination. The Philippine Independent Church (Aglipayan), founded in 1902, and the Church of Christ (Iglesia ni Cristo), established in 1914, are two prominent independent Filipino churches. Protestant organizations include the National Council of Churches of the Philippines and the Council of Evangelical Churches of the Philippines. Islam: Islam was introduced to the Philippines during the 14th century. Muslims are concentrated primarily in the Sulu archipelago and on Mindanao, where about 19 percent of the population is Muslim and Muslim extremist groups have been active. Most Muslims in the Philippines belong to the Sunni branch of Islam. Ethnic and cultural discrimination by the Christian majority is a continuing problem, as Christians try to settle in Muslim areas and Christian missionaries pros- elytize in Muslim communities. In 1990, the Autonomous Region in Muslim Mindanao (ARMM) was established to ensure Muslim autonomy in areas of Mindanao where they are in the majority. A 1996 peace agreement with the Moro National Liberation Front (MLNF) concluded a 20-year struggle, but the area is still subject to violent uprisings. Muslims are treated as second-class citizens throughout the country, with little influence in either the government or the economy. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○103

Philippines, cont. Health and Health Care Health Status: Malnutrition is a major health concern in the Philippines. Health care is a matter of location and ability to pay. Few doctors want to practice in remote rural areas. A German government organization assisting with social and economic development in the Philippines, GTZ, notes on its Web site that the country faces an increasing burden from chronic diseases such as diabetes due to urbanization, changing lifestyles, and environmental health problems. GTZ is working with Filipinos on issues including family planning, expanding social health insurance coverage, and strengthening local health systems. Many nurses are leaving the Philippines for the United States, Canada, and Western Europe where they can make up to $40 an hour as opposed to $108 a month. Filipino physicians are retraining as nurses to be eligible for these jobs as well. Medical doctors in the Philippines earn about $400 a month. Traditional Practices: Traditional folk healers in the Philippines practice centuries-old treatments including herbalism, massage, psychic healing, and the laying on of hands. Many Filipinos maintain their belief in spirits and the role of spirits in health and illness. Faith healers claim, with little justification, to perform surgery without instruments or bloodshed. Medical System: According to the Philippines Department of Health, 13 percent of the national budget is spent on public health. The health care delivery system is highly fragmented, which means inequality in health care delivery among population groups and regions. Provincial hospitals do not have enough money and have high patient loads. District hospitals suffer from poor facilities, inadequate personnel, and insufficient drugs. The department notes that rural health units are often ineffective, providing poor quality service and poor implementation of health programs and disease control. They point to a lack of coordination among the various health facilities including private clinics and hospitals and advocate for participation in inter-local health zones. Tips for Health Care Providers When working with Filipino patients who are Muslim, refer to page 22 for information on the influence of Muslim beliefs and practices on health care. Attitudes: Filipinos may see health as a matter of balance (timbang), with illness representing an imbalance. Some will use herbal medicine prior to seeking Western medical help. The family is very solicitous of a sick member. Filipinos generally hold medical professionals in high regard and tend to follow their directions. Donating blood is thought to upset the balance of the body; receiving transfusions is more readily accepted. Family Authority: The father or eldest son often acts as the family spokesperson, but decisions are generally made by the entire family. Addressing Clients: Greet clients formally by using the last name. Handshakes are not commonly used. Most Filipinos understand English, but the health care provider should speak slowly and clearly. Nonverbal Exchange: Filipinos are typically shy and awkward in unfamiliar surroundings. They make little direct eye contact, especially with authority figures and superiors. Smiling is common as a greeting or acknowledgement. Filipinos may be sensitive to shame and/or saving face. Verbal Exchange: Speaking in their own language, Filipinos use tone of voice to convey meaning and may talk loudly or get emotional. They typically speak softly and avoid expressing disagreement. Health care providers should explain procedures clearly and encourage feedback and questions. Hospitalization: Filipinos prefer soft and warm foods and drinks without ice when they are ill. If an Asian or Chinese menu is available, this would be appropriate. Female family members may expect to stay at the patient’s bedside at all times, and the entire family may visit. Some Filipinos may refuse pain medication for fear of addiction or because they are stoic or have a high pain threshold. ○○○○○○○○

104 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Philippines, cont.

Death and Dying: In cases of serious or terminal illness, the family, at least the eldest son or daughter, should be told and allowed to convey the information to the patient. In cases of terminal illness, a DNR order will be decided upon by the family. Patients prefer to die at home with hospice care except in cases of acute illness. A Catholic hospitalized patient should see a priest if terminally ill. The body after death is given high regard. The family may ask to wash the body and say good-bye. Cremation is not usually practiced, and organ donation and autopsy may not be welcome. Celebrations and Holidays January 1 New Year’s Day: Celebration begins with fireworks and media noche (midnight snack) on New Year’s Eve. Customs include banging on pots and pans to frighten away evil spirits, opening doors and windows to bring in good luck. January 6 Epiphany or Feast of the Three Kings February 22 People’s Power Day Lent, Holy Week A very somber season in this mostly Roman Catholic country; Holy Week includes the blessing of palm fronds woven in intricate designs, processions with flower-decked carts carrying scenes of the events of the Passion, enactments of the Passion, some featuring people suspending themselves from crosses or flagellantes beating themselves raw. April 9 Bataan Day, Day of Valor May 1 Labor Day June 12 Independence Day (celebrates independence from Spain) June 24 Manila Day August 31 National Heroes Day November 1 All Saints Day: A time for remembering the dead, cleaning and decorating graves, visiting the cemetery and perhaps staying overnight. November 30 Bonifacio Day: Anniversary of the death of hero Andres Bonifacio. December 25 Christmas Day is the high point of a long celebration that concludes on Jan. 6. From December 16 to 23, families attend 4 a.m. Mass and eat a breakfast of native treats following the service. Holiday customs include caroling in exchange for food and money, and decoration of homes with the Filipino Christmas symbol, elaborate parols, five-pointed star-shaped lanterns made of bamboo sticks covered with rice paper or colored cellophane. They are symbols of hope that bring blessings and luck to the home. Nativity scenes or belens, some featuring elaborate figu- rines and added to year after year, are a common feature of homes at Christmas. December 30 Rizal Day: Anniversary of the death of hero Jose Rizal. Eid-al-Fitr Three-day feast at the end of Ramadan, the month-long Muslim fast; the last day is now an official holiday. Date varies according to the lunar calendar. Filipinos in the United States Filipinos, also called Pinoys, are the second largest immigrant group in the United States, according to Census 2000, with nearly half of the 1.4 million foreign-born Filipinos living in California. They have been immigrating to the United States since they served as seahands on Spanish galleons that began trading with America in 1587. From 1906 to 1946 the first major wave of immigrants came as farm laborers to Hawaii. Filipino immigrants make up 8 percent of the population of Hawaii, where they account for nearly half of all foreign-born residents. Filipinos are sometimes spoken of as “invisible” due to being mistaken for other Asian groups or for Latinos. Most speak English, and they have a very low poverty rate (less than 1 percent in 2000). Other states with sizeable numbers of Filipino immigrants are New York, New Jersey, and Illinois. Filipinos make up 23 percent of the population of Daly City, and they account for 7.5 percent of the state’s population. Some 46 percent of recent Filipino immigrants to the United States have a college degree or more. Increasing numbers of Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○105

Philippines, cont.

Filipino nurses and physicians retrained as nurses are coming to the United States to meet the ongoing nursing shortage. Remittances from Filipinos working in the United States and other foreign countries totaled $7.6 billion in 2003. Accord- ing to Migration News from UC Davis, the Philippines sends some 3,000 female migrants abroad each day to work. “The most common sort of first-time migrant is a 25-year-old female college graduate going abroad to work as a domestic helper on a two-year contract,” according to the organization’s Web site. The Philippine Overseas Employment Administration assists and tracks overseas workers, who perform more than 250 different jobs in more than 150 countries. In 2003, 25,000 nurses left the Philippines for the United States and other countries; there are close to 300 nursing schools in the Philippines. Some analysts suggest that availability of nurses from the Philippines may have the effect of lowering overall wages for U.S. nurses, as the immigrants are willing to work for less. In December of 1995, some 750 California Filipinos, 85 percent of whom were born abroad, were interviewed. Most spoke English well; 74 percent were naturalized U.S. citizens. More than 90 percent said they were happy living in the United States, and two-thirds said they sent money—remittances—to the Philippines. Language; Useful Words and Phrases English is taught in Philippines schools from elementary grades. It is an official language of the Philippines, which is the third-largest English-speaking country in the world. The basis for Filipino is Tagalog, which was spoken only in Manila when the 1930 Commonwealth constitution provided for a national language but did not specify one. During the 1980s under Ferdinand Marcos a new constitution was adopted; Filipino was named the national language. According to the Web site Tagalog Lang, “Filipino is Tagalog Plus—it is supposed to be more inclusive of languages other than Tagalog. . . . It is somehow more considerate to refer to Filipino, not Tagalog, as the Philippine national language, if only to recognize Filipinos who do not regard Tagalog as their first language.” While many Filipino immigrants can communicate in English, some Tagalog words and phrases for health care providers and teachers to learn include: Good morning. Magandang umaga. Good afternoon. Magandang hapon. Good evening. Magandang gabi. Hello/Goodbye Kumasta/Paalam How are you? Kumusta po kayo? (polite) Kumusta ka? (casual) Where does it hurt? Saan po masakit? Fine. Mabuti. Thank you. Salamat. Don’t mention it. Walang anuman. Yes/No Oo/Hindi Merry Christmas. Maligayang Pasko. Prosperous New Year. Manigong Bagong Taon. Happy Birthday. Maligayang Bati. References Alipalo, Melissa. 2003. “Doctors Leaving Philippines to Become Nurses—for the Money.” San Francisco Chronicle. 5 Nov. http://www.sfgate.com (10 Oct. 2004). Baguioro, Luz. 2004. “Philippine Schoolkids Learn the Wrong Things.” The Straits Times, 14 Oct. hkttp:// straitstimes.asia1.com.sg/storyprintfriendly/0,1887,277866.00.html? (15 Oct. 2004). Borah, Eloisa Gomez. Chronology of Filipinos in America Pre-1898. (1997–2001) http://personal.anderson.ucla.edu/ eloisa.borah/chronology.pdf. “Case of the Philippine Nurses.” Globalization.Org. http://www.globalization101.org/issue/migration/4b.asp (9 Feb. 2004). de Torres, Sheila. 2002. Understanding Persons of Philippine Origin: A Primer for Rehabilitation Service Providers. Buffalo, NY: State University of New York, Buffalo, Center for International Rehabilitation Research Information and Ex- change (CIRRIE). http://cirrie.buffalo.edu (28 Feb. 2005). ○○○○○○○○

106 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Philippines, cont.

Defense Language Institute Foreign Language Center. The Philippines in Perspective. http://www.lingnet.org/areaStudies/ perspectives/philippines/phil_011.html (14 Oct. 2004). Dolan, Richard, ed. Library of Congress Country Studies: Philippines. http://lcweb2.loc.gov/cgi-bin (14 Oct. 2004). Estrella, Cicero. 2003. “Daly City among Top 5 in Nation for Foreign-Born.” San Francisco Chronicle. 20 Dec. http:// www.sfgate.com (10 Oct. 2004). Filipino and Korean Integration in the US. http://migration.ucdavis.edu/mn/comments/php?id=873_0_2_0 (6 Oct. 2004). Freeman, Nancy. Philippines. http://www.sallys-place.com/food/ethnic_cuisine/philippines.htm (11 Oct. 2004). Grieco, Elizabeth. 2003. “The Foreign Born from the Philippines in the United States.” Migration Policy Institute. 1 Nov. http://www.migrationinformation.org (5 Feb. 2004). Habitat for Humanity. Philippines. http://www2.habitat.org/intl/countryprofiles.fm (24 Mar. 2004). Indonesia, Philippines, India. Migration News. http://migration.ucdavis.edu/mn/comments/php?id=3009_0_3_0 (6 Oct. 2004). Infoplease. Timeline: Philippines History. http://www.infoplease.com/sppot/philippinestime1.html (7 Feb. 2004). Joaquin, Nick. The Philippines: A Manifold Land. http://www.koleksyon.com/filipinoheritage/customs_traditions/fiesta/ fiesta_philippines.asp (9 Feb. 2004). Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. Local Health Systems. Philippines Department of Health. http://www.doh.gov.ph/hsra/tsk/link%20sites/local%20health.htm (15 Oct. 2004). Lonely Planet World Guide: Destination Philippines. http://www.lonelyplanet.com/destinations/south_east_asia/philippines/ index.htm (7 Feb. 2004). Nakashima, Ellen, and Edward Cody. 2004. “Troubling Exodus of the Philippines’ Best and Brightest.” Washington Post. 30 May http://www.sfgate.com (10 Oct. 2004). Paddock, Richard C. 2005. “Bridging Philippines’ Islands of Faith.” Los Angeles Times. 14 Apr. http://www.latimes.com/ news/nationworld (14 Apr. 2005). “Philippines.” Encyclopaedia Britannica. 2004. Encyclopaedia Britannica Premium Service. 9 Oct. 2004. http:// www.britannica.com/eb/article?tocid=23752. Philippines by Rochelle. Education. http://members.aol.com/ATINYROCK/page 18.htm (9 Oct. 2004). ———. Holidays and Fiestas. http://members.aol.com/ATINYROCK/page 21.htm (9 Oct. 2004). Tagalog Lang. http://tagaloglang.com (11 Oct. 2004). Philippines Country Portfolio. GTZ Philippines. http://www.gtz.de/philippines/priority/family.html (15 Oct. 2004). Philippines Country Profile. World Trade Press. http://www.tradeport.org/countries/philippines/01grw.html (15 Oct. 2004). Thomas, Laura. 2003. “Maligayang pasko: Filipinos savor old and new holiday traditions.” San Francisco Chronicle. 13 Dec. http://sfgate.com (10 Oct. 2004). ———. 2003. “Parol Brings Blessings at Christmas.” San Francisco Chronicle. 13 Dec. http://sfgate.com Tope, Lily, and D.P. Noonan-Mercado. Philippine Festive Isles. http://www.koleksyon.com/filipinoheritage/religion/ folk_christianity.asp (9 Feb. 2004). UNESCO. Philippines Education System. http://www.unesco.org/iau/cd-data/ph.rtf (9 Oct. 2004). U.S. Department of State. Background Notes: Philippines. http://www.state.gov/r/pa/ei/bgn/2794.htm (9 Oct. 2004). U.S. Department of State Bureau of Democracy, Human Rights, and Labor. “International Religious Freedom Report 2002: Philippines. http://www.state.gov/g/drl/rls/irf/2002 (28 Feb. 2004) Vieira, Odete, and S. Vemuri. 2002. Philippines. Toronto, Canada: University of Toronto Anti-Racism, Multiculturalism and Native Issues Centre, 2002. World Bank Group. Education in The Philippines. http://www.worldbank.org/eapsocial/countries/phil/educ1.htm (9 Oct. 2004). WOW Philippines. http://www.tourism.gov.ph/discover (7 Oct. 2004). The World Factbook: Philippines. http://www.cia.gov/cia/publications/factbook/geos/rp.html (8 May 2005). Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○107 Vietnam

Census Figures (2000) United States Residents Born in Vietnam: 988,174 (3.2%) California Residents Born in Vietnam: 418,249 (4.7%) Quick Facts Country Area: 127,800 sq. miles (slightly larger than New Mexico) Population: 83,535,576 Median Age: 25.51 years Population Growth Rate: 1.04% Life Expectancy at Birth: 70.61 years Below Poverty Line: 28.9% Literacy Rate: 90.3% Currency: dong (VND) Population Groups: Vietnamese 85–90%, Chinese, Hmong, Thai, Khmer, Cham, Mountain Groups Languages: Vietnamese (official), English (increasingly favored as a second language), some French, Chinese, and Khmer; mountain area languages (Mon-Khmer and Malayo-Polynesian) Religion: Buddhist, Hoa Hao, Cao Dai, Christian, Indigenous Beliefs, Muslim Government: Socialist Republic of Vietnam: capital Hanoi is economic and political center of the north, Ho Chi Minh City is largest city in country, economic center of south Climate: tropical in south; monsoonal in north with hot, rainy season (mid-May to mid-Septem- ber) and warm, dry season (mid-October to mid-March) Natural Hazards: occasional typhoons (May to Jan.) with flooding, especially in the Mekong River delta Natural Resources: phosphates, coal, manganese, bauxite, chromate, offshore oil/gas, forests, hydropower Arable Land: 19.97% Agricultural Products: paddy rice, corn, potatoes, rubber, soybeans, coffee, tea, bananas, sugar; poultry, pigs, fish Agricultural Exports: rice, coffee, tea, rubber; crude oil, marine products, garments, shoes Industries: food processing, garments, shoes, machine-building, mining, cement, chemical fertilizer, glass, tires, oil, coal, steel, paper Labor Force: agriculture 63%, industry and services 37% ○○○○○○○○

108 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Vietnam, cont. Brief History The early history of Vietnam is anything but clear. According to some sources, it originated with the Dong Son culture in what is now the far northern part of the country in about the 3rd century BC and spread south through the Red River Delta to form Van Lang, which means “country of cultured people.” From the 1st to the 6th centuries AD, the southern part of what is now Vietnam was part of the kingdom of Funan. The Hindu kingdom of Champa arose in the area of Danang in the late 2nd century and spread southward. In the 2nd century BC, the Chinese conquered the Red River Delta and ruled it until 938 AD when Ngo Quyen defeated Chinese armies at the Bach Dang River. During the following centuries, Vietnam fought off repeated invasions by China and expanded its territory southward, absorbing a variety of groups including the Champa and Khmer. In 1858, following the killing of several missionaries, Spanish and French troops stormed Danang. By 1867, France controlled all of southern Vietnam as a colony called Cochinchina. Under French rule, peasants lost their land and there were many uprisings, culminating with a declaration of independence by Ho Chi Minh in 1945. The French, aided by U.S. forces, were defeated at Dien Bien Phu in 1954. Under the Geneva Accords of May 1954, Vietnam north of the 17th Parallel became an independent communist state. In the southern part of the country, Ngo Dinh Diem consolidated power with the support of Western governments. Northern forces supported by Russia and China sought to liberate the south; this ushered in the Vietnam War which ultimately cost more than 4 million Vietnamese lives, killed some 60,000 foreign troops, and devastated the jungles, forests, and cultivated land. In 1976 Vietnam was reunified under communist rule as the Socialist Republic of Vietnam. Following the end of the Vietnam War, Vietnam became embroiled in conflicts with the Khmer Rouge in neighboring Cambodia; this conflict officially ended as a result of U.N. intervention in 1989. When the Cold War ended with the collapse of the Soviet Union in 1991, movements began between Vietnam and Western nations to re-establish diplomatic and trade relations. The United States resumed diplomatic relations with Vietnam in 1994. A Bilateral Trade Agreement was signed in July 2000. Vietnamese Prime Minister Phan Van Khai met with President Bush at the White House in June 2005; the two pledged greater cooperation. Housing, Family, Work, Traditions Housing: Rural areas are divided into communes of 4,000 to 8,000 people. Each commune includes primary and secondary schools, a clinic, a post office, and service facilities for the activities of daily life and work. Rural housing varies depending on materials available. According to one source, 90 percent of rural housing in the Mekong River Delta is made of non-permanent materials. Houses are typically made of brick, tile, or wood. Oxfam Netherlands (Novib) has been engaged in a project to help the growing urban population acquire affordable housing through creating savings groups and providing low-cost housing models, manpower, and construction material supply services. In both Hanoi and Ho Chi Minh City, integrated urban development projects are under way. Family: The traditional Vietnamese family is strongly influenced by ancestor worship. Both Buddhism and Confucianism stress the importance of respecting and venerating ancestors. Children learn early to respect elders and ancestors and to work hard and achieve to bring honor to the family. The father is the provider, and his wife and children look to him for guidance. According to one source, the woman of the house is called the “general of the interior,” noi tuong, with responsibilities for in-laws as well as husband and children. Traditional values for Vietnamese women are hard work, beauty, refined speech, and excellent conduct. Communism and war have brought many changes to the Vietnamese family structure, including more freedom for women but also increased burdens as they have been forced to assume more economic responsibility in addition to their traditional chores. This has resulted in stress for both urban and rural women. Legal age for marriage is 18 for women and 20 for men, but girls in rural areas may marry as young as 13. Traditions: In general, Vietnamese men and women wear Western-style clothing. For special occasions, women may wear the traditional ao dai, a long, high-necked tunic with a slit in the side, with silk pants and Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○109

Vietnam, cont.

sandals called guoc. For many centuries, until the French stopped the practice in 1954, upper-class Vietnamese girls’ teeth were blackened with Betel nuts at puberty. This was believed to be more attractive and to prevent tooth decay. The conical hat worn by farmers to shade their faces from the sun, the non la, is woven of palm leaves and goes back to the 13th century. Vietnamese traditionally greet each other by joining hands and bowing slightly. Hugging is acceptable only between relatives. Vietnamese names begin with the family name, followed by the middle name, with what we know as the “first” name in the last position. Vietnamese in the United States may change their names to reflect the order popular here. Women traditionally keep their maiden name when they marry. Vietnamese seek to avoid conflict and to draw attention to themselves. Making direct eye contact may be considered impolite, and sensitive topics are often discussed indirectly. Strong emotions are generally not expressed except in the presence of family and close friends. Employment: The majority of Vietnamese, as high as 80 percent, work in agriculture. In 1986, the government introduced doi moi, the controlled transition of the communist economy to a market-based system including private enterprise and competition. According to one source, in Hanoi thousands of people support themselves by making shoes, tools, and other things from discarded materials. Obtaining bank credit has been difficult, leading to a practice called ho where people pool resources and bid for the right to take out loans. Foods and Eating Habits Dietary Practices: Vietnamese cuisine has three distinct regional flavors: northern, central, and southern. Vietnamese prefer warm, soft foods such as rice porridge and lots of fruits and vegetables when sick, and do not like to eat anything cold. In general, they do not like extremely cold beverages, especially with ice. The typical diet includes few dairy products; they may be lactose-intolerant. Everyday Diet: Rice is the staple food of the Vietnamese diet. The Vietnamese prefer long-grain rice, and most meals include soup and a stir-fry in addition to rice. Vietnamese cuisine tends to be lighter than some other countries in the region. In the northern part of the country, noodles are more commonly used than rice. Fish is a main ingredient. Vegetables are often served raw; many leafy green vegetables are part of the daily diet. Many Vietnamese dishes are very hot, as the Vietnamese often use hot peppers as well as coriander, lemon grass, mint, star anise, basil, and other spices to flavor their food. Popular Foods: The national dish is a soup of rice noodles, meat, and spices. Fermented fish sauce, nuoc mam, is used in many dishes. It looks like tea and is quite mild. Blending nuoc mam with sugar, lime juice, vinegar, chopped shallots, garlic, and carrots creates a popular sauce, nuoc cham. Vietnamese are very fond of soups and may eat them at any meal; favorites include pho, a thick noodle soup with beef, and bun bo hue, a spicy beef noodle soup. Vietnamese spring rolls, cha gao, are very light and made of ground pork or shrimp and vegetables; they are dipped in fish sauce. Rice paper wrappers, banh trang, or fresh rice wrappers, banh uot, are used for wrapping a variety of tasty ingredients, including lemongrass beef, thit bo nuong, grilled meatballs, nem nuong, and steamed shrimp, tom. Popular snacks include peanuts and watermelon seeds, which are often dyed red. One popular dessert, xoi nuoc dua, is made of sweet rice and coconut milk, cooked in banana leaves. Beverages: Tea is the most popular beverage at all times of the day, with lotus tea a specialty. Tea is grown in the Dalat region of the country. Freshly pressed sugarcane juice and coconut juice are popular, and Vietnamese beer is reputed to be good. The Vietnamese enjoy iced tea without sugar or lemon; they drink warm tea or room temperature water when sick. ○○○○○○○○

110 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Vietnam, cont. Education Status: Both public and private schools are contolled by the Department of National Education. Accord- ing to a 2003 report, education is no longer subsidized and has become expensive. Due to economic constraints, many children drop out of school to help support their families. Children are supposed to attend school half days six days a week. Many schools are overcrowded and short of supplies, and teacher salaries are low. Teachers are greatly respected, and parents do not question their decisions. Students are expected to work hard, do a great deal of homework, and succeed in school to bring honor to their families. Curricula includes Vietnamese history, language, and literature as well as morality, government, and Vietnamese customs. According to one source, all students are required to do manual labor at their schools each week. Primary School: Primary education is compulsory and lasts from ages 6 to 10. Boys and girls are equally represented at this age. Secondary School: Secondary school lasts for seven years. There is a substantial gender and attendance gap between urban and rural areas as students reach the later teens. In rural areas, about 45 percent of young men and 33 percent of young women are in school, compared with 62 and 58 percent in cities. Higher Education: Following secondary school, students have opportunities to attend vocational schools, colleges, or universities. Large universities are very competitive. Overall, 5.4 percent of men and 3.9 percent of women ages 20 to 29 were attending universities in 2000. Many students do not pursue higher education because of the expense. Nearly three times as many urban as rural men are enrolled in universities, and nearly five times as many urban as compared to rural women. In rural areas, women at this level are entering the marriage market and contributing to their families economically rather than pursuing higher education. Religion Buddhism: About 50 percent of Vietnamese are Buddhist, according to the 2002 International Religious Freedom Report compiled by the U.S. Department of State. That report states that many Bud- dhists actually practice a religion containing elements of Mahayana Buddhism, Taoism, and Con- fucian traditions, sometimes called a “triple religion.” According to one estimate, about 30 percent of those considered Buddhist practice their faith regularly. Most Buddhists are members of the ethnic Minh majority found throughout the country. A Khmer ethnic minority in the Mekong Delta practice Theravada Buddhism. Many Vietnamese visit Buddhist temples even though they may not practice Buddhism. Cao Dai: Founded in 1919 by Le Van Trung, Cao Dai combines elements of many religious traditions. The basic belief system was influenced by Mahayana Buddhism, but adherents recognize Jesus, Siddharta, Confucius, Lao Tse, and Moses as among those through whom divine revelation has come. Cao Dai includes 13 different sects; the largest, headquartered in Tay Ninh Province, contains more than half of all adherents, estimated to be between 1 and 3 million. Hoa Hao: This religion, founded in south Vietnam in 1939 by Huynh Phu So, is considered by some a reform branch of Buddhism. Hoa Hao emphasizes private acts of worship and devotion; there is no priesthood and few ceremonial elements. Believers comprise between 1.3 and 3 million Viet- namese, concentrated in the Mekong Delta, where it was a political and military force before 1975. Roman Catholicism: Roman Catholics account for perhaps 9 percent of the population or about 7 million Vietnamese. Christianity was introduced in the 17th century by French missionaries. Roman Catholics fought against Communist guerrillas until 1954, when many northern Catholics moved to the Saigon (now Ho Chi Minh City) area in the south prior to the partition of the country. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○111

Vietnam, cont.

Protestantism: Protestants comprise about 1.2 percent of the population; more than half of these are affiliated with Pentecostal evangelical house churches. Missionaries from the Christian and Missionary Alliance introduced Protestantism in 1911. Two-thirds of Protestants today are members of ethnic minorities in the northwest provinces and Central Highlands. Islam: The Muslim population of Vietnam is estimated at about 65,000, primarily located in western An Giang province, Ho Chi Minh City, and Hanoi. About half are Sunni Muslims; the others practice Bani Islam, which is unique to the ethnic Cham people who live on the central coast. They use an abridged Koran and participate in some traditional Cham festivals. Health and Health Care Health Status: The Vietnamese government reports great strides in reducing infant mortality and childhood diseases. Polio has been eradicated, and more than 95 percent of children under one year have been vaccinated against six common diseases. A California public health physician, Mark Horton, MD, who visited the country in 2002, was impressed with the way the government is working with UNICEF and the World Health Organization. Through iodizing the country’s salt supply, goiter has been significantly reduced; the country is producing its own hepatitis B vaccine. Traditional Practices: Vietnamese both in their own country and in the United States may consult traditional medical practitioners, perhaps to exorcise an evil spirit. Many Vietnamese use amulets and other forms of spiritual protection such as the bua, an amulet of cloth containing a Buddhist verse that is blessed by a monk and worn on a string around the wrist or neck of a baby or child. Incense may be burned on a home altar to appease ancestors, and Buddhists monks may be consulted for prayer. Like people in many other Asian cultures, Vietnamese commonly believe the maintenance of health is a matter of keeping a balance between opposing forces—am and duong (yin and yang in Chinese), which are frequently translated as “hot” and “cold” when applied to health. An imbalance of these forces is thought to cause illness. A variety of dietary, traditional medical, and Western medical practices are used to bring about the proper balance and restore health. These are described on the Baylor University site (http://www3.baylor.edu/~Charles_Kemp/vietnamese_health.htm), and are, briefly: Coining (cao gio, “catching the wind”)—This involves dipping a coin in mentholated oil and rubbing it across the skin in a prescribed manner to release excess force or “wind” from the body. Cupping (giac)—A series of small, heated glasses are placed on the skin, forming suction that draws out the bad force, leaving a red mark. Some sources have noted that these marks may be mistaken for evidence of child or spousal abuse. Pinching (bat gio)—Like coining and cupping, this practice involves pinching the skin to release the bad force. It may also produce marks suggestive of abuse. Steaming (xong)—Medicinal herbs are boiled and the steam inhaled or used for bathing. Other traditional practices include the use of balms, acupuncture, acupressure or massage, and the use of powdered patent medicines that are acquired from China and Thailand. Medical System: According to the government of Vietnam on its tourism Web site, “Vietnam’s community health care network is well developed compared to other countries in the region. Quality health care has been provided nationwide, especially in remote and mountainous areas.” All districts reportedly have health centers and hospitals, and nearly all communes have health centers, with medical workers providing health care in villages. Dr. Horton noted after his 2002 visit that hospital facilities are inadequate and lack nearly all modern diagnostic and therapeutic technology. However, he was very impressed with the emphasis on prevention that has produced dramatic results compared with similarly developed nations. ○○○○○○○○

112 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Vietnam, cont. Tips for Health Care Providers Refugees from Vietnam and other Asian countries may be suffering from such things as nutritional deficits, hepatitis B, tuberculosis, parasites, malaria, HIV, and post-traumatic stress disorder.According to an excellent source from Baylor Uni- versity, most Vietnamese follow Buddhist concepts that affect their health care beliefs and practices. Consult the section on Buddhism, page 22, for additional information. Patient education materials in the Vietnamese language can be found on the EthnoMed Web site, http://ethnomed.org, as well as the California Health Department and other sites. Attitudes: The Buddhist respect for authority means that Vietnamese will be reluctant to challenge those in positions of authority. In cases of disagreement, saving face by appearing to go along with a doctor’s advice is preferable to confrontation. The Buddhist approach to life stresses acceptance of the cycle of suffering and rebirth, enduring pain and perhaps delaying seeking medical attention. Preventive health care is not part of this world view. When a Vietnamese person visits a Western medical professional, he or she may expect a medicine to be prescribed immediately, without tests, and for that medicine to work immediately to relieve symptoms. The patient will often discontinue a medication when symptoms have disappeared rather than completing the prescription. According to the Baylor site, “it is quite common for Vietnamese patients to amass large quantities of half- used prescription drugs, even antibiotics, many of which are shared with friends and even make their way back to family in Vietnam.” When a physician does not prescribe medicine, a Vietnam- ese person may go to a traditional practitioner or obtain medicine from a specialized “injectionist” or a relative in a country where antibiotics and other drugs are available without prescription. Family Authority: The father or eldest son is the family spokesperson. Addressing Clients: Greet clients formally by using the last name. Show respect to elderly clients by making a gentle bow. The typical Vietnamese greeting is a smile and bow. Do not shake a woman client’s hand unless she offers it. Nonverbal Exchange: Respect is demonstrated by avoiding direct eye contact, bowing the head slightly, and using both hands in giving something to another person. Vietnamese prefer to keep a good distance between themselves and others. As in other cultures, the head may be considered sacred and the feet pro- fane. Gentle touch may be appropriate during conversation. A smile may mean many things, including apology, embarrassment, or appreciation. Verbal Exchange: Vietnamese are generally soft-spoken. Raising the voice and pointing are considered signs of dis- respect. Open expression of emotions may be considered inappropriate. Explain procedures carefully. The client may nod to indicate that he or she has heard, but this does not indicate understanding or agreement. The Vietnamese client may be reluctant to ask questions or disagree. Hospitalization: Vietnamese may fear lab procedures that require drawing blood, and surgery might be considered a last resort because of its potential for upsetting the balance of the body. They may not request pain medication for fear of addiction or side effects. Death and Dying: Discuss a diagnosis of terminal illness with the family spokesperson, who may not want to reveal it to the patient. DNR is a sensitive issue that will probably be decided by the whole family. Viet- namese Catholics may request the presence of a priest, and Buddhists may want to have incense and a monk at the time of death. The body is highly regarded, and family members may want to wash it themselves. Cremation is preferred by Buddhists. Many Vietnamese are opposed to organ donation and autopsy because of respect for the body. Celebrations and Holidays January–February Tet, the New Year: Celebrated on the first new moon of the year; considered everyone’s birthday, a time for starting over, paying debts, being on best behavior. People visit their parents on the first day of the celebration, and the season includes much socializing and eating, firecrackers, drums, Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○113

Vietnam, cont. and the dragon dance. Children receive gifts of li xi, lucky money, in red envelopes. People decorate their homes and streets with flowers and may display the cay neu, signal tree, a bamboo pole with a basket on top containing areca nuts, betel, and woven bamboo. February 3 Founding Day of the Communist Party of Vietnam February Lantern Festival March Hai-Ba-Trung Day: Celebrates the anniversary of the death of the Trung Sisters, who led a revolt against the ruling Chinese and won freedom for Vietnam in AD 41. The two sisters made Me- Ling in North Vietnam their capital. When the Chinese recaptured Vietnam after three years, the sisters drowned themselves in the Hat-Ciang River. April Thanh Minh (Ancestors) Day: Vietnamese clean and whitewash graves to please the ancestors. Throughout the year, deceased relatives are remembered with special meals and rituals on the anniversaries of their deaths. April 30 Liberation Day: Celebrates anniversary of the liberation of Saigon in 1975. May 1 Labor Day May 7 Defeat of the French at Dien Bien Phu May 19 Ho Chi Minh’s birthday May 28 National holiday commemorating the birth, enlightenment, and death of the Buddha July 28 War Invalids and Martyrs Day August Trung Nguyen, Day of the Wandering Souls: Souls of the dead believed to wander to their descen- dents’ homes. Celebrations are held in Buddhist temples; food is spread on house altars and fake money is burned. September 2 Independence/National Day September 3 Death of Ho Chi Minh September Trung Thu, autumn celebration where children parade through the streets with lanterns; moon cakes are featured. Date varies according to the lunar calendar. Vietnamese in the United States According to tne Web site for Migration Information Source, there were nearly 1 million foreign born people from Viet- nam living in the United States at the time of the 2000 census. This makes them the fifth-largest immigrant group in this country, accounting for just over three percent of the total foreign-born population. The number of foreign born from Vietnam increased by 82 percent between 1990 and 2000. They make up 1.2 percent of the population of California, some 418,249 people in the 2000 census. Most of the Vietnamese living in the United States came here as refugees beginning in 1975 when the country was reunified. The first group to arrive were educated and urban professionals and their families airlifted from Saigon in 1975. Most of these people were closely associated with American interests, spoke English, and were familiar with American culture. The second group of immigrants, arriving from the late 1970s through the mid 1980s, included many “boat people” who escaped Communist Vietnam in small boats, often landing in refugee camps where they spent many years before eventually making it to the United States. With rural backgrounds and/or limited education, these refugees had a more difficult time adjusting than the first group. The third refugee group, which includes Vietnamese still arriving in this country, comes as Vietnamese political prisoners or the children of Vietnamese women and American fathers. Language; Useful Words and Phrases Vietnamese is the official language of Vietnam, although there are many dialects and other languages; many older people know French and/or English. Vietnamese uses the Roman alphabet, but the language structure is very different from English. Each word has only one syllable (so that Viet Nam is the correct rendering of the country’s name), and meaning is based on up to six tones which give words that look the same entirely different meanings. The word ma, for example, has six ○○○○○○○○

114 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Vietnam, cont. different meanings, depending on the tone in which it is pronounced: with a high falling tone it means “mother;” a high flat tone signifies “ghost;” a low to rising tone indicates “grave.” When the word ma or any other word is written, the presence of one of five accents or no accent above or below a word’s vowel indicates the tone and therefore the meaning of the word. The following words and phrases might be helpful for the health-care provider: Hello. Chao (pronounced “chow”). Please. Xin/Lam on. How are you? Ong khoe khong (“own khway-eh kown”). Thank you. Cam on (pronounced “cam un”). You’re welcome. Khong co chi/Khong dam. I don’t understand. Khong hieu (“kowm hee-you”). Yes/No Da/Khong What is your name? Ten (ba, co, ong, em) la gi? My name is . . . Ten toi la (“tain toy la”) . . . Friend Ban References Grieco, Elizabeth. 2004. “The Foreign Born from Vietnam in the United States.” Migration Information Source. http:// www.migrationinformation.org/USfocus/print.cfm?ID=197 (5 Feb. 2004). Habitat for Humanity Vietnam. http://www2.habitat.org/intl/countryprofiles.fm (24 Mar. 2004). Hong, Khuat Thu. 2003. Adolescent Reproductive Health in Vietnam. January. http://www.policyproject.com/pubs/ countryreports/ARH_Vietnam.pdf (18 Nov. 2004). Horton, Mark. 2002. “Vietnam: Progress Through Prevention.” Community Health Beat. http://www.ochealthinfo.com/ public/healthbeat/2002/2002_07.htm. Hunt, Peter Cody. 2002. An Introduction to Vietnamese Culture for Rehabilitation Service Providers in the U.S. Buffalo, NY: State University of New York, Buffalo, Center for International Rehabilitation Research Information and Exchange (CIRRIE). http://cirrie.buffalo.edu (11 Jul. 2005). Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. National Institute for Urban and Rural Planning. Rural Infrastructure Planning. http://www.apo-tokyo.org/icd/ act_inti_stm.lib/ICD-OS1-00/Study/Mission/Country%20Papers/Vietnam(1)final.dlc (19 Nov. 2004). “Public Holidays.” http://www.hanoitravel.com/index.cfm?menuid=8 (6 Dec. 2004). Schiffer-Graham, Beate, and S. Vemuri. 2002. Vietnam. Anti-Racism, Multiculturalism and Native Issues Centre, Faculty of Social Work, University of Toronto, Canada. http://www.settlement.org/cp/english/vietnam (18 Nov. 2004). Tick, Edward. 2005. “Fallen Leaves, Broken Lives.” Utne Reader. Jan-Feb. U.S. Department of State Bureau of Democracy, Human Rights, and Labor. “International Religious Freedom Report 2002: Vietnam. http://www.state.gov/g/drl/rls/irf/2002/13916pf.htm (28 Feb. 2004). Useful Vietnamese Phrases. http://www.worldroom.com/pages/wrnhcm/customs/hcm_lang.phtml (6 Dec. 2004). “Vietnam.” Encyclopaedia Britannica. 2004. Encyclopaedia Britannica Premium Service. http://www.britannica.com/eb/ article?tocid=52700 (18 Nov. 2004). “Vietnam Aims to Provide Health Care Services for All.” http://www.vietnam-tourism.com/vietnam_gov/e_pages/Xahoi/ yt-bh_service03.htm (6 Dec. 2004). “Vietnamese Cuisine.” http://www.vietnamsaigontourist.com/vietnamcuisines.htm (6 Dec. 2004). Vietnamese Health. http://www3.baylor.edu/~Charles_Kemp/vietnamese_health.htm (18 Nov. 2004). Vietnamese Patient Education Materials. EthnoMed. http://ethnomed.org/ethnomed/patient_ed/viet/index.html (6 Dec. 2004). Wamsley, Laurel. 2005. “The Fog of Peace.” Utne Reader. Jan-Feb. The World Factbook: Vietnam. http://www.cia.gov/cia/publications/factbook/geos/vm.html (8 May 2005). Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○115 Laos

Census Figures (2000) United States Residents Born in Laos: 204,284 (0.7%) California Residents Born in Laos: 68,306 (0.8%) Quick Facts Country Area: 91,400 sq. miles (slightly larger than Utah) Population: 6,217,141 Median Age: 18.74 years Population Growth Rate: 2.42% Life Expectancy at Birth: 55.08 years Below Poverty Line: 40% Literacy Rate: 66.4% Currency: kip (LAK) Population Groups: Lao Loum (lowland) 68%, Lao Theung (upland) 22%, Lao Soung (highland) including the Hmong, Mien, and Yao 9%, ethnic Vietnamese/Chinese 1%; (49 ethnic groups) Languages: Lao (official), French, English, and various ethnic languages Religion: Buddhist 60%, Animist and Other 40% (including Christian denominations 1.5%) Government: Lao People’s Democratic Republic: communist state, capital is Vientiane; country divided into 16 provinces, 1 municipality, and 1 special zone Climate: tropical monsoon; rainy season (May to November); dry season (December to April) Natural Hazards: floods, droughts Natural Resources: timber, hydropower, gypsum, tin, gold, gemstones Arable Land: 3.8% Agricultural Products: sweet potatoes, vegetables, corn, coffee, sugarcane, tobacco, cotton, tea, peanuts, rice, water buffalo, pigs, cattle, poultry Exports: coffee; garments, wood products, electricity, tin Industries: tin and gypsum mining, timber, electric power, agricultural processing, construction, garments, tourism Labor Force: agriculture 80% ○○○○○○○○

116 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Laos, cont. Brief History Artifacts discovered in the Huaphan and Luang Prabang provinces indicate the presence of hunter-gatherer groups in present-day Laos about 40,000 years ago. Evidence of agriculture dates to 4000 BC, and bronze tools date to 1500 BC. Between 300 and 700 AD, settlement began along the Mekong River. In 1353 King FaNgum established Lane Xang, the kingdom of a million elephants. King Setthathirat, who ruled from 1548 to 1571, moved the capital from Luang Prabang to Vientiane, where he built an elaborate religious shrine and temple for the Phra Keo, the Emerald Buddha. The height of the Lane Xang Kingdom came during the 17th century under the reign of King Souliyavongsa. A Dutch merchant and later Italian missionaries visited the country and described Vientiane as the most magnificent city of South- east Asia. Infighting led to the division of the Lane Xang Kingdom into three kingdoms: Vientiane, Luang Prabang, and Champassack, with the effect of weakening the culture and allowing foreign aggressors to invade. The Siamese (Thai) attacked and virtually destroyed Vientiane, taking the Emerald Buddha to Bangkok. The French took control of the country in 1893. Many Hmong immigrated to the mountains of Laos from China in the early 1800s. The Communist Party of Indochina, founded in 1930, led the fight to regain the country’s independence, which was recognized in the Geneva Agreement on Indochina of 1954, which also recognized the independence of Cambodia. They were later replaced by a secret U.S. military mission in Vientiane. During the Vietnam War, in what is known as the “Secret War,” despite the Geneva Accord of 1962 recognizing the neutrality of Laos and forbidding the presence of military personnel, U.S. forces dropped more bombs on Laos than they did over the entire world during World War II. Per capita, Laos has the dubious distinction of being the most heavily bombed nation in history. The bombing was justified as being directed at a portion of the Ho Chi Minh trail, a key supply route that crossed the country. International teams are still clearing unexploded ordnance from that war, which ended with a 1973 Paris agreement. Many of the people from Laos now living in California are members of the Hmong people. In 1966, as many as 40,000 Hmong troops were reportedly involved in the Vietnam War on the side of the United States, enlisted and supported by the CIA. The cease-fire that formally ended the war removed U.S. support from the Hmong troops and made them vulnerable to retribution from their countrymen who had sided with Communist North Vietnam. In 1975, the Communist Lao People (Pathet Lao) gained control of their country and established the Lao People’s Democratic Republic (LPDR) on December 2. The Hmong were declared enemies of the state. With the aid of North Vietnamese troops, the new government destroyed Hmong villages, resulting in a mass exodus of hundreds of thousands of Hmong to refugee camps in Thailand, and eventually to the United States, France, Canada, and Australia. Hmong who were not able to leave hid in the jungle, where they were hunted down by Pathet Lao troops, with about 50,000 killed between 1975 and 1978. In 1992, the last officially sanctioned refugee camp in Thailand closed, with the remaining Hmong taking refuge in Wat Tham Krabok. In 2004, the Thai government closed that camp and most of the 14,400 residents were able to emigrate to the United States, many to California. By the end of September 2005, Fresno County will have received about 2,000 of these refugees. After 1986, LPDR leaders introduced market incentives, private investment and decentralization of the economy, abandoning earlier efforts at establishing collective farms. A 1991 constitution allowed citizens more freedom of movement and participation and reduced the influence of Vietnam. The breakup of the Soviet Union has caused Laos to turn to other countries including Japan, Austraila, Sweden, the European Community, and international organizations for assistance. Housing, Family, Work, Traditions Housing: Lao Theung (midland) and Lao Loum (lowland) Lao houses are raised off the ground on wooden or bamboo piles. Houses have woven bamboo or sawn lumber floors and walls with grass thatch or bamboo shingle roofing. Houses include a kitchen hearth and are open on at least one end. The Lao Sung or highland Lao, including the Hmong, live at the highest elevations along mountain ridges. Hmong houses are built on the ground with dirt floors and walls constructed of vertical wooden planks and gabled roofs of thatch or split bamboo. Houses include a kitchen alcove at one end and sleeping quarters at the other, with raised beds or sleeping benches. Most houses include an altar mounted on a wall and used for ceremonies associated with ancestral spirits. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○117

Laos, cont.

Family: Hmong society is organized into 18 clans, with sub-lineages, each with its particular religious rituals, and individuals are designed as clanmates (kwv tij) and in-laws (neej tsa). People who have the same clan name are considered brothers and sisters and forbidden to marry, even if they have been born and raised in different countries. Hmong clans, which are constituted by last name, are determined by ancestral lineage through the great-great grandfather and according to which ancestral traditions they practice. Clan leaders are selected for their honesty and ability to make wise decisions, and may need to be consulted by health care providers. Clan members take responsibility to support one another. The male-headed household is a powerful force in Laotian society. Laotians went by first names only until 1943, when a law required the use of surnames. American- ized Hmong clan names are: Chang, Chue, Cheng, Fang, Her, Hang, Khang, Kong, Kue, Lee, Lor, Moua, Pha, Thao, Vang, Vue, Xiong, and Yang. Hmong women retain their clan name for identification purposes when they marry, but they become part of the husband’s clan and children take the name of the father’s clan. A naming or soul-calling ceremony on the third day after the birth of a child traditionally involves an astrologer or bonze selecting a meaningful name, usually referring to a natural object. Families include parents, children, and often other relatives. After the marriage the couple traditionally lives with the wife’s household for several years before moving to their own home near the husband’s parents. Traditional Hmong households are generally large, something seen frequently in California, including parents, children, and wives and children of married sons living together. Marriage is traditionally arranged by go-betweens who approach the girl’s family on behalf of the boy’s family. In Laos, some traditional Hmong practice polygamy, although this is discouraged by the government. Gender roles are strict, with women responsible for all household chores and child care plus farming tasks. The elders are the most respected members of the family. They are consulted on decisions and take part in raising children. Traditions: The traditional form of Laotian greeting, the Nop, involves placing the palms together in a position of prayer at chest level, not touching the body, accompanied by a slight bow to show respect to persons of higher status or age. The higher the hands, the greater the sign of respect (but hands should never be held higher than the nose). This gestures serves also as a means of expressing thanks or regret, or of saying goodbye. The head is considered the most sacred part of the body, the soles of the feet the lowliest. Therefore, one should not touch another person’s head or use one’s foot to point at a person or object. Men and women rarely show affection in public. Removing one’s shoes upon entering a temple or private house is customary. The handshake is not a common greeting among the Hmong, particularly women. Looking directly into the face or making eye contact when speaking to a person is considered inappropriate. Men and women generally keep some distance between them in an encounter. Hmong people are often humble and may be hesitant to express their true emotions in the company of others, perhaps saying “yes” when they do not mean it. Traditional families are headed by males who make most of the decisions, often in consultation with others. Direct comments about children are generally not welcome by Hmong who hold traditional beliefs in spirits, as they believe that if a bad spirit hears positive comments it may take away the child’s soul. When visiting a Hmong household, one should watch for a taboo sign on a stick in front of the outside door, which warns the visitor not to disturb the family as the house is being protected from evil spirits. Before entering, one should inquire as to whether visitors are appropriate. Shoes and handbags are often left ouside the house. A visitor should accept any food or drink offered, even if one does not consume all of it. One of the Hmong traditions with which most Californians will be familiar is the unique handwork, called Paj Ntaub, Pa Ndau, or Pandau (flower cloth), thought to have originally sym- bolized the knowledge required for passage from this world into the next world. Hmong girls as young as three years of age begin learning ths intricate embroidered and quilted work using tiny ○○○○○○○○

118 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Laos, cont.

cross stitches, applique, and reverse applique. This colorful work is found on everything from slippers to wall hangings. It illustrates a young girl’s qualities of discipline and creativity, and is often displayed and sold at craft fairs and art exhibits. Employment: In traditional villages in all parts of Laos, agriculture is the occupation of the majority of people. According to the Library of Congress study, “Everyone is first and foremost a subsistence farmer.” Swidden or slash-and-burn agriculture is traditionally practiced in the hilly midland and highland areas, with paddy rice cultivation more common in the flatter lowlands. Midland and highland crops include rice, corn, and vegetables as well as opium and forest products. Livestock include chickens, ducks, pigs, buffalo, oxen, and horses. The manufacturing sector is located primarily in and around the capital city, Vientiane. Foods and Eating Habits Dietary Practices: When ill, Hmong people may eat plain boiled rice soup with a small amount of chicken; they prefer to kill their own chickens to guard against unhealthful chemicals. Aside from ice cream, dairy products are rarely eaten. Everyday Diet: Refrigeration is uncommon, so meals must be prepared from fresh ingredients. Rice, klao, is the staple food throughout Laos, usually eaten at every meal. In the lowland area, glutinous, or sticky rice, klao niaw, is most common; because it has a high starch content, it must be steamed rather than boiled. It is eaten with the fingers, rolled into balls and dipped into soup or a vegetable or meat dish. Pa daek, fermented fish sauce, is a common ingredient, and chiles are added to many foods, with the hotness of the chiles varying among ethnic groups. A typical meal would include rice, fish, vegetables, and chiles. Popular seasonings include lemon grass, lime juice, mint, ginger, coconut milk, and fresh coriander (cilantro). Vegetables include corn, cassava, white radish, sweet potato, and cucumber. Popular fruits are papaya, bananas, oranges, and berries. Peanuts are a common ingredient. Festive meals might include eggs, poultry, beef, or game (including snake). Popular Dishes: Laap, a popular Lao dish whose name means “good fortune,” is made of meat or fish with lime juice, garlic, rice, green onions, mint, and chiles. A popular salad, tam som, contains shredded green papaya seasoned with padek and chiles. Klao poun, a popular dish at weddings and other celebrations, is a kind of rice vermicelli served cold with raw chopped vegetables and coconut milk flavored with meat and chiles. A popular Lao meal, feu, comes from Vietnam and is a combination of vermicelli in hot meatball soup served with vegetable leaves that are stirred into the soup as desired. Fish sauce, chile sauce, and sugar may also be added. Two popular soups are keng no may, made of bamboo shoots, and keng het bot, a mushroom soup. Or lam, a dish from Luang Prabang, is created from dried buffalo meat and skin along with eggplant, seasoned with lemon grass, chiles and pa daek, highlighted with crisp-fried pork skin and sweet basil. Other popular main dishes include stir-fried chicken with mushrooms (aioan chua noeung phset kretni), and sousi pa, fish with coconut cream. Beverages: Both tea and coffee are grown and drunk in Laos. Fermented rice is used to make a type of whiskey, lao lao, and wine, khao kam. Education Status: Prior to the 1850s, formal education was available through Buddhist temples to a select number of males. When the French took control of the country, secular schooling was established but limited to a minority of children. The government made secular education compulsory in 1951, but relatively few children graduated from secondary school. According to the Library of Congress Coun- try Study on Laos, the Lao People’s Democratic Republic planned to implement universal pri- Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○119

Laos, cont.

mary education by 1985. This goal was later extended to 2000. The LPDR replaced the French system with a Laotian curriculum and conducted an extensive adult literacy campaign in 1983–84. The lack of educational materials continues to be a serious problem. Education reforms initiated in 1986 focused on improving science training, recruiting minority teachers, and expanding education to remote areas. Primary School: Primary education begins at age six and lasts for five years. The school year lasts for nine months. In 1996–97 there were 695 kindergartens with 37,851 students and 7,896 primary schools serving 786,335 students. Most villages have a school, but schools are poorly constructed and teaching materials are scarce. Many schools offer only one or two grades, and teachers are paid irregularly and often must spend most of their time doing other jobs to earn a living. According to the Library of Congress, in the late 1980s the average student took 11 to 12 years to complete the primary course, with much repetition of grades and dropping out. School quality and student performance vary widely between urban and rural areas and among different ethnic groups. Secondary School: Secondary school begins at age eleven and lasts for six years, three years of lower and three years of upper secondary. In 1996–97, there were 180,160 students attending secondary schools. Some students go from three years of lower secondary to a vocational course such as agriculture or teacher training. Secondary education is concentrated in the provincial capitals and district centers. Students who do not live in such a place must board away from home, which discourages rural students from pursuing their education. Higher Education: Sisavangvong University offers courses in education, agriculture, forestry, Pali, Sanskrit, technical studies, and the arts. Other institutions of higher education include regional technical colleges, a National Polytechnic Institute, a Pedagogical University, and a Medical Sciences University. In 1994–95, there were 4,507 university students reported in Laos. Religion Buddhism: The majority of lowland Lao, who comprise two-thirds of the population, practice Theravada Buddhism. Buddhism was introduced in the eighth century and was widespread by the fourteenth century. Theravada Buddhists believe that each individual is responsible for his or her own nirvana, as opposed to Mahayana Buddhists, who believe that nirvana will come only when all people are prepared for salvation. The temple, wat, is a focal point of village life and provides a location for ceremonies and festivals as well as a symbol of village identity. Theravada Buddhism is tolerant of other religions, and many Laotians combine Buddhism with other religious practices. Animism: Animist beliefs are widespread even among practicing Buddhists; some wat include small spirit huts associated with the phi khoun wat, the spirit of the monastery. This belief in spirits, called neeb by the Hmong, is the common religion of midland and highland Lao ethnic groups, although beliefs and practices differ widely among tribes. Spirits are everywhere and involved in all aspects of life. Many Lao people believe that they are protected by khwan, thirty-two spirits, and that illness occurs when one or more of these spirits leaves the body. Balance can be restored by a ceremony called the soukhkwan or baci that calls back the spirits to bestow health, prosperity, and well-being. Cotton strings are tied around the wrists to keep the spirits in place. Ceremonies associated with the practice of animism often involve an offering of a chicken and rice liquor. Christianity: Roman Catholicism claims perhaps 40,000 adherents in Laos, primarily ethnic Vietnamese who live in major urban areas along the Mekong River. Protestantism is growing, with approximately 300 congregations throughout the country. Two groups are officially recognized: the Lao Evan- gelical Church, an umbrella group that includes most Protestant denominations, and the Seventh- Day Adventist Church. Proselytizing is prohibited by the government. Other: Small numbers of Laotians practice Islam, Baha’i, Confucianism, and Taoism. ○○○○○○○○

120 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Laos, cont. Health and Health Care Health Status: Chronic vitamin and protein deficiencies are common, especially in the upland ethnic groups. Poor sanitation throughout the country contributes to the spread of disease. Children’s deaths are primarily the result of such communicable diseases as malaria and acute respiratory infections as well as diarrhea. Immunization efforts are increasing. Diarrheal diseases are especially prevalent at the onset of the rainy season, when drinking water is contaminated by human and animal waste washed down from higher locations. Traditional Practices: As indicated above, most Lao people believe in the power of spirits in their lives, especially in the matter of health and illness. Illness is believed to be a matter of imbalance between the body and the spirit. Spiritual causes of illness include evil spirits or one’s own spirit leaving the body. In cases of serious illness, the Hmong will engage a shaman (tix neeb), which could be a man or a woman specially called to this role, to climb a ladder to heaven on a magical horse to consult the spirits for a cure. Shamans study for several years with a master, learning the chants, techniques, and procedures of healing rituals as well as the names and natures of the spirits responsible for good fortune or illness. The Hmong recognize both spiritual and physical causes of illness. Herbal remedies are widely used, and women traditionally handle childbirth themselves or turn to female relatives or midwives for assistance. Herbs may be made into drinks, rubbed into the skin, or used for soaking baths. The Ministry of Public Health includes an Institute of Traditional Medicine which formu- lates and markets preparations from medicinal plants. Hmong use the same kind of cupping and pinching treatments described in the earlier section on Vietnam, page 111. Death is viewed as a passage from one phase of existence to the next; traditional animist Hmong believe in three souls: one that goes to heaven, one that remains with the body, and one that is reincarnated. Medical System: In 1995, there were 25 hospitals, 131 health centers, and 542 dispensaries in Laos, which claimed 3,100 physicians. Most health care personnel are concentrated around the capital. According to the Library of Congress study, in the early 1990s the condition of the health care facilities was poor and supplies were limited. Health care workers are not well paid and are held in low esteem by the public. Unregulated pharmacies sell drugs, often inappropriately, and in rural areas vendors may sell small packets of assorted drugs such as antibiotics, vitamins, and fever suppressants. Tips for Health Care Providers Most of the Laotian immigrants U.S. health care providers will deal with are members of Hmong or other highland groups that hold animistic beliefs and whose daily lives are heavily influenced by the spirit world. All health care providers who work with Lao (especially Hmong) people would do well to read Anne Fadiman’s book, The Spirit Catches You and You Fall Down, for insight into the beliefs that cause these clients to have difficulty with Western medical practices. This is the story of a Hmong family’s experience with the health care establishment in Central California during the birth and subsequent diagnosis of epilepsy and death of their fourteenth child, Lia, and it contains valuable information about Hmong beliefs and practices. Several excellent Web sites provide health information materials in the Hmong language as well as information for health care providers on working with Hmong patients. The Hmong Health Education Network, funded by the Na- tional Library of Medicine, can be found at http://www.hmonghealth.org. It contains a health dictionary, information on traditional healing, and a wide variety of useful resources. A handbook for health care providers containing words and phrases in both Hmong and English as well as extensive information on working with Hmong patients and clients will soon be available. Briefly, some things to keep in mind when working with foreign-born Hmong and many other Laotians in the health care setting: Attitudes: Hmong respect authority but may be suspicious that U.S. doctors take advantage of their unfamil- iarity with Western medicine. They will generally try traditional remedies first and even after consulting a Western practitioner. Surgery is often not acceptable to and feared by the Hmong Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○121

Laos, cont.

unless tests have identified a disease that requires surgery for a cure. Immunizations are traditionally not acceptable. Like surgery or organ donation, the idea of removing something from or putting something into the body means that the person will be reincarnated with less than a complete body or something foreign included in it. When Hmong parents understand that their children need to be immunized to attend school, most will allow the procedure. Many Hmong and other Laotians see a spiritual component to illness and believe that healing requires the work of a shaman (acharn) to communicate with the spirit world. Disease prevention and health promotion are not highly valued or widely practiced. Family Authority: The father or eldest son is the primary decision-maker, but the family spokesperson may be another person who speaks better English. Addressing Clients: Greet clients using Mr. or Mrs. and their last name. Handshakes and smiles are appropriate. Nonverbal Exchange: Hmong are very polite and reticent. They consider prolonged direct eye contact rude. Touching between members of the opposite sex is considered disrespectful. Because the Hmong believe the soul resides in the head, refrain from touching the head without permission, and do not pat children on the head. Verbal Exchange: Explain procedures and recommendations clearly in simple language, and ask the patient to repeat or interpret the information to ensure understanding. Be aware that “yes” may not mean assent. A Hmong patient may be hesitant to ask questions. Most respect firmness and politeness. Personal questions should be deferred until a comfortable relationship has been established. Hospitalization: Physical privacy is important and should be protected by using curtains and not requiring patients to undress more than is strictly necessary. Do not remove jewelry or amulets without the permission and understanding of the patient, oldest male family member, or spiritual leader. Encourage and support a visit from the shaman if the patient desires one. In the hospital setting, try to serve plain foods without spices to Hmong patients. Encourage family members to bring in special foods, particularly those needed following childbirth. If the family wants to bring an herbal drink, arrange for a portion to be analyzed for chemicals that might interact negatively with prescribed medications. If possible in this kind of situation, get a list of common herb treatments from an herbalist and give it to the hospital pharmacist to check for possible drug interactions. Work with the dietician to ensure that foods are consistent with dietary practices to the extent possible. Pa- tients may be unwilling to drink water unless it has been boiled. Offer tea or juice as an alternative, or offer to boil the water. Try to determine what herbal medicines the Hmong patient is using at home in order to check for negative drug interactions. Death and Dying: Discuss a diagnosis of terminal illness with the family spokesperson. It is considered inappropriate to talk about impending death, and Hmong people often present a positive attitude even when they know the person is dying. Traditional Hmong do not accept autopsy or organ donation. Celebrations and Holidays April 15 Boun Pee Mai, New Year: Celebrated by Lowland Lao; lasts up to a week. Houses are cleaned to expel bad spirits. Processions with elephants are held in Luang Prabang. May Vixakha Bouxa: Celebrates the birth, enlightenment, and death of the Buddha, observed at the full moon of the sixth lunar month. Boun Bang Fai, Rocket Festival: Celebrates start of the rainy season. This ancient festival was to remind the gods that rain is needed; people fire bamboo rockets filled with gunpowder. Dancing, singing, processions, and puppet shows; rocket judging takes place in Vientiane. August Haw Khao Padap Din, Festival of the Dead Fall Boun Nam, Water Festival: Celebrated with boat races on the rivers. ○○○○○○○○

122 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Laos, cont.

November-December Boun That Luang, Harvest festival: Celebrated by Lowland Lao on the full moon of the twelfth lunar month; week-long event also celebrates the country’s greatest national monument, the Pha That Luang, Great Stupa, a tower built in Vientiane in 1566, supposedly on the site of an earlier building housing relics of the Buddha. December 2 National Day Dec. 1–Jan. 15 Hmong New Year Festival: The only formal Hmong holiday, celebrated for up to a week beginning the first day of the waxing moon of the twelfth month with a “Calling of the Spirit of the New Year” ritual. There are songs and ball tossing games and competitions, people wear their finest traditional costumes, boys and girls to get acquainted and courtships begin. This was traditionally a time to honor all beings both living and dead and to show gratitude to and/or placate the spirits. Village elders have the responsibility of calling the spirits home for the new year. Hmong in the United States Because the majority of people from Laos living in California are members of the Hmong ethnic group, discussion will be limited to Hmong in the United States and California. According to the 2000 census, 204,284 foreign-born from Laos were living in the United States, and 68,306 were in California. Foreign-born Hmong living in the United States that year numbered 102,773, with the largest number, 41,133 in California. That figure increased during 2004 as the illegal refugee settlement at Wat Tham Krabok monastery in Thailand was closed in June and the United States agreed to take 15,000 refugees by the end of 2004. According to the Migration Information Source, most of these refugees had passed up earlier opportunities for resettlement in the United States in hopes that they would be able to return to their homes in Laos. All official refugee camps in Thailand were closed in the 1990s. About 5,000 of these refugees were to be resettled in California, another 5,000 in Minnesota, and the remainder distributed among more than a dozen other states. In the United States, prior to the arrival of the latest group of refugees, the Minneapolis-St. Paul area had the largest concentration of foreign-born Hmong, followed by Fresno, Sacramento, Milwaukee-Racine, and Merced. As of January 1, 2005, approximately 315,000 Hmong still lived in the highlands of Laos, and several million Hmong lived in China, Vietnam, Thailand, and Burma. More than 200,000 Hmong have fled Laos since the Pathet Lao took power in 1975. Language; Useful Words and Phrases There are as many as 70 distinct ethnic groups in Laos, each with its own traditions and language. The national language, Lao, is the language of the majority lowland Lao people who live in the valleys along the Mekong River and grow irrigated rice. The Lao are Buddhist, like their neighbors in Thailand, and the Lao language shares many characteristics with the Thai language. Both use the alphabetic script used in India. The Khmu people who live in the midlands are descendants of the original inhabitants of Laos, and their language is completely different from Lao. Like the Hmong, they are animists rather than Buddhists. In the highlands, in addition to the Hmong, the Mien or Yao people live and speak a language related to but distinct from Hmong. Some of the Mien people have also fled Laos for the United States and other countries and can be found in California. Speaking at a 1995 symposium in St. Paul, Minn, Gary Yia Lee made this comment about the Hmong language:

A Hmong is expected to be able to speak the Hmong language which is distinctly different from all other languages. Being members of a minority and living among many other ethnic groups, most Hmong need to learn, in addition to their mother tongue, one or more of the local or national foreign languages. These could be Mandarin for those in China, Lao for those in Laos, Vietnamese for those in Vietnam and Northern or Central Thai for those in Thailand. In the process, they have also borrowed foreign words from these languages, some of which become assimilated as Hmong. . . . The more educated a Hmong is in another language, the more words from that language the person is likely to use in everyday conversations.

The valuable reference produced by Bruce Bliatout and others in the Folsom Cordova Unified School District in 1988, Handbook for Teaching Hmong-Speaking Students, includes some helpful basics about the Hmong language, which consists Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○123

Laos, cont. of two major dialects: White Hmong and Green (or Blue) Hmong, with the colors referring to the colors traditionally used in women’s garments of the two groups and reflecting somewhat different cultures and residential distribution in distinct regions of China. These two dialects are mutually intelligible, with differences in pronunciation being similar to those found between various regions of the United States. Both are spoken by Hmong living in California. The White Hmong dialect uses the Romanized Practical Alphabet (RPA), which uses consonant letters at the ends of syllables to represent the different tones on which the preceding vowel may be pronounced. The alphabet was created in the 1950s by missionary linguists. It uses the ordinary letters of the Roman alphabet, although the letters do not represent the same sounds in English and Hmong. The Hmong language is one of the group called the Miao-Yao languages spoken in Southeast Asia and Southern China. Hmong is spoken in Laos, Thailand, Burma, Vietnam, and by the Miao minority in Southern China. The Hmong language shares several characteristics with other languages of the region, including: ■ A preference for one-syllable words. ■ The use of tone to indicate word meaning. Hmong contains eight different tones: high (indicated in the RPA by the consonant b), high falling (j), mid-rising (v), mid (no consonant), breathy mid-low (g), low (s), low falling (m), and low falling and rising (d). Teachers and health care professionals who wish to speak to Hmong students and clients would do well to make use of the speaking dictionaries available from the St. Paul, Minnesota school district. ■ Lack of inflections indicating different forms of words such as possessive, different genders, or verb tenses. Hmong words have only one form, with number, case, tense, etc. made clear by the order and combination of words used. ■ Use of noun classifiers. Hmong nouns are divided into different classes, with words possibly taking on different meanings depending on the classifier used. ■ Use of multiple verbs in one sentence. Like Mandarin, the Hmong language allows the use of two or more main verbs in a single clause, without any connection between them. Instead of saying “I go to his house,” for example, the Hmong speaker would say “I go arrive his house.”

Useful Words and Phrases Words and phrases helpful to health care providers are being compiled in a separate handbook to be available from www.health- careers.org. When deciding how to pronounce the Hmong words, keep in mind the use of the consonant following a vowel to indicate the tone, as described above. When there is no consonant, the voice’s natural speaking tone is indicated. Hello. Nyob zoo. Goodbye. Sib ntsib dua. How are you? Koj puas nyob zoo? Thank you. Ua koj tsaug. Where does it hurt? Koj mob qhov twg? What is your name? Koj lub npe hu li cas? I am glad to meet you. Kuv zoo siab tau ntsib koj. I am fine. Kuv nyob zoo. What is your telephone number? Koj nus naj npawb xov tooj yog li cas? Where do you live? Koj nyob qhov twg? References Batica, Elsa. 2004. Community Partners in Children’s Care: the Hmong Americans. Children’s Hospitals and Clinics, Minne- apolis, Minn. http://xpedio02.childrenshc.org/stellent/groups/public/@web/@healthprof/documents/ policyreferenceprocedure/038697.pdf (1 Feb. 2005). Bello, Sheila. 2000. Laos. Anti-Racism, Multiculturalism and Native Issues Centre, Faculty of Social Work, University of Toronto, Canada. http://www.settlement.org/cp/english/laos (30 Jan. 2005). Bliatout, Bruce, et al. 1988, Handbook for Teaching Hmong-Speaking Students. Sacramento, CA: Folsom Cordova Unified School District, Southeast Asia Community Resource Center. http://www.seacrc.org/media/pdfiles/HmongBk.pdf (1 Feb. 2005). ○○○○○○○○

124 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Laos, cont.

Building Bridges: Teaching about the Hmong in our Communities. Slide Presentation. http://www.learnabouthmong.org/ prsentation/index_files/frame.htm (1 Feb. 2005). Children’s Hospitals and Clinics, Minneapolis/St. Paul, Minn. 2003. “Homng Culture and Medical Traditions.” http:// xpedio02.childrenshc.org/stellent/groups/public/@xcp/@web/@clinicsanddepts/documents (1 Feb. 2005). Evans, Grant. “Lao Cuisine: The Raw and the Cooked.” http://asiarecipe.com/laoculture.html (31 Jan. 2005). Fadiman, Anne. 1998. The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures. New York: Farrar, Straus and Giroux. Gannett News Service. 2004. “Starting Anew, Part II.” Gannett Wisconsin Newspapers Special Report. http:// www.wisinfo.com/thailand/ (2 Feb. 2005). “History of Laos.” Laos Infosite. http://www.ocf.berkeley.edu/~kongsab/h_laopdr.htm Hmong Cultural Center. “The Hmong Language.” http://www.hmongcenter.org/hmonglanguage2.html (2 Feb. 2005). ———. 2000. ‘Etiquette for Interacting with the Hmong.” http://www.hmongcenter.org/hmonhisandpa.html (2 Feb. 2005). ———. 2000. “Hmong Clans.” http://www.hmongcenter.org/hmongclans.html (2 Feb. 2005). ———. 2001. “Hmong History and Paj Ntaub. (Excerpt from Hmonguniverse). http://www.hmongcenter.org/ etforinwitle.html (2 Feb. 2005). ———. “Information for Visitors to a Hmong Home.” http://www.hmongcenter.org/thintowatfor.html (2 Feb. 2005). Hmong Dictionary. http://ww2.saturn.stpaul.k12.mn.us/Hmong/Dictionary/Hmongeng/ (1 Feb. 2005). Hmong Health Website. http://www.hmonghealth.org/ (1 Feb. 2005). Hmong National Development. “The Hmong New Years in Perspective.” http://www.hndlink.org/30feast.htm (1 Feb. 2005). Kemp, Charles. Laotians. http://www3.baylor.edu/~Charles_Kemp/laotian_health.html (14 Feb. 2005). Lao Embassy. “Social Overview.” http://www.laoembassy.com/discover/intro/society.htm (7 Dec. 2004). Lao Family Community of Minnesota. 1997. “Cultural Competency.” http://www.laofamily.org/culture/culture_info5.htm (1 Feb. 2005). “Laos.” Encyclopaedia Britannica. 2005. Encyclopaedia Britannica Premium Service. http://www.britannica.com/eb/ article?tocid=52522 (30 Jan. 2005). Laos Travel Guide. “History of Laos.” http://www.asia-discovery.clm/Laos/travel-guide/history.htm (7 Dec. 2004). Learn About Hmong. http://www.learnabouthmong.org (1 Feb. 2005). Lee, Gary Yia. 1995. “Cultural Identity in Post-Modern Society: Reflections on What Is a Hmong?” http:// www.hmongcenter.org/culidinposso.html (2 Feb. 2005). Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. “Recent History of the Hmong.” 2004. http://www.twincities.com/mld/twincities/news/special_packages/hmong_journey/ 8042147.htm (7 Dec. 2004). Turner, Barry, ed. 2002. The Statesman’s Yearbook: the Politics, Cultures and Economies of the World. 2003. New York: Palgrave MacMillan. U.S. Department of State Bureau of Democracy, Human Rights, and Labor. 2002. “International Religious Freedom Re- port 2002: Laos.” http://www.state.gov/g/drl/rls/irf/2002/13878pf.htm (28 Feb. 2004). U.S. Library of Congress. Country Studies: Laos. http://countrystudies.us/laos/ (31 Jan. 2005). The World Factbook: Laos. http://www.cia.gov/cia/publications/factbook/geos/la.html (8 May 2005). Xiong, Mai. “Hmong Journey for Freedom.” Hmong Studies Internet Resource Center. http://www.hmongstudies.org/ hmongjourforf.html (2 May 2004). Yau, Jennifer. 2005. “The Foreign Born Hmong in the United States.” Migration Information Source. http:// www.migrationinformation.org/Feature/display.cfm?id=281 (1 Feb. 2005).

Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○125 Thailand

Census Figures (2000) United States Residents Born in Thailand: 169,801 (0.5%) California Residents Born in Thailand: 62,114 (0.7%) Quick Facts Country Area: 198,114 sq. miles (slightly more than twice the size of Wyoming) Population: 65,444,371 Median Age: 30.88 years Population Growth Rate: 0.87% Life Expectancy at Birth: 71.57 years Below Poverty Line: 10% Literacy Rate: 92.6% Currency: baht (THB) Population Groups: Thai 75%, Chinese 14%, Other 11% Languages: Thai, English (secondary language of elite), ethnic and regional dialects Religion: Buddhist 92.5%, Muslim 5.3%, Christian 1.3%, Hindu 0.1%, Other 0.7% Government: Kingdom of Thailand: constitutional monarchy; capital Bangkok; 76 provinces; prime minister designated from among members of the House of Representatives; leader of party that can organize majority coalition usually appointed prime minister by the king Climate: tropical; rainy, warm, cloudy southwest monsoon (mid-May to September); dry, cool northeast monsoon (November to mid-March); southern isthmus always hot, humid Natural Hazards: tsunamis Natural Resources: tin, rubber, natural gas, tungsten, timber, lead, fish, gypsum, lignite, fluorite, arable land Arable Land: 29.36% Agricultural Products: rice, cassava (tapioca), rubber, corn, sugarcane, coconuts, soybeans Exports: rubber; computers, office machine parts, transistors, motor vehicles, plastic, seafood Industries: tourism, textiles/garments, agricultural processing, beverages, tobacco, cement, light manufacturing, furniture, plastics, tin Labor Force: agriculture 49%, industry 14%, services 37% ○○○○○○○○

126 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Thailand, cont. Brief History Research suggests that Bronze Age peoples were living in what is now Thailand by 4000 BC. Cultivation of wet rice and metallurgy formed the basis for early civilization in the region. It is unclear whether these innovations came from China to Thailand or vice versa. The Thai are related linguistically to various groups originating in southern China. Malay, Mon, and Khmer civilizations had migrated from China to Southeast Asia by the 7th century. Evidence suggests that the Thais migrated to present-day Thailand from Nan Chao in the Yunnan area of China in the 8th and 9th centuries. According to some stories, in 1238 Thai chieftains overthrew Khmer overlords and established a Thai kingdom at Sukhothai (Dawn of Happiness). When this kingdom declined, a new Thai kingdom grew up about 1350 on the Chao Phraya River. The first Thai ruler, King Rama Thibodi, established the Kingdom of Ayutthaya, made Theravada Buddhism the official religion, and compiled a legal code based on Hindu sources and Thai customs. The kingdom established contact with Portugal in the 16th century. In 1767, the kingdom was defeated and destroyed by invading Burmese armies, who controlled it for 14 months. Phya Tak Sin established a new capital called Thonburi on the Chao Phraya River. He was deposed in 1782, and Thong Duang was chosen as King Rama I, establishing the Chakri dynasty that still rules Thailand (called Siam until 1939). He moved his capital across the river to Bangkok. The Siamese signed a treaty with the United Kingdom in 1826 and began diplomatic relations with the United States in 1833. It is the only country in South and Southeast Asia not to have been colonized by Western nations. A bloodless coup during the reign of King Rama VII in 1932 transformed the country into a constitutional monarchy, its current form of government. In fact, a series of military dictators ruled the country, through a series of 17 coups, from 1932 until 1992, when elections were held. Field Marshal Pibul Songgram followed a pro-Japanese policy that put Thailand on the side of Japan in World War II. A new constitution was drafted after the 1996 election, allowing for the separation of the executive, legislative, and judicial branches of government. In the 1996 elections, Banharn Silpa-archa became Prime Minister and formed a coalition government. Corruption and the subsequent Asian financial crisis forced him to hand over power to Chuan Leekpai in November 1997. The Thai currency virtually collapsed in 1997, but assistance from the International Monetary Fund helped turn things around. The economy, which is essentially a free enterprise system, had been the fastest-growing in Asia between 1985 and 1995, with a growth rate averaging about 9 percent annually. The current king, Bhumibol Adulyadej, has been ruler since 1950. The Thai Rak Thai Party led by Thhaksin Shinawatra was victorious in 2001 elections. Until the SARS epidemic in 2003 (Thailand had no outbreaks) and the devastating tsunami of Dec. 26, 2004, the Thai economy was continuing to rebound. Tourism is a major industry, and many of those killed in the tsunami were tourists. Compared to other countries such as Indonesia and Sri Lanka, Thailand’s tsunami losses were relatively modest, when one considers that some 290,000 people were killed in this epic disaster. As of Jan. 31, 2005, some 5,392 people were known to have been killed in Thailand (including a grandson of the king); 8,457 were injured; and 3,066 were still listed as missing. Housing, Family, Work, Traditions Housing: Houses in rural areas are often raised, with domestic livestock living underneath the family living quarters, often a single room. Different parts of the country have slightly different styles of houses. Houses in the central plain are noted for their high gabled roofs, wide eaves, and ample space underneath the house. In addition to serving as a storage space for equipment or livestock, this area may be used for creating handicrafts. Many Thais build a spirit house for spirits that might have been disturbed during construction of a house. This small house is placed on a pole for the spirits to live in, in a location where the shadow of the main house never falls upon it. The inhabitants offer food and flowers to keep the spirits happy. Habitat for Humanity has been active in Thailand since 1998, building houses on the outskirts of Bangkok using affordable housing technology, such as concrete blocks and steel roofing, due to the shortage of timber. Family: In rural areas, extended families may live together under one roof. A typical family unit would include grandparents, aunts, uncles, cousins, and perhaps distant relatives. Children are raised to Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○127

Thailand, cont.

respect their elders and to avoid conflict. Boys are often given greater freedom than girls. Divorce is allowed and requires only mutual consent or proof of desertion. The status of women is improving, but domestic violence is common; an old law permits husbands to beat their wives. The eldest male is generally the family patriarch. The youngest daughter inherits the house and is responsible for caring for her parents in their old age. Until 1913, Thais were known by only a single name, and they prefer to be called by a single name or nickname rather than the required surname. Traditions: Traditional dress for both men and women, still worn in some rural areas, is an ankle-length piece of cloth wrapped around the waist, called a sarong in the south, phasin in the north, and phathung in central Thailand. Western-style clothing is common. When a baby is three days old, a traditional family holds a ceremony to ward off evil spirits. Ceremonies and family gatherings mark a baby’s first haircut at one month and again at puberty. The traditional Thai greeting, called the wai, involves placing the palms together at chest level with the fingers extended, accompanied by a slight bow. Deeper bows and higher placement of the fingers (but not above the eyebrows) signifies deeper respect. Thais address one another by their first names preceded by Khun. The head is considered sacred and not to be touched except for parents patting their children’s heads. The feet are the least sacred part of the body and should not be pointed at anyone or used to touch a person or object. Shoes are removed when entering a temple and often a house. When seated, Thai people avoid crossing their feet. Crossing the legs is OK for men when seated on the floor; women generally bend their knees and tuck their feet under and to one side of the body. Men and women generally do not show affection in public. Only the right hand is used to pass and receive items such as gifts. Women are not supposed to touch images of the Buddha, and they are not allowed to touch Buddhists monks or hand anything directly to them. The Thai people are very patient and not aggressive, often using the phrase mai pen rai, “it’s nothing.” The royal family is greatly revered by the Thai people, and visitors are advised not to criticize the monarchy and always to stand during the national anthem, which is generally played in schools and other public places at 8 a.m. and 6 p.m. every day. Respect must be shown to Buddhist objects and sites. Employment: About half the Thai people are employed in agriculture, most in cultivating, processing, marketing, and transporting rice, the country’s major crop—grown in Thailand for more than 700 years. Thailand has an extensive food processing industry. In the northeastern part of the country, silk worms are raised and silk is processed and woven. Fishing is a large industry, but overfishing of the Gulf of Thailand is a serious problem. Automobile assembly factories and textile production plants provide employment, and many Thais are employed in the thriving tourist industry. Rivers and canals provide a major means for transportation of people and products within the country. Foods and Eating Habits Dietary Practices: No known food taboos. Muslim Thais would not eat pork or drink alcohol. Everyday Diet: Most Californians are familiar with Thai food as a result of having eaten at some of the many Thai restaurants in the state. Interestingly, “to eat” in the Thai language, kin khao, means “to eat rice.” This staple of the Thai diet is eaten at most meals. Jasmine rice, khao hawm mali, is the finest Thai rice, with a distinctive sweet smell. In the north and northeast, khao niaw, sticky rice, is common. A typical meal would include rice with several meat and/or vegetable dishes. Chopsticks are not generally used in Thailand except for eating noodles, ta kiap. For the most part, Thais use a fork held in the left hand and a tablespoon in the right hand from which the food is eaten. It is considered rude to put the fork into one’s mouth. As in other Asian countries, sticky rice is rolled into a ball and eaten with the hands. Thai food is highly spiced, with seasonings and cooking methods introduced from China (stir-frying and deep-frying of meat), India (curries), and by Portuguese ○○○○○○○○

128 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Thailand, cont.

missionaries (chiles). Seasonings frequently found in Thai cuisine include lime juice, fish sauce (naam pla), salty shrimp paste (kapi), garlic, lemon grass, black pepper, basil, ground peanuts, tamarind juice, ginger (khing), coconut milk (kati) and fresh coriander. Stewing and grilling are traditional methods used for preparing food. Popular Dishes: In Thailand, fresh fast food is available day and night in open market street kitchens. Night markets are especially popular. The most common dishes at street kitchens are soups. Curry (chicken, beef, or fish) with rice is also commonly served, or noodles with duck, chicken, beef balls or pork. One can even find fried locusts and other delicacies. Perhaps the best-known Thai dish in Western restaurants is phat tai, often spelled pad thai, which consists of fried noodles with bean sprouts, peanuts, and lime juice. Another popular Thai dish found in many California restaurants is som tam, green papaya salad, a favorite in northeastern Thailand made with chiles, peanuts, lime, and a special sauce. Other popular Thai dishes include phat pak lai yang, stir-fried vegetables; neua phat bai ka prao, beef stir-fried with vegetables and Thai basil; gai phat met ma-muang, chicken stir-fried with vegetables and cashews; kaeng khiaw waan, green curry with beef and tiny eggplants; plaa thawd, deep-fried fish; tom khaa gai, chicken soup flavored with coconut milk and lemon grass; raat naa taleh, wide noodles with seafood; and khao phat, fried rice. Beverages: Thai iced tea, cha yen, is a popular drink made with black tea, ice, and condensed milk. Education Status: Public education is free and compulsory for children ages 6 through 12. Pre-school is provided for children from age three. The first school term lasts from May to October. Following a three-week break, the second term runs from November to March, with summer vacation until May. Many schools were destroyed by the Dec. 2004 tsunami, and both children and their parents were killed. The Ministry of Education maintains a Web site indicating statistics and reconstruction efforts. An interview with Education Minister Pongpol Adkreksarn featured on the ministry’s Web site discusses the role of educational institutions in boosting the country’s economy through free enterprise and the creation of small businesses. Through the “One School, One Product” initiative schools at all levels are encouraged to use locally available raw materials to produce products, through which they learn budgeting skills as well as production know-how. In the 1999 education act, teachers are directed to “teach students to think, not just listen and agree.” Primary School: Primary education lasts from ages 6 to 12. Classes meet for six hours a day Monday through Friday. The curriculum includes math, history, geography, science, Thai literature, religious instruction, and English. Many schools have uniforms and begin the day with a prayer service. Beginning in 2000, the ministry instituted a free school lunch program to improve nutrition. Secondary School: Secondary school is divided into lower secondary, ages 12 to 15, and upper secondary, ages 16 to 18. Students may take vocational subjects or academic courses if they plan to attend university. After six years, students receive the Higher Secondary School Certificate. Higher Education: In 1996 there were 13 universities, two open universities for distance learning, four technology institutes, and one institute of development administration in the public sector; the private sector had nine universities and a technology institute. Military service is compulsory for men at age 21: service varies from two months to two years depending on education and prior military training. Religion Status: According to the International Religious Freedom Report 2002, close to 100 percent of the Thai people claim some type of religious faith. The Constitution requires the Thai government to pa- tronize and protect Buddhism and other religions, and the state subsidizes the activities of the Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○129

Thailand, cont.

Buddhist, Islamic, and Christian communities. Religious instruction in Buddhism and Islam is required in both primary and secondary public schools; interfaith dialogue is also encouraged and funded by the government. Laws proscribe speech likely to insult Buddhism. In the Muslim south, government-run schools and teachers have been the targets of terrorism, with more than 700 people killed since violence began escalating in January 2004. Buddhism: Recent estimates suggest that 85 to 90 percent of the population practices Theravada Buddhism. Mahayana Buddhism is practiced by a small number of Chinese and Vietnamese immigrants, who have more than 650 shrines and temples throughout Thailand. Buddhists practice the daily ritual of bintabat, giving alms to monks, to gain spiritual merit. They may offer monks the first portion of their morning meal and receive a blessing. Buddhist temples in Thailand are known as wat; they range from tiny spaces sheltering one or two monks and a statue of the Buddha to huge complexes with schools, libraries, halls for public ceremonies, and housing for hundreds of monks. Theravada Buddhists believe each individual is responsible for his or her own nirvana, as opposed to Mahayana Buddhists, who believe that nirvana will come only when all people are prepared for salvation. The wat is a focal point of village life and provides a venue for ceremonies and festivals as well as a symbol of village identity. Theravada Buddhism is tolerant of other religions. Islam: Up to 10 percent of Thais practice Islam, which is the dominant religion in four of the five southernmost provinces that border Malaysia. Most Muslims are ethnic Malay, but they also include descendants of immigrants from South Asia, China, Cambodia, and Indonesia. There are more than 3,000 mosques in 59 provinces, with the largest number in Pattani province. Most Thai Muslims are affiliated with the Sunni branch of Islam. Christianity: The Thai government reports that 0.7 percent of the population is Christian; half of this group lives in Chiang Mai province and the remainder in the Bangkok area and the northeastern provinces. About 25 percent of the Christian population is Roman Catholic. Most Protestant churches belong to one of four umbrella organizations, including the Church of Christ in Thailand, formed in the 1930s, and the Evangelical Foundation of Thailand as well as organizations of Baptists and Seventh-Day Adventists. Other: Six tribal groups are officially recognized as practicing animism. Other groups combine practices of Buddhism, Christianity, Taoism, and spirit worship. South Asian immigrants have established Hindu and Sikh communities. Members of the Mien hill tribe practice a form of Taoism. Health and Health Care Health Status: The 8th National Economic and Social Development Plan contained major strategies for reform- ing the health system by improving access and efficiency, developing a consumer protection system, and encouraging health behaviors to promote health and prevent disease, among other things. HIV/AIDS is a serious health threat in Thailand as in many other countries. Air pollution in Bangkok causes many health problems. In 2004, 32 people in Thailand and Vietnam died of bird flu; millions of poultry birds in the region have been exterminated, but new cases continue to crop up in these countries as well as China. Because many people living in poverty in the region are reluctant to kill their flocks without compensation, some experts see the threat of a flu pandemic caused by combination of a severe strain of bird flu virus with the human flu virus. Traditional Practices: Many traditional herbal remedies are used to treat illness and maintain health in Thailand. Nuat Boraan, traditional Thai massage, has been used since ancient times and is related to Chinese acupuncture and Indian yoga. This type of massage is believed to release channels of energy, soothe tired muscles, relax the patient, and balance the four elements: earth, water, fire, and air. Some Thai people wear amulets to protect them from diseases, witchcraft, and accidents. ○○○○○○○○

130 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Thailand, cont.

Medical System: The father of Thailand’s current king introduced Western medicine to Thailand following his education at Harvard Medical School. The first modern hospital was established in 1886. Thai- land has both public and private hospitals. The Ministry of Public Health has overall responsibility for all physical and mental health activities. Various public sector ministries and agencies over- see health promotion activities and services. About 375 health-related private non-profit organizations receive government and outside funding to work in areas including disease prevention, traditional medicine, HIV/AIDS prevention and treatment, and care for the disabled. The public health care system is organized into three levels. On the primary level, Commu- nity Primary Health Care Centers provide care in rural areas. Community health posts staffed by a single community health worker provide simple curative care as well as health promotion and disease prevention assistance to populations of up to 1,000 in remote villages. Health centers serve populations up to 5,000 and include a health worker, a midwife, and a technical nurse. In cities, health centers staffed by physicians and other health professionals provide outpatient care. Sec- ondary care at the district level comprises services provided by medical and health personnel and includes community hospitals serving populations of 10,000 or more. General or regional hospitals have more beds, up to 500, and employ medical specialists in all fields. Private hospitals are operated as businesses and require fees for service. Tertiary care at the province level includes regional hospitals, general hospitals, university hospitals, and large private hospitals. In most cases, family members or friends stay with the hospitalized individual, especially in private hospitals, which provide sleeping space for at least one companion for each patient. When it came to power in 2001, the Thai Rak Thai party introduced universal healthcare for some treatments and services, including dental care, at a cost of 30 bhat/THB per visit. Tips for Health Care Providers Nearly all the Thai people practice Buddhism. See the section on Buddhism, page 22, for information on how the Buddhist faith may impact the health care encounter. Tips in profiles for other countries where the majority of people are Buddhist will probably be helpful in working with patients from Thailand. No suggestions specific to working with clients from Thailand could be located. Celebrations and Holidays February Maghapucha: Buddhist festival commemorating an occasion when more than a thousand disciples gathered to hear the Buddha speak; celebrated with candlelight processions at Buddhist temples. April 6 Chakri Day: Celebrates the Chakri dynasty. April 12–14 Songkhran, Thai New Year: Celebration involves cleaning houses, young people offering gifts to elders and asking for their blessing, perhaps releasing caged birds or putting live fish into rivers; hill tribes celebrate for eight days. May Visakhapucha: Celebrates the birth, enlightenment, and death of the Buddha, observed at the full moon of the sixth lunar month and observed with candlelight processions at Buddhist temples. May Boun Bang Fai, Rocket Festival: Celebrates start of the rainy season. This ancient festival was to remind the gods that rain is needed; people fire bamboo rockets filled with gunpowder. Dancing, singing, processions, and puppet shows are part of the festivities. May Royal Plowing Ceremony marks the beginning of the rice planting season; sacred red-and-gold plow pulled by two decorated oxen who plow three furrows accompanied by a procession of drum- mers. Rice is planted in the furrows, and the bulls are offered bowls of rice, corn, hay, sesame seed, water, and rice wine. Thais believe the food selected by the bulls from this assortment will be plentiful in the coming year. At the conclusion of the ceremony, participants rush into the field to collect rice to take home to add to their own rice to ensure a good crop. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○131

Thailand, cont.

July Asalhapucha: Festival marking the beginning of the period that young men spend in a monastery beginning at age 20. August 12 Queen’s Birthday September Narathlwat Festival in southern Thailand; involves fishing boat racing. November Loy Krathong: Festival held at the full moon involving a krathong, small cup made of banana leaves containing a lighted candle and incense sticks, placed in a river or stream; participants ask the goddess Mae khongkha (Mother Water) to wash away their sins and grant them a wish, which will come true if the candle continues to burn as their krathong floats out of sight. December 5 King Bhumibol’s Birthday. The Thai people revere their ruler, who was educated in Switzerland, speaks French and English, and is an accomplished jazz saxophonist and yachtsman. The Grand Palace and other buildings are decorated with colored lights, and participants enjoy stage shows, parades, fireworks, and movies on giant screens. December 11 Constitution Day Thais in the United States The first Thai immigrants to the United States may have been Chang and Eng, the conjoined (Siamese) twins born in 1811 and discovered by an English trader in 1824. He took the twins from Thailand in 1829, and they never returned. They came to the United States in 1830 and settled in White Plans, North Carolina, both marrying and fathering 22 children in all. According to the 2000 Census, 169,801 (0.5%) native-born Thais lived in the United States, with 62,114 of those in California. The number of Thais in California increased by 46.2 percent between 1990 and 2000. The largest number of Thais live in Los Angeles, followed by San Francisco and San Diego. Language; Useful Words and Phrases Thai is the official language of the country. The first Thai alphabet was created in the thirteenth century by King Ramkamhaeng of the Sukhothai Kingdom. Like many Asian languages, Thai depends on pitch to differentiate the meanings of words that are otherwise pronounced alike. The five Thai tones are mid, low, high, rising, and falling. For example, the word sua (rising) means “tiger,” sua (falling) means “shirt,” and sua (low) means “mat.” The alphabet contains 44 consonants and 32 vowels. Thai is written from left to right, and the basic sentence structure is similar to English: subject, verb, object, with adjectives following nouns. Thai does not use punctuation or capital letters. Pronouns are used to indicate social standing and familiarity. Chinese is widely spoken in Thailand, and English is required in public schools and spoken widely in Bangkok and other major cities. There is no widely accepted method for translating Thai into the Roman alphabet. The following are some transliterated words and phrases: Hello. Sawadee khrap (from a man). Hello. Sawadee ka (from a woman). My name is . . . Pom chew (boy) . . . My name is . . . Dee chan chew (girl) . . . How are you? Sabai deerue? Very well, thank you. Sabai di, khopkhun. Excuse me. Kaw toht. Yes/No Chai/Mai chai

○○○○○○○○

132 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Thailand, cont. References Adireksarn, Pongpol. 2003. “Universities and Colleges as the Foundations for SMEs.” http://www.moe.go.th/main2/article/article_pongpol/SMEs_ENG.htm (4 Feb. 2005). Country Reports. “Thailand: General Overview.”CountryReports.org. http://www.emulateme.com/ expandedprofile.asp?countryid=237&countryname=Thailand (4 Feb. 2005). ———. “Thailand: Culture and Customs.”http://www.countryreports.org/customs.asp?countryid= 237&countryname=Thailand (4 Feb. 2005). ———. “Thailand: In Their Language.” http://www.countryreports.org/greetings.asp?countryid= 237&countryname=Thailand (4 Feb. 2005). Ethnicity Online. Cultural Awareness in Healthcare: Buddhists. http://www.ethnicityonline.net/buddhism_summary.htm (6 Feb. 2005). GayThailand. “Thai Customs and Social Mores.” http://www.gay-thailand.net/customs.htm (4 Feb. 2005). ———. “Thai Language, 101.” http://www.gay-thailand.net/language.htm (4 Feb. 2005). Habitat for Humanity Thailand. http://www2.habitat.org/intl/countryprofiles.fm (24 Mar. 2004). JobMonkey.com. “Enjoying Thai Food.” http://www.jobmonkey.com/teaching/asia/html/food_in_thailand.html (4 Feb. 2005). ———. “Common Customs of Thailand.” http://www.jobmonkey.com/teaching/asia/html/thailand_customs.html (4 Feb. 2005). Lonely Planet World Guide. Thailand. http://www.lonelyplanet.com/destinations/south_east_asia/thailand/history.htm (3 Feb. 2005). Mydans, Seth. 2005. “Schools in Thailand under Ethnic Siege.” New York Times. 6 July. http://www.nytimes.com (7 Jul. 2005). Rajendra, Beena. 2001. Thailand. Anti-Racism, Multiculturalism and Native Issues Centre, Faculty of Social Work, Uni- versity of Toronto, Canada. http://www.settlement.org/cp/english/thailand (4 Feb. 2005). “Thai Church Tackles Domestic Violence.” 2005. National Catholic Reporter. 8 April, p. 3. ThailandOutlook.com. “Thai Health System.” http://www.thailandoutlook.com/thailandoutlook1/about+thailand/health/ (5 Feb. 2005). ThailandLife.com. “Spirit Houses.” ThailandLife.com. http://www.thailandlife.com/spirithouses.htm (4 Feb. 2005). ———. “Traditional House of the Central Plain.” http://www.thailandlife.com/thaihouse_central.html (4 Feb. 2005). ———. “The Original Siamese Twins.” http://www.thailandlife.com/siamese_twins.html (4 Feb. 2005). Turner, Barry, ed. 2002. The Statesman’s Yearbook: the Politics, Cultures and Economies of the World. 2003. New York: Palgrave MacMillan. U.S. Department of State Bureau of Democracy, Human Rights, and Labor. 2002. “International Religious Freedom Re- port 2002: Thailand.” http://www.state.gov/g/drl/rls/irf/2002/13911pf.htm (28 Feb. 2004). Vanichkorn, Kathy. “The Thai Language.” InterSol, Inc. http://www.intersolinc.com/newsletters/newsletter_24htm (6 Feb. 2005). Wikipedia. “Thai Immigration to the United States.” http://en.wikipedia.org/wiki/Thai_immigration_to-the_United_States (6 Feb. 2005). Wibulpolprasert, Suwit, ed. 2002. Thailand Health Profile, 1999–2000. Bangkok: Bureau of Policy and Strategy, Ministry of Public Health. The World Factbook: Thailand. http://www.cia.gov/cia/publications/factbook/geos/th.html (8 May 2005). World Health Organization. 2005. “Thailand Tsunami Situation Report 01 Feb. 2005.” http://www.reliefweb.int/rw/ RWB.NSF/db900SID/MHII-6994EF?OpenDocument (3 Feb. 2005).

Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○133 Cambodia

Census Figures (2000) United States Residents Born in Cambodia: 139,978 (0.4%) California Residents Born in Cambodia: 53,544 (0.6%) Quick Facts Country Area: 69,898 sq. miles (slightly smaller than Oklahoma) Population: 13,607,069 Median Age: 19.91 years Population Growth Rate: 1.81% Life Expectancy at Birth: 58.87 years Below Poverty Line: 40% Literacy Rate: 69.4% Currency: riel (KHR) Population Groups: Khmer (pronounced “Kami”) 90%, Vietnamese 5%, Chinese 1%, Other 4% Languages: Khmer (official) 95%, French, English Religion: Theravada Buddhist 95%, Other 5% Government: Kingdom of Cambodia: multiparty democracy under a constitutional monarchy established in September 1993; 20 provinces, capital Phnom Penh Climate: tropical; rainy, monsoon season (May to November); dry season (December to April); little seasonal temperature variation Natural Hazards: monsoonal rains (June to November), flooding, occasional droughts Natural Resources: oil, gas, timber, gemstones, iron ore, manganese, phosphates, hydropower potential Arable Land: 20.96% Agricultural Products: rice, rubber, corn, vegetables, cashews, tapioca Exports: rice, fish, tobacco; clothing, timber, rubber, footwear Industries: tourism, garments, rice milling, fishing, wood and wood products, rubber, cement, gem mining, textiles Labor Force: agriculture 75% ○○○○○○○○

134 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Cambodia, cont. Brief History Present-day Cambodia had its beginnings in the Angkor Empire of the Khmers, established in 802, which covered much of Southeast Asia and reached its height between the 9th and 14th centuries. Yasovarman I ruled Cambodia in the late 9th century, making his capital at Angkor. The temple-mountain known as Angkor Wat was constructed during the reign of Suryavarman II, 1113–1150. Thailand took control of Angkor in 1431 and moved the capital to Phnom Penh. In 1863, the King of Cambodia put his empire under the protection of France. Cambodia became part of French Indochina, with Vietnam and Laos, in 1887. Prince Norodom Sihanouk became king in 1941. The Japanese occupied Cambodia during World War II, when the French submitted to Japanese demands for bases in that country. Anti-French guerilla activities, beginning in 1946 when France re-imposed its protectorate, gave rise to the communist-led revolution. Cambodia won independence from France in 1953 and became the Kingdom of Cambodia under King Sihanouk. In 1967 the Khmer Rouge supported peasants in an uprising to protest a tax on rice. The Khmer Rouge sought to create a communist rice-growing dynasty combining Maoist ideology with Cambodian nationalist beliefs. 1n 1969, Sihanouk broke off relations with the United States and allowed North Vietnamese guerillas to set up bases in Cambodia to combat the U.S.-backed government of South Vietnam. That same year, the United States began a secret bombing campaign against North Vietnamese forces in Cambodia. King Sihanouk was deposed in a coup in 1970, while he was out of the country. Prime Minister General Lon Nol assumed power and proclaimed the Khmer Republic, sending the army to fight the North Vietnamese in Cambodia. Sihanouk formed a guerilla movement while exiled in China. At this time the Cam- bodian army was facing two enemies: the North Vietnamese and its own communist Khmer Rouge guerillas. Lon Nol was overthrown by the Khmer Rouge, led by Pol Pot, in 1975. King Sihanouk briefly resumed power, and the country was renamed Kampuchea. City dwellers were forcibly evacuated to the countryside to become agricultural workers, money became worthless, basic freedoms were curtailed, and the practice of religion was banned. Sihanouk resigned in 1976 and Khieu Samphan became head of state, with Pol Pot serving as prime minister. Hundreds of thousands of Cambodians were driven from their homes into labor camps, or were tortured and executed in what is now called the Killing Fields period as the Khmer Rouge sought to build a new society with no trace of the past. Buddhist monks, city dwellers, government officials, and Cambodians with Western educations were among the first to be killed. Many tried to escape across the Thai border; those who made it often found starvation, disease, and violence in refugee camps in Thailand and Malaysia. The international community assisted with food, medical supplies, and volunteers, and more than 180,000 Cambodians were able to find asylum in the United States, often after spending time in acculturation programs in the Philippines. Fighting broke out with Vietnam in 1977. By the time the Vietnamese took over Phnom Penh in January 1979, nearly 2 million Cambodians had been executed or died of disease or starvation. The People’s Republic of Kampuchea was established and much of life returned to its pre-Khmer Rouge patterns. In 1985 Hun Sen became prime minister; he renamed the country the State of Cambodia in 1989 and Buddhism was reestablished as the state religion. A 1991 peace agreement signed in Paris between various rival factions brought King Sihanouk back as symbolic head of state. In 1993 the monarchy was restored and the country renamed the Kingdom of Cambodia; thousands of Khmer Rouge surrendered in a government amnesty in 1994. Factional fighting ended the first coalition government; 1998 elections brought a new coalition and political stability. In the 2003 elections, the Cambodian People’s Party won but did not establish a governing coalition of rival parties until 2004. Housing, Family, Work, Traditions Housing: Rural houses are generally built on stilts, with ladders or stairs, for protection against monsoon flooding. Floors are made of wood, walls are woven bamboo, and thatched roofs are constructed of palm leaves. The area underneath the house is used for storage or for animals. People sleep on the floor on mats and eat sitting on the floor on a mat. Urban housing is generally of brick or wood. In Phnom Penh, about one-fourth of the city’s million residents live in shantytowns and other informal settlements on public land on the outskirts of the city. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○135

Cambodia, cont.

Family: Most Cambodians live in small villages located near roads or water, generally centered around the local wat or temple, which is used for activities and religious ceremonies. Children are treated affectionately and encouraged to be independent. While men have traditionally been the heads of Cambodian households, years of war and genocide have resulted in a situation where only 20 to 30 percent of adult Cambodians are male. About 25 percent of households are headed by women; other families live as subfamilies with relatives or other extended family. Traditional Khmer women were to stay at home raising children; husbands were allowed to have extramarital affairs, but women were expected to be faithful, even after the death of the husband. This has posed a problem for women widowed in fighting or genocide. In refugee camps in the 1980s, food was often given only to women and children, as men and boys were suspected of being guerillas. Many women were raped in these camps. Traditions: According to Elizabeth Chey: “The Khmer Rouge return to year zero destroyed the social, economic and political framework of Khmer life and traditions. After twenty years, Cambodia is emerging again . . . .” Traditionally, Khmer women were virtuous and responsible for upholding their families. Traditional Khmer dress includes the krama, a checked scarf worn on the head or around the neck. Women wear a blouse and a sarong. For working in the fields, both men and women wear loose shirts and trousers. In urban areas, Western-style clothing is worn. Cambodian names are spoken and written last name first. As in other Buddhist cultures, the head is considered the place where the spirit dwells and should not be touched; the feet are the lowest part of the body. Eye contact with an older or superior person is considered impolite. The traditional greeting is a slight bow accompanied by hands together in a position of prayer at chest level. Men often shake hands, but women may still be reluctant to do so. In formal situations, people are addressed as Lok (Mr.) or Lok Srey (Mrs.) followed by the given name or both given and family names. Employment: Most Cambodians work in agriculture, primarily in the growing and processing of rice, which is harvested twice a year because of the country’s tropical climate. Rubber plantations were plentiful prior to the war and genocide years, when they were destroyed. Some have been revived, creating employment both on the rubber farms and in rubber-processing plants. Logging was a source of employment before excessive logging resulted in deforestation and a 1995 ban on timber exports. According to one source, nearly 40,000 families along the Tonle Sap (Great Lake) live in floating houses and support themselves by catching and fattening fish for market. Rice mills and factories producing textiles, clothing, and pharmaceuticals provide employment. Cottage industries produce woven cloth and clothing sold at local markets. Residents of urban areas may have several jobs in various service industries. Foods and Eating Habits Dietary Practices: Many Cambodians are lactose intolerant. They enjoy soy drinks and specially brewed coffee. Like many Asian people, they do not use ice in beverages. They believe in the hot/cold properties of foods to cure illness and maintain health. Rice is considered neutral; chicken is a hot food; vegetables are cold. The combination of ingredients determines whether a food is hot or cold. Everyday Diet: Cambodian families traditionally eat together. During the Khmer Rouge period, when people were sent into the countryside to live in collectives, farm people ate together in large halls rather than in family units. People eat most foods with their hands, although noodles are eaten with chopsticks. Rice and fish form the basis of the everyday diet. Breakfast might be chicken soup or a noodle dish. Other meals include rice or noodles with fish paste and vegetables. Rice may be steamed, fried, or made into noodles. Fish is eaten fresh, salted, or dried. Prahoc, a spicy fish paste, is used to season many dishes. Commonly used spices are mint, lemon grass, chiles, and ginger. Most Khmer love spicy hot food. Before they sit down to eat, they cut a bunch of fresh hot chili ○○○○○○○○

136 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Cambodia, cont.

peppers and mix them with fish sauce to dip. Fruit is popular and includes bananas, mangoes, papayas, pineapple, oranges, lychee, rambutan, longan, jackfruit, mangosteen, and a sweet creamy fruit called the durian. Some markets and restaurants have special areas set aside for the eating of this fruit; many people find the smell so objectionable that airlines and hotels may ban them. Cambodian cooking is often compared to Thai cooking. There are many similarities between the two countries, but there are significant differences as well. Thai cooks use red chiles a lot, where Cambodians prefer to spice up their dishes by hot side servings, allowing for individual preference in the hotness of the food. Some Cambodian women chew the betel nut, which is thought to aid digestion but which turns the teeth, lips, and gums a dark red when used frequently. Popular Dishes: Sach ko char spee khieu (beef with Chinese broccoli); vegetable spring rolls (num cha gio pale); salor kor ko sap (Khmer vegetarian soup): nhoam sach ko tirk krote (crispy sliced spicy fried beef with crisp lettuce orange sauce); num pachok sach ko chagio (cold noodles with lemon grass beef kebab and spring rolls); kari krahum saich moan (red chicken curry); kari baitongh saich trey (green fish curry). Beverages: Tea is the most common drink. Soda water with lemon, palm juice (teknot), and coconut water (tekdong) are also popular. An alcoholic drink is made of fermented palm juice. Locally brewed rice wine is a popular drink. However, in the late 1990s some brewers responded to the demand for a higher alcohol content by spiking the wine with insecticide, causing blindness and death.

Education Status: Most Cambodians grew up without formal education due to the fighting that has devastated the country, one of the poorest in the world, for decades. Education is now mandatory for children ages six through twelve, and instruction is conducted in the official language, Khmer. According to a UNESCO source, the new constitution mandates nine years of education and calls for a restructuring of the system. The school year runs from October until June. Education is controlled primarily by the Ministry of Education, Youth and Sport. In 1998–99, the ministry reported that 64.1 percent of seven-year-olds were enrolled in school, with a net primary school enrollment of 78.3 percent. Only 14.2 percent of children were enrolled in secondary school, and 6.3 percent were enrolled in preschool. The repetition rate was 21.9 percent, and 31 percent of Cambodians ages 5 to 24 had never attended school. Save the Children Norway reports that there are 653,000 Cambodian children between ages 5 and 17 working; 72 percent of those have dropped out of or never attended school. Some 19,250 working children were involved in the commercial sex trade. Many young people use meth- amphetamine smuggled in from Thailand. Land mines are a serious problem in Cambodia. As many as six million unexploded mines litter the country. Cambodia has one of the highest rates of disability in the world, much of it due to land mines, which have injured more than 40,000 Cam- bodians. Students are taught to recognize various kinds of mines, which can be made of wood, metal, or plastic. Primary School: Primary school lasts six years. In 1997–98, there were 5,026 primary schools operating in Cambo- dia, with more than 2 million students. Pre-school education lasts three years. In addition to academic subjects, students in primary and lower secondary schools learn about agriculture, which is integrated into the curriculum as part of a subject called Lifeskills. Secondary School: Lower secondary or middle school lasts three years, with students receiving a diploma when they have completed this level. Upper secondary school lasts three years; upon completion of two years a student receives a diploma called a baccalaureate, with a second diploma given at completion of the third year. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○137

Cambodia, cont.

Higher Education: Higher education in Cambodia, called tertiary education, lasts from four to seven years. Special- ized secondary schools, called technical and professional training institutions, offer tertiary instruction in various technical areas for upper secondary school graduates. Cambodia has nine public institutions of higher education, all of which are free to students. Religion Buddhism: More than 90 percent of Cambodians practice Theravada Buddhism. Before Buddhism was introduced, Hinduism was the main religion. The wat is a major symbol in villages, and Angkor Wat, the largest religious building in the world, is considered one of the architectural wonders of the world. When Cambodian males are 16 years old, most enter the wat and live the life of a monk for at least a few days, gaining merit toward their salvation. Other ways of gaining merit include giving food to the monks, celebrating holy days, and visiting shrines of the Buddha. All religions were banned during the reign of the Khmer Rouge, when monks were forced to leave the wats and go to work on collective farms with everyone else. More than a third of the wats were destroyed, and many monks and novices were killed or became refugees. In 1989 Buddhism was reestablished as the official religion of Cambodia. Islam: The approximately 700,000 Muslims in Cambodia are mostly ethnic Chams who live mainly on the banks of the Mekong and Tonle Sap rivers and in Kampot province. Most practice the Malay- influenced Shafi variety of Islam. Christianity: Less than 1 percent of Cambodians are Christian, although the religion is growing. More than a hundred different Christian organizations and denominations operate freely in the country, which has more than 1,000 congregations of various kinds. Foreign missionaries operate unhindered. Other: Animism, Cao Dai, and Bahai’i are all practiced in Cambodia. Health and Health Care Health Status: Cambodia is one of the poorest nations in the world. Its citizens have a life expectancy of only 58 years, as compared to 71 years in neighboring Thailand. During the Khmer Rouge period, many hospitals were destroyed and physicians were killed to stamp out Western influence. Many Cam- bodians drink water from streams and rivers and are at risk for a host of diseases including hepatitis and cholera. Only 29 percent have access to clean water, 15 percent have electricity, and 14 percent have indoor sanitation. Malnutrition is common. Diseases that have been largely controlled in other countries are still rampant in Cambodia, including tuberculosis, smallpox, malaria, diphtheria, typhoid fever, leprosy, dengue fever, and trachoma. The incidence of AIDS continues to rise. Land mines injure thousands of Cambodians each year. Traditional Practices: Traditional healers, kru khmers, are widely used in Cambodia; healers called accha conduct diagnostic and healing activities in the client’s home. Many people rely on folk and herbal medicines. A study by the University of Alabama of the role of traditional healers in TB treatment indicates that Cambodians generally seek Western medicine first but turn to healers for relief from the side effects of drugs. A formal organization, The Cambodian Association of Traditional Healers, is working with Western organizations in a TB project in Phnom Penh. The main forms of medical treatment in rural areas comprise herbs; dermal techniques such as cupping, pinching, and coining, which are thought to restore balance by releasing excess air from the body and leave marks on the skin that might be mistaken for signs of abuse; maintenance of the body’s hot-cold balance; and various rituals. Herbs are often grown in the family garden, or they may be gathered in the jungle by a kru khmer. Many people attribute illness to possession by evil spirits as a result of a spell cast by another person or by the individual’s neglect or errors in performing rituals. Dermal techniques are ○○○○○○○○

138 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Cambodia, cont.

used for such things as headache, muscle pain, colds, sore throat, and diarrhea. Techniques, as described on the EthnoMed Web site, are: Cupping: A heated cup is placed on the skin (usually the forehead or abdomen). As it cools, it draws the skin and the excess energy or air into the cup. Pinching: Pressure is applied by pinching the skin firmly between the thumb and index finger, usually at the base of the nose, between the eyes, or on the neck, chest, or back. This is designed to release excess air and will probably produce a contusion. Rubbing or coining: The skin is lubricated and rubbed with a coin or spoon to bring toxic air to the body surface. Medical System: Medical services are provided through provincial hospitals, district clinics, and village dispensaries. Hospitals are often short of equipment and supplies as well as trained staff. In 1996, the U.S. Agency for International Development and the Royal Government of Cambodia founded the Reproductive and Child Health Alliance (RACHA) to improve health care by integrating the traditional structures with modern medical practices. The program trains rural health workers, including Buddhist nuns and village shopkeepers, to provide health care in rural areas using a holistic approach to capitalize on existing resources. RACHA trains village midwives and traditional birth attendants in Life Saving Skills (LSS) to make home deliveries safer. The Cambodian Ministry of Health has instituted village feedback committees to encourage community partnerships in the public health decision-making process and build the confidence of the people. Tips for Health Care Providers The information on Buddhism, page 22, will be applicable to caring for Cambodian patients who practice Buddhism. The following information may be helpful for those working with Cambodians in the health care setting. According to EthnoMed: “Western health care is confusing and overwhelming for many Cambodians. Language and cultural barriers, crowded waiting areas, multiple interviews, mysterious procedures, and the somewhat abrupt behavior of personnel combine to make obtaining health care an unpleasant experience.” While many Khmer language patient education materials are available at http://ethnomed.org/ethnomed/patient_ed/camb/index.html, many Cambodians are illiterate. Medical Condition: On the whole, Cambodians arrived in the United States in worse health than many other refugee groups, due to the horrific conditions many endured in their own country or in refugee camps. Common diseases found in new refugees were tuberculosis, hepatitis B, and intestinal parasites. Unsurprisingly, given their history, Cambodians are at high risk for post-traumatic stress disorder (PTSD) and other psychiatric problems. EthnoMed, which works with the Cambodian community in Seattle, reports that many are depressed and suffer with PTSD. One problem in dealing with these individuals is that the Khmer language contains no comparable terms for describing the conditions. In addition, some are afraid to take prescribed anti-depressants for fear of addiction or that they may never awaken if they take them. Attitudes: Cambodians think drawing blood will make them weaker because blood is taken away and not replaced. Some believe that X-rays destroy red blood cells and decrease life expectancy. Women in general prefer to have a woman health care provider. Formal prenatal care may be avoided because of physical examinations. Cambodians expect to be given medications for every illness, as this makes them feel as though something is being done. If one physician does not prescribe medication, a Cambodian might go to another practitioner. As is the case with many people even in our own culture, medications are often taken only until the symptoms have abated rather than until the prescribed regimen has been completed. Drugs are often shared with family members and friends. Health care providers often have trouble convincing Cambodian patients of the need to take medications for a chronic condition such as high blood pressure or diabetes, as they often expect instant results from taking a drug. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○139

Cambodia, cont.

Family Authority: The father or the eldest son or daughter is the family spokesperson. Elders are important in the decision-making process. Addressing Clients: Greet clients formally by using “Mr.” or “Mrs.” and the last name. The usual greeting involves bringing the palms together, fingers pointed upward. Some Cambodians who have been in this country longer may shake hands. Nonverbal Exchange: Eye contact is acceptable, but polite women lower their eyes. Cambodians are very modest. Touch- ing the head without permission is considered rude, as some believe the soul is located in the head. Verbal Exchange: Speak softly and be polite. Silence is preferable to aimless chatter. Some clients may be uncomfortable with written consents due to experiences with the Khmer Rouge. Hospitalization: Both adults and children may wear strings or chains around their necks with an amulet containing Buddhist transcription for protection. This should not be removed without permission. Surgery is traditionally seen as a last resort, and may be a very frightening prospect. Cambodians tend to be stoic. They may use tiger balm, apply medicated tapes to painful areas, and use cupping to draw out pain. Many are lactose-intolerant. They prefer warm tea or water to ice water. Death and Dying: Discuss a diagnosis of serious or terminal illness with the family first; let them talk with the patient. Cambodians may prefer dying at home. Monks and religioius laypersons, aacha, may be needed to recite prayers for a dying individual. The family and religious helpers may want to wash the body. Mourners wear white. The body is cremated. Cambodians are unlikely to agree to organ donation or autopsy. Celebrations and Holidays January 7 National Day: Celebrates Vietnamese overthrow of the Khmer Rouge. February 18 Cambodian Vietnamese Friendship Day February Meak Bochea: Buddhist festival celebrated on the full moon of the third lunar month; commemorates the Buddha’s enlightenment and entering nirvana. February Chinese/Lunar New Year: Many Cambodians, especially in Phnom Penh, celebrate. April 14–16 Khmer New Year: Day 1, Moko Sangkran, inaugurates the new angels who come to take care of the world for the coming year; people clean and decorate their houses, older people meditate or chant the dharma. On Day 2, food, fruits, and clothing are offered to the monks in return for their prayers for the ancestors and deceased relatives. Gifts are given to parents to ask forgiveness. April 17 Victory over American Imperialism Day May 1 Labor Day May 9 Genocide Day: Marks Khmer Rouge atrocities. May Pisak Bochea: Celebrates the Buddha’s birth, enlightenment, and entering into nirvana; celebrated on the full moon of the sixth lunar month. May 26 Bonn Chroat Preah Nongkoal, Royal Plowing Ceremony: The king leads the yoked sacred cows, followed by the queen, who sows the rice seeds; foods chosen by the cows after they have circled the field three times and been blessed is used to make predictions for the coming year. Very similar to ceremony in Thailand. August/October Bonn Pchum Ben (full moon): Spirit Commemoration Festival held for spirits of the dead on the fifteenth day of the tenth month; offerings of food and clothing for the monks made for at least 15 days, collected on the day of the full moon. People gather at the temple with offerings of rice which they toss on the ground for their dead ancestors. Buddhists believe that if departed souls do not find their families making offerings at the temple, the soul will be cursed and will bother the descendent throughout the year. November 9 Independence Day: Celebrates independence from France in 1953; celebrated with parade including floats, bands, and other spectacles in front of the palace. ○○○○○○○○

140 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Cambodia, cont.

October/November Water Festival includes the Boat Race, Moon Festival, and Bonn Ork Om Bok (eat the flat rice) events. Thousands of people come to the Tonle Sap, “Great Lake,” and Phnom Penh from all over the country to participate in and watch the boat races. Cambodians in the United States The Cambodian population in the United States grew by nearly 40 percent between 1990 and 2000; during that period, California’s Cambodian population grew by 24 percent. Long Beach and Stockton are home to the largest Cambodian communities in the state; Long Beach has the largest Cambodian population in the United States, estimated to be about 55,000 in 2000. According to information provided by EthnoMed, three groups of Cambodians have been resettled in the United States since 1975. The first group—government officials, military officers, and business and professional people—arrived soon after the fall of Phnom Penh to the Khmer Rouge in 1975. In 1979, the U.S. Congress approved admission of a large number of rural Cambodians who had fled across the border into Thailand and had been living in refugee camps. The third group comprises Cambodians who have been admitted to the United States since 1980, a mixture of rural and urban, educated and illiterate refugees. With the exception of the first group, most of the Cambodian refugees arrived in the United States unable to read or write their native Khmer language. Some of the educated Cambodians have been able to establish businesses or find employment, but many are on public assistance. Those who have jobs often work in low-wage areas that require more than one job to support a family. Cambodians look to education to help their children become productive members of society. An article from the June 1, 2000 Asian Week discusses the situation of Khmer students in Long Beach, pointing out that those who were born in this country or arrived here as small children are fluent in English while the older generation is not. This creates a generation barrier that often causes problems within Cambodian families. Language; Useful Words and Phrases As indicated above, many Cambodian refugees and immigrants are illiterate in their own language and might be unable to read patient materials, many of which are available through EthnoMed. The use of interpreters may be necessary in the health care setting, as discussed in the introductory materials. The Khmer language has the oldest written records of any Southeast Asian language, with stone inscriptions dating back to the seventh century. Historical ties with the Indian culture mean that there are similarities in the language. The complex written language, based on an Indian alphabet, includes 66 consonant sounds, 35 vowel symbols, 33 superscripts, and 33 subscripts. People educated from 1862 until the defeat of the French in 1953 were educated in French. Since 1979 the study of Khmer language and literature have been revived. The following words and phrases may be helpful: Hello. Chum reap sur/som pas. Goodbye. Chum reap lir/Lear heouy. Yes (used by men). Baat. Yes (used by women). Jas. No. Te’. Please. Suom. Thank you. Ar kun. Excuse me. Suom tous. How are you? Tau neak sok sapbaiy jea te? Good morning. Tivia Surday. Good night. Readray Surday. Mr. Lok Mrs. Lok srey Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○141

Cambodia, cont. References BBC News. Timeline: Cambodia. http://news.bbc.co.uk/go/pr/fr/-/1/hu/asia-pacific/country_profiles/1244006.stm (23 Feb. 2004). Chey, Elizabeth. “The Status of Khmer Women.” http://www.mekong.net/cambodia/women.htm (7 Feb. 2005). EngenderHealth. “Country by Country: Cambodia.” http://www.engenderhealth.org/ia/cbc/cambodia.html (9 Feb. 2005). Ethnicity Online. Cultural Awareness in Healthcare: Buddhists. http://www.ethnicityonline.net/buddhism_summary.htm (6 Feb. 2005). EthnoMed. Cambodian Cultural Profile. http://ethnomed.org/ethnomed/cultures/cambodian/camp_cp.html (9 Feb. 2005). Festivals in Cambodia. http://www.frizz-restaurant.com/pearls3.html (8 Feb. 2005). Inbaraj, Sonny. 2005. “In Cambodia, Hope Rises from Squalor.” World Social Forum. http://ispnews.net/ print.asp?idnews=27150 (8 Feb. 2005). Graceffo, Antonio. “Feeding the Ancestors: The Cambodian Pchum Ben Festival.” http://www.mekong.net/cambodia/ pchum.htm (7 Feb. 2005). Kannitha, Kong. 2002. “EngenderHealth Makes Creative Strategies in Low-Resource Settings.” http:// www.engenderhealth.org/news/in_the_news/020404.html (9 Feb. 2005). “Landmines in Cambodia.” http://www.mekong.net/cambodia/mines.htm (7 Feb. 2005). Lee, Cecelia. 1999. Cambodia. Anti-Racism, Multiculturalism and Native Issues Centre, Faculty of Social Work, University of Toronto, Canada. http://www.settlement.org/cp/english/cambodia.html (7 Feb. 2005). Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. Lopez, Alejandra. 2002. Asians in California: 1990 to 2000. Stanford, CA: Center for Comparative Studies in Race and Ethnicity, Stanford University. http:// ccsre.stanford.edu/reports/report_8pdf. (6 Feb. 2005). Sakhan, Nuth, and Ngin Chhay. “Country Report: Cambodia.” http://www.communityipm.org/docs/PAC_2001.pdf (8 Feb. 2005). Save the Children Norway. “Cambodia: Programs and Projects 2001.” http://bigpond.com.kh/users/rb.cambodia/ program_dept.htm (7 Feb. 2005). ———. “Cambodia in Brief.” http://bigpond.com.kh/users/rb.cambodia/fact_about_children.htm (7 Feb. 2005). Savy, Bou. “Traditional Healers and TB Care in Phnom Penh, Cambodia.” http://www.uab.edu/gorgas/Documents/ TraditionalHealers%Final.pdf (8 Feb. 2005). Sharp, Bruce. “The Banyan Tree: Untangling Cambodian History.” http://www.mekong.net/cambodia/banyan1.htm (7 Feb. 2005). Sophoan, Pich. “Cambodia.” http://www.unescobkk.org/education/aceid/higher-edu/Handbook/HB_Cambodia.htm (8 Feb. 2005). Turner, Barry, ed. 2002. The Statesman’s Yearbook: the Politics, Cultures and Economies of the World. 2003. New York: Palgrave MacMillan. U.S. Department of State Bureau of Democracy, Human Rights, and Labor. 2002. “International Religious Freedom Re- port 2002: Cambodia.” http://www.state.gov/g/drl/rls/irf/2002/13869pf.htm (28 Feb. 2004). The World Factbook: Cambodia. http://www.cia.gov/cia/publications/factbook/geos/cb.html (8 May 2005). Zimmer, Jessica. 2000. “Language Barriers.” Asian Week, 1 June. http://www.asianweek.com/2000_06_01/ feature_khmer_longbeach.html (6 Feb. 2004).

○○○○○○○○

142 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Other Countries India Iran Armenia Russia ○○○○○○○○

144 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○145 India

Census Figures (2000) United States Residents Born in India: 1,022,552(3.3%) California Residents Born in India: 198,201(2.2%) Quick Facts Country Area: 1,269,346 sq. miles (one-third the size of the United States) Population: 1,080,264,388 Median Age: 24.66 years Population Growth Rate: 1.4% Life Expectancy at Birth: 63.35 years Below Poverty Line: 25% Literacy Rate: 59.5% Currency: Indian rupee (INR) Population Groups: Indo-Aryan 72%, Dravidian 25%, Other 3% Languages: 15 official languages include Hindi, the national language, spoken by 30% of people, plus Bengali, Punjabi, Tamil, Urdu, Gujarati, Malayalam, Kannada, Oriya, Punjabi, Assamese, Kashmiri, Sindhi, and Sanskrit; English is used nationwide in politics and commerce. Religion: Hindu 81.3%, Muslim 12%, Christian 2.3%, Sikh 1.9%, other groups including Bud- dhist, Jain, Parsi 2.5% Government: Republic of India: federal republic; 28 states, 7 union territories; New Delhi is the capital Climate: varies from tropical monsoon in south to temperate in north Natural Hazards: floods, droughts, earthquakes, tsunamis Natural Resources: coal, iron ore, manganese, mica, bauxite, titanium ore, chromite, natural gas, diamonds, petroleum, limestone Arable Land: 54% Agricultural Products: rice, wheat, oilseed, cotton, jute, tea, sugarcane, potatoes, cattle, water buffalo, sheep, goats, poultry, fish Exports: textiles, gems and jewelry, engineering goods, chemicals, leather goods Industries: textiles, chemicals, food processing, steel, transportation equipment, cement, mining, petroleum, machinery, computer software services Labor Force: agriculture 60%, services 23%, industry 17% ○○○○○○○○

146 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

India, cont. Brief History The highly developed urbanized civilization in the Indus Valley goes back to about 3000 BC. The Indus had a written language and built complex cities that were home to as many as 30,000 residents. Aryan tribes from the northwest invaded about 1500 BC.; their merger with the earlier inhabitants created the classical Indian culture. The Aryans spoke and wrote Sanskrit, and they introduced the Indus to the caste system. Persian invasions occurred around 500 BC., but occupation lasted only about 150 years before the Greeks under Alexander conquered the Persians. Buddhism was founded in India by Siddhartha Gautama in the 5th century BC. Arab incursions started in the 8th century, introducing Islam to the largely Hindu culture; Turkish invasions began in the 11th century, and were followed in the late 15th century by European traders, most notably the British East India Company, which gained control of all European trade in India by 1769. By the 19th century, Britain had assumed political control of virtually all Indian lands. Nonviolent resistance to the British Raj under Mohandas Gandhi and Jawaharlal Nehru led to independence in 1947. The subcontinent was divided into the secular state of India and the smaller Muslim state of Pakistan. Mass movement of Hindus, Muslims, and Sikhs was accompanied by widespread violence and death. India became a republic in 1950; Nehru became prime minister in 1951. Indira Gandhi, his daughter, was prime minister from 1966 until her assassination in 1984. India and Pakistan went to war in 1965 over Kashmir; the settlement in 1966 left that region divided between the two nations. In 1971 India invaded East Pakistan, which became the separate nation of Bangladesh at the end of hostilities. India carried out nuclear tests in 1998. Fundamental concerns in India include the ongoing dispute with Pakistan over Kashmir, where more than 35,000 have died since uprisings began in 1998. Other major concerns are overpopulation, the environment, widespread poverty, and ongoing ethnic and religious conflict. The tsunami of Dec. 26, 2004, struck the east and southwest coasts of India and left more than 10,700 people dead, more than 5,000 missing, and hundreds of thousands homeless. Greatest damage was caused to the outlying Andaman and Nicobar Islands in the Bay of Bengal and the mainland southeast coast state of Tamil Nadu, where some 8,000 people in 373 villages perished. Housing, Family, Work, Traditions Housing: As might be expected in such a large and diverse country, housing varies greatly. The more affluent city-dwellers live in modern houses and have servants and cars. Middle-class families often live in smaller houses or apartments, and the urban poor—of whom there are millions—live in shacks or slums due to the lack of affordable housing. Rural Indians live in simple huts or thatched houses. Family: The senior male is generally the head of the family; his wife determines tasks to be done by other female family members. Males are more highly regarded than females. Children are brought up to obey their fathers without question. Mothers often cater to their sons while treating their daughters more strictly. Most marriages are arranged by family elders on the basis of factors including caste, education, and astrology. Although this practice is now illegal, the bride’s family traditionally provides a dowry to the groom’s family, a major financial burden that is thought to encourage couples to abort female children. The bride traditionally moves to her husband’s village. The 2001 movie “Monsoon Wedding” provides insight into this aspect of Indian culture. Four major kinds of families can be found in India: (1) traditional joint family: head of household (usually male), his extended family, his married brothers, and their extended families; (2) patriarchal extended family: male head of household, his wife, his married sons and their wives and children; (3) intermediate joint family: male head of household, his wife, his unmarried children, and the family of one of his sons; (4) nuclear family: man, wife, and unmarried children. This is the basic family unit among immigrant Indian families, although many may have other relatives or friends living with them temporarily while they get settled in the United States. Caste System: Although caste, jati, is becoming less important in urban areas, it is still an important aspect of Indian society. People are generally expected to marry into the same caste and perhaps to follow a Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○147

India, cont.

hereditary occupation. The four Hindu castes are Brahmans (priests, the highest class), Kshatriyas (warriors), Vaisyas (traders), and Sudras (workers). About 15 percent of Hindus are labeled “un- touchables” (Dalit) due to their hereditary occupations such as garbage collector or handling the dead. Untouchability is illegal but still practiced. Caste is not an important factor among Indians living in the United States, although about 83 percent of them are Hindu. The majority of Indians in California are Sikhs, who are opposed to caste distinctions. Dress: Western clothing is increasingly common throughout India, especially for the non-Hindu and higher-caste Hindu groups, with Western-style school uniforms seen throughout the country. Traditional dress for most Indians is simple and minimal. Women wear saris and short blouses, but the technique for wrapping the sari varies from place to place. In the Punjab, the region most California Indians come from, women commonly wear the shalwar-kamiz, a combination of paja- mas and a long-tailed shirt. Sandals are the preferred footwear. Employment: Many U.S. citizens with tech support questions are served by men and women in India who are trained to speak in the appropriate American accent. The outsourcing of U.S. jobs to India provides employment for large numbers of educated Indians. The unemployment rate in 2004–2005 was 9.11 percent. Young people often leave the country to seek better employment opportunities. According to a recent survey, 58 percent of the working urban population in India is employed in the services sector—one-fourth of these are involved in retail or wholesale trade. Some 33 percent work in the manufacturing sector, and the survey reports that less than a quarter of the working population is involved in agriculture. Foods and Eating Habits Dietary Practices: Food is highly respected in most South Asian cultures. People generally eat with reverence and avoid distractions such as watching television or excessive talking while eating. Indians never use the left hand for eating, as it is reserved for personal hygiene. Many Indians prefer to eat with their fingers rather than use utensils. Eating off another person’s plate, offering somebody a bite of something one has already tasted, or using dishes or glasses that have been used by others are often taboo. Many Indians are vegetarians, especially those from the south. Strict Muslims do not drink alcoholic beverages. Hindus do not eat beef, as cows are considered sacred, and Muslims do not eat pork. Muslims fast during Ramadan; no food or drink is allowed from sunrise to sunset each day. Everyday Diet: Food preferences vary considerably from north to south due to tradition, religion, and climate. Throughout the country, the diet is based on simple ingredients such as lentils, cauliflower, peas, spinach, potatoes, grains, and rice cooked with a variety of spices. When meat is eaten, it is generally goat, lamb, or chicken. More meat is eaten in the north and northwest, where a staple of the diet is chappati, unleavened wheat bread fried on a griddle like the tortilla; it is used to scoop up other foods from the plate and then eaten. In the east and south, more food is vegetarian, rice is a staple, and foods tend to be hotter than in the north. Popular Foods: Dal (lentils) is a favorite food throughout the country. Preparation varies, with dal makhni in the north made with butter and cream, dal in the western part of the country sweetened, and southern dal cooked with vegetables. South Indian dishes are more spicy, with favorites including Idli, Dosa, and Sambar. Coconut is widely used in southern cooking. Punjabi tandoori cooking is often available at Indian restaurants in California, where one enjoys marinated meat, fish, and chicken cooked in very hot earthen ovens. Curry is said to be a British invention, developed by returning colonialists who wanted to recreate the spicy flavors they became accustomed to in India. Beverages: Tea is generally the beverage of choice in the northern and eastern parts of the country; southern Indians drink more coffee. Water and buttermilk (lasi) are believed to help the digestive process. ○○○○○○○○

148 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

India, cont. Education Status: The Indian constitution calls for free and compulsory education for all children up to age 14. More than 90 percent of children are enrolled in the primary grades, although attendance is not regular, especially among girls. Education is a joint responsibility of the union and state governments. Public schools are free in most states to both boys and girls at least through class IX. A 2005 report found that only 47 percent of students enrolling in Class I reach Class VIII. This was due to lack of adequate facilities, teacher absenteeism, and inadequate local supervision. Primary Level: Children ages 6 to 11 attend primary school, classes I through V. In addition to public schools, private and religious schools (mainly Christian, English-language) are available. The national curriculum includes the mother tongue or regional language, mathematics, environmental studies, and art of healthy and productive living. Upper Primary Level: Following primary school, students attend upper primary classes VI through VIII. Curriculum at this level includes three languages (the mother tongue or regional language, modern Indian language, and English), mathematics, science and technology, social sciences, work education, art education, and health and physical education. Secondary Level: Secondary school is divided into lower secondary, classes IX and X, and higher secondary, classes XI and XII. Curriculum includes three languages, mathematics, science and tehcnology, social sciences, work education, art education, and health and physical education. Higher Education: Higher education is very important in India. In India’s first 40 years as an independent nation, the number of universities increased more than sevenfold, with a fifteen-fold increase in the number of students. Many important universities are controlled by the union government, but the majority are under the control of individual states. Instruction is still primarily in English, but state languages are also used. Religion Hinduism: About 80 percent of Indians practice Hinduism, the largest religion in Asia. Hindus have many gods and holy books, and they believe that individuals proceed through a series of reincarnations, each one taking the person closer to or farther from enlightenment. Karma, a word that means action and is related to the Western notion of fate, is an accumulation of past actions that influence the present. Hindus, many of whom still abide by the caste system, are found throughout the country. Cows are sacred to Hindus, who do not eat beef of any kind. Islam: More than 100 million Indians are Muslims who practice Islam, which is the dominant religion of neighboring Pakistan and Bangladesh. More than 90 percent of India’s Muslims are of the Sunni branch, with the remainder being Shi’a. Muslims are spread across India, but they form the majority in Jammu and Kashmir. Strict Muslims pray five times each day and are not exempted even when hospitalized. Before praying, they wash their hands, face, and feet. Prayer times are before sunrise, just after noon, late afternoon, after susnset, and at bedtime. Muslims do not eat pork, and may be offended if offered it. Christianity: Christians, both Catholic and Protestant, make up about 2.3 percent of the Indian population; they form the majority in three small northeastern states. Hindu-Christian tensions are common in many areas of India. Sikhism: About two percent of the Indian population practices Sikhism, a religion founded in the late 15th century, intended to bring together the best of Hinduism and Islam. They form the majority in the state of Punjab, from which the largest number of California Indian immigrants come. Sikhs believe in one god and the equality of all people. The holy scripture is called the Guru Granth Sahib. Sikh places of worship are called Gurdwaras. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○149

India, cont.

Other: Buddhism was founded in India. Indian Buddhists belong to both the Mahayana and Hinayana schools. Jainism, which claims about 4 million adherents in India, originated in the 7th century BC. Jainists practice strict vegetarianism and nonviolence toward all living creatures. B’hai, a religion founded in the mid-19th century, stresses the unity of all religions and all humanity. B’hai has grown in recent years due to extensive evangelism. Health and Health Care Health Status: Malnutrition is widespread, and lack of access to pure drinking water is common. Dysentery and other diseases carried by waterborne organisms are common and deadly, especially to children. Tuberculosis rates are high, and many people are blind due to trachoma. Malaria is still a problem. Traditional Practices: Three major systems of indigenous medicine are practiced in India: Ayurveda, Yoga, and Unani Tibb. Ayurveda is taught at some 100 colleges, often with government support. California has its own College of Ayurveda in Grass Valley, with classes in San Francisco, San Jose, and Seal Beach for students seeking to become Clinical Ayurvedic Specialists. Ayurveda developed among the Brahmans about 4.000 years ago. It focuses on the interaction between body, mind, and soul, and posits three universal energies controlling all of life. Ayurveda stresses establishing and maintaining a balance of life energies rather than dealing with individual symptoms, paying particular attention to individual differences between people that call for different remedies. Yoga, a system of rigorous mental and physical discipline, dates to the second century BC. Unani Tibb is based on Greek medicine and includes some elements of Ayurveda; it is taught at 16 schools in India. Medical System: Primary Health Centers are the basic unit of health care in India. These are operated by the states and generally staffed by trained paramedical personnel, with weekly visits in some cases from a trained government physician. Private medical practitioners may practice traditional or Western medicine. Recent figures indicate more than 7,000 rural health centers and 83,000 sub-centers in operation. The doctor-population ratio is 1:3,600, with an estimated 178,000 physicians. One of the national goals of health education has been the promotion of small families. Tips for Health Care Providers Attitudes: Research indicates that Indians tend to respect medical professionals, not asking many questions or disputing treatment directions. If recommended treatment conflicts with family beliefs, they may ignore the treatment. Clients and families expect medical practitioners to be confident and not give them choices, which may be seen as weakness. The concept of karma may play a role in that Indians may see illness as the result of actions in a previous life. It is important for Indians to have same-sex providers during medical treatments. Indians often prefer showers to baths, and may shower more than once a day. Body odors are not considered offensive. Family Authority: The family’s senior male is the chief decision-maker who must be included in discussions and decisions about the care of family members. Addressing Clients: People older than you are never addressed by only first names. Except among their peers, Indians generally do not use first names. The word “aunty” or “uncle” is often used after the first name even for people who are not related. When working with Indian clients, stick to formal language and ask how the individual would like to be addressed. The traditional all-purpose Indian greeting is “namaste.” Nonverbal Exchange: Public displays of affection are not encouraged. Do not touch an Indian you do not know well, as he or she may take offense and be uncomfortable. Avoid unnecessary physical contact. Verbal Exchange: When speaking with clients and family members, be direct and concise and do not expect them to ask questions. Do not offer a variety of options, as Indians expect the health-care professional to ○○○○○○○○

150 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

India, cont.

have the correct answer. When discussing the possible risks of a treatment plan, provide positive reassurance. Hospitalization: Family members, particularly the male head of household, must be consulted if a patient is to be hospitalized. In the hospital, a patient may refuse to eat Western foods. Serving meat to Indian clients is problematic, as Hindus do not eat beef, Muslims do not eat pork, and many Indians are vegetarians. Some Sikhs are vegetarians; others eat meat of all kinds. The only proscription seems to be against eating meat that has been killed as part of a religious ritual, which would not present a problem in the hospital setting. Some Indians may hold to the hot-cold theory which is part of Ayurvedic medicine. Hindu and Sikh patients will accept narcotics for pain, but Muslims will probably refuse except for severe pain. Death and Dying: Discuss a serious or terminal illness with family members before telling the patient. The family may not want the patient to know the serious nature of the illness. Hindus, Muslims, and Sikhs all believe in the immortality of the soul. They would prefer to die at home, surrounded by family members. In the case of death in the hospital, family members should be called, and they may wish to include a spiritual leader to pray for the dying person and purify the body. Expression of grief may be loud and sustained. The body is ritually washed. Muslims bury the body as soon as possible after death. Hindus and Sikhs cremate their dead. None of these faiths allows organ donation, and most families would not agree to an autopsy unless absolutely necessary. Celebrations and Holidays January 1 English New Year’s Day January 13 Lohri: Celebration of fertility and the spark of life, focuses on a bonfire; celebrated primarily in Punjab state. January 14/15 Makar Sankranti: Three-day harvest festival after winter solstice; houses are cleaned and cattle decorated. January 26 Republic Day: Celebrates anniversary of adoption of the Indian constitution in 1950; celebrations in state capitals and parade with folk festival in New Delhi. February Bakrid: Muslim festival honoring the trials of the Prophet Ibrahim; Muslims say special prayers, sacrifice a goat or sheep and share with the poor. March Muharram: Muslim (Shi’a) festival marks the beginning of the Muslim year. March Holi: Two-day spring festival known as the color-throwing festival; a time of great merriment and feasting when people throw out grievances and celebrate brotherhood. tApril Mahabir Jayanti: Jain festival celebrates the birth of the founder of Jainism. April/May Vaisakhadi Festival: Sikh celebration in Punjab; feasting and dancing follow reading of the Guru Granth Sahib, the Sikh holy book. May Milad-Un-Nabi: Muslim celebration of the birth of the Prophet Muhammad, 570 A.D. May Buddha Purnima: Celebrates birth, death, enlightenment of the Buddha. August 15 Independence Day: Marks independence from Britain in 1947. August/September Janmashtami Festival: Hindu festival celebrates Lord Krishna’s birthday. September/October Dussehra Festival: 10-day Hindu celebration of the triumph of good over evil. October 2 Gandhi Day: Celebrates birth of Mohandas Gandhi in 1869. October/November Diwali, Festival of Lights: Five-day Hindu festival of Laxmi, goddess of prosperity and wealth; celebrated nationwide with fireworks, homes lighted with oil lamps, special cooking, decorating, and purchase of new clothing and jewelry; businesses start new accounting year. Oct–Nov/Dec–Jan Sikhs celebrate the birthdays of two important gurus, Guru Nanak in October-November and Guru Gobind Singh in December-January; the holy book is read continuously and taken out in procession during celebrations. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○151

India, cont.

November 14 Children’s Day celebrates the birthday of Jawaharlal Nehru; children participate in rallies and cultural programs. November/December Idu’l Fitr: Muslim festival at the coming of the new moon marking the end of Ramadhan, a month of fasting in honor of the Koran. December 25 Christmas Asian Indians in the United States Foreign-born Indians are the third-largest immigrant group in the United States. The majority of Indian immigrants to California are from the state of Punjab in north India, which borders Kashmir and Pakistan. Between 1903 and 1908, about 3,000 Punjabis crossed into the United States from Canada. During that time they worked on highways and railways in Northern California. By 1910, there were more than 6,000 Punjabis—primarily Sikhs—in the region. Punjabis soon began moving to the Central Valley to work in agriculture. A U.C. Davis Web site notes that British rule had caused economic hardships for India, and that Punjabi peasants often had to mortgage their small plots of land to pay for taxes for water and land. Peasants’ daily income was under 10 cents per day, so the propsect of earning $2 a day in Canada or the United States encouraged many to emigrate. The National Origins Act of 1924 banned Asians from entering the United States. Between 1920 and 1930, 3,000 Indians left the United States due to lack of employment. In 1946, about 1,500 remained in the United States and were given the right to become U.S. citizens and to bring relatives to the country (with an annual quota of 100 people!). Revised immigration laws in 1965 opened the doors for those with education and technical training to enter the country; by 1985 there were more than 500,000 South Asians in the United States. The Immigration Act of 1987 made visas easier to obtain, resulting in an annual migration of more than 20,000 Indians to this country. Between 1990 and 2000, the Asian Indian population in California increased by 125.3 percent, with the largest concentrations of Asian Indians living in Los Angeles (29,604), San Jose (28,301), and Fremont (21,618). During that same period, the U.S. Asian Indian population increased by 133 percent. Indian immigrants to the United States have the highest level of education of any group, according to the 1990 census. Some 71 percent held bachelor’s and master’s degrees, and many came to this country to advance their professional careers and to ensure better opportunities for their children. A July 2005 article in Time magazine details the importance of the South Asian or “desi” market in the United States, noting that of the 2.5 million desis in the United States the vast majority are Indians, whose median household income is nearly 50 percent higher than the national average. The article notes that, to be successful, U.S. advertisers targeting the Indian immigrant market must reflect core Indian values of education, hierarchy, and status that differ from the values of mainstream U.S. consumers. Language; Useful Words and Phrases Of the 15 official languages of India, Hindi, Punjabi, Urdu, Gumarati, and Bengali are some of the most common. Because most of the Asian Indians living in California are Punjabi-speaking Sikhs from the state of Punjab, we will focus on Punjabi words and phrases. Punjabi does not have a European system of greeting. Indian culture is steeped in religion and the formal greetings reflect one’s faith. In the Sikh community it is “Sat sri akaal.” Muslims say “Aslam alaikam,” and Hindus say “Namaste.” The informal greetings is “Kiddha” (the respectable one being “Pranaam”), which roughly translates as “Hello,” or “What’s up?” To say goodbye the Sikhs say “Rab rakka” and the Muslims “Khudaa haafiz.” It is polite for each culture to address each other with that community’s chosen phrase. A separate handbook containing comprehensive Punjabi vocabulary for health care providers is available from the Kern Resource Center, www.health-careers.org. The following words and phrases from that handbook may be helpful. Hello. Sat sri akaal. Goodbye. Rab rakka. Please. Kirpa karkay or please Thank you. Dhanvad/shukriya OK. Achaa. ○○○○○○○○

152 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

India, cont.

What is your name? Tuhaada naam ke ha? You are welcome. Tuhada swagatt hai. How are you? Ki haal nay? Tuhaada haal theek ha? I do not know. Neinu ni pata. Show me. Dekhavo menu. Do you understand me? Tuhanu meri samajh aagi? I don’t understand. Meri smajhich nahi aanda. Where does it hurt? Ehy kithy dard karda hai? Do you need help? Kee thuhannu madhat chahidee hah? Let me help you. Menu thuhaddi madhat karn dhano. References “Basic Principles of Ayurveda.” http://niam.com/corp-web/definition.html (13 Apr. 2004). Dhillon, Rupinderpal Singh. Punjabi Lessons. http://www.5abi.com (26 Mar. 2005). “Fifty-two Percent Dropout in Schools.” 2005. The Hindu. 22 Feb. http://www.hinduonnet.com/thehindu (15 Apr. 2005). Freeman, Nancy. “India.” Sally’s Place. http://sallys-place.com/food/ethnic_cuisine/india.htm (13 Apr. 2004). Grieco, Elizabeth. 2003. “The Foreign Born from India in the United States.” Migration Information Source. http:// www.migrationinformation.org (5 Feb. 2004). “Health.” Discover India. http://www.meadev.nic.in/social/health.htm (13 April 2004). “Holidays of India.” http://www.pardesiservices.com/tradition/holidays.asp (14 Apr. 2004). “India.” Encyclopedia Britannica. 2004. Encyclopaedia Britannica Premium Service. http://www.britannica.com/eb/ article?eu=121166 (12 Apr. 2004). “India History.” http://www.hoteltravel.com/india/guides/history.htm (13 Apr. 2004). “India Holidays and Festivals.” http://www.hoteltravel.com/india/guides/festivals.htm (13 Apr. 2004). “Indian Cuisine.” Indian Travel Portal. www.indiantravelportal.com (13 Apr. 1004). Kang, Jasbir Sing. “Punjabi Migration to United States.” 2002. SikhNet. http://www.sikhnet.com (5 Feb. 2004). Kiviat, Barbara. 2005. “Chasing Desi Dollars.” Time. 11 July. (A22–A24) Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. Lonely Planet. Tsunami Update: India. http://www.lonelyplanet.com/tsunami/india.cfm (25 Mar. 2005). Lopez, Alejandra. 2002. Asians in California: 1990 to 2000. Stanford, CA: Center for Comparative Studies in Race and Ethnicity, Stanford University. http:// ccsre.stanford.edu/reports/report_8pdf. (6 Feb. 2005). Malhotra, Ajay. “History of Indians in US.” http://www.itihaas.com/independent/contrib3.html (5 Feb. 2004). National Council of Educational Research and Training. Organisation of Curriculum at Elementary and Secondary Stages. http://www.ncert.nic.in/sites/schoolcurriculum/schoolcurriculum.htm (15 Apr. 2005). Pinto, Priya E., and Nupur Sahu. 2001. “Working with Persons with Disabilities: An Indian Perspective.” Center for International Rehabilitation Research Information and Exchange (CIRRIE). http://cirrie.buffalo.edu (5 Feb. 2004). “Pioneer Asian Indian Immigration to the Pacific Coast.” http://lib.ucdavis.edu/punjab/pacific.html (5 Feb. 2004). “Services Sector Top Employer of Urban Workers.” 2005. The Economic Times, New Delhi Edition. 7 Apr. http:// www.naukri.com/demosection/hr-zone.php (15 Apr. 2005). Tourism of India. Useful Phrases. http://www.tourismofindia.com/us/phrasepunjabi.htm (26 Mar. 2005). Turner, Barry, ed. 2002. The Statesman’s Yearbook: the Politics, Cultures and Economies of the World. 2003. New York: Palgrave MacMillan. U.S. Department of State Bureau of Democracy, Human Rights, and Labor. “International Religious Freedom Report 2002: India. http://www.state.gov/g/drl/rls/irf/2002/4023pf.htm (28 Feb. 2004). The World Factbook: India. http://www.cia.gov/cia/publications/factbook/geos/in.html (8 May 2005). Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○153 Iran

Census Figures (2000) United States Residents Born in Iran: 283,226 (0.9 %) California Residents Born in Iran: 158,613 (1.8%) Quick Facts Country Area: 636,300 sq. miles (slightly larger than Alaska) Population: 68,017,860 Median Age: 23.23 years Population Growth Rate: 0.86% Life Expectancy at Birth: 69.96 years Below Poverty Line: 40% Literacy Rate: 79.4% Currency: Iranian rial (IRR) Population Groups: Persian/Farsi 51%, Azeri 24%, Gilaki and Mazandarani 8%, Kurd 7%, Arab 3%, Lur 2%, Baloch 2%, Turkmen 2%, Other 1% Languages: Persian and Persian dialects 58%, Turkic and Turkic dialects 26%, Kurdish 9%, Luri 2%, Balochi 1%, Arabic 1%, Turkish 1%, Other 2% Religion: Shi’a Muslim 89%, Sunni Muslim 9%, Zoroastrian, Jewish, Christian, and Baha’i 2% Government: Islamic Republic of Iran since 1979: capital Tehran; country divided into 28 provinces; most political activities conducted by various pressure groups Climate: mostly arid or semiarid, subtropical along Caspian coast Natural Hazards: periodic droughts, floods; dust storms, sandstorms; earthquakes Natural Resources: petroleum, natural gas, coal, chromium, copper, iron ore, lead, manganese, zinc, sulfur Arable Land: 8.72% Agricultural Products: wheat, rice, other grains, sugar beets, fruits, nuts, cotton; dairy products, wool; caviar Exports: petroleum 80%, chemical and petrochemical products, fruits and nuts, carpets Industries: petroleum, petrochemicals, textiles, cement and other construction materials, food processing (particularly sugar refining and vegetable oil production), metal fabricating, armaments Labor Force: agriculture 30%, industry 25%, services 45% ○○○○○○○○

154 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Iran, cont. Brief History Known to the rest of the world as Persia, its ancient Greek name, until 1935, Iran’s location puts it at the center of history, with the earliest settled cultures dating from around 16,000 BC. A fairly sophisticated agricultural society with large population centers existed in the 6th century BC. The country we now know as Iran was invaded and ruled by a bewildering number of outside groups while developing a unique identity. Cyrus the Great ruled an empire stretching from northwestern India to Greece from 559 to 330 BC., when he was defeated by the Greeks under Alexander the Great. Alexander was defeated by the Parthians, who were followed by the Sassanians. In the 7th century AD. Islamic Arab forces conquered the country, only to be followed by the Seljuk Turks, the Mongols, and Tamerlane. The Safavid dynasty (1502 to 1736) brought a renewed independence to the country, most especially under Shah (king) Abbas. He was conquered by Nadir Shah; the Zand, Qajar, and Pahlavi dynasties followed. In 1905, a nationalist uprising against the ruling Shah brought a limited constitution. Oil was discovered in 1908. Reza Kahn seized control of the government in 1921 and named himself Reza Shah Pahlavi in 1925. Under his rule the country began to modernize, politics became somewhat secularized, and the central government exerted power over provinces and tribes. During World War II, Iran served as a supply line for lend-lease supplies to the Soviet Union. When the Allies occupied western Iran in 1941, Reza Shah was forced from the throne; his son, Mohammed Reza Pahlavi, ruled as Shah until 1979. Following the war, Soviet troops refused to withdraw from northwestern Iran, backing revolts that established brief separatist regimes in Azerbaijan and Kurdistan. In 1951, Premier Mohammed Mossadeq forced the parliament to nationalize the British-owned oil industry; he was removed from power during “Operation Ajax,” a complex plot orches- trated by British and U.S. intelligence agencies. The Shah became increasingly dictatorial, implementing social, economic, and administrative reforms known as the Shah’s White Revolution—funded in large measure by petroleum. The Shah’s heavy-handed methods, including systematic torture and other human rights violations, led to a revolution in 1978; the Shah left the country in 1979 and died in exile. On Feb. 1, 1979, Ayatollah Ali Khamenei returned from 15 years of exile in Turkey, Iraq, and France to direct a revolution that resulted in establishment of an Islamic republic. Khamenei, the spiritual leader and highest authority of the Islamic Republic of Iran, runs the country according to strict Shi’ite Muslim rules. On Nov. 4, 1979, militant Iranian students took 52 Americans hostage at the American Embassy in Tehran, holding them for 444 days. In 1980, a border dispute with Iraq led to a devastating war that lasted until 1987. An earthquake in 1987 killed more than 50,000 Iranians. Mohammad Khatami-Ardakani, a reformist, was elected president in 1997 and reelected in 2001. In December 2003 a major earthquake devastated the city of Bam in southeastern Iran, killing more than 30,000 people. Relations between the United States and Iran are extremely tense; President George W. Bush labled the country part of the “Axis of Evil” for its support of terrorists, human rights abuses, violent opposition to the Middle East peace process, and alleged efforts to develop nuclear weapons. In June 2005 the conservative mayor of Tehran, Mahmoud Ahmadinejad, was elected president; his commitment to nuclear energy seems likely to worsen U.S.-Iran relations. Housing, Family, Work, Traditions Housing: As might be expected in a country where the population has doubled in 25 years, housing is at a premium in Iraq. Private investment in the construction industry has been growing, along with an increase in building permits and housing loans. The domestic construction industry has been expanding to meet increased demand. In 2002, 98,000 housing units in urban areas were privately financed. Each year some 800,000 new families are formed in Iran, but the building capacity is about 450,000 units. According to the country’s Minister of Housing and Urban Development, more than 1 million housing units will need to be constructed by March 2007 to alleviate the shortage. Most new urban housing units are constructed of concrete. Family: Iran’s people comprise a mosaic of different ethnicities, religions, and social classes, making generalizations about family structure and customs difficult. Like many cultures outside the Western world, however, most Iranians regard the family or other group as being more important than the individual. Most families are patriarchal, with authority descending through the male line by age. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○155

Iran, cont.

Children are brought up to be disciplined and to respect their elders. Young people often marry before the age of 20. Shi’ite Muslims are permitted to have as many as four wives, provided they can support them and the existing wife/wives approve of additional wives, but polygamy is rare and must also be approved by the government. Mothers and other female family members are caregivers, while men are protectors and control the outside world. Large families with many sons are preferred; unmarried children live with their parents. A marriage custom unique to Shi’a Islam is the temporary marriage or sigheh. Children of this kind of marriage are legitimate but have fewer rights and privileges than other children. Divorce is rare in Iranian culture. Traditions: Iranians dress conservatively in public. Women over age nine must be covered from head to foot in hejab, Islamic dress; many wear the chador, a long black dress, but other clothing is permitted if it fits loosely and only the hands and face are visible. The black head cover or maghan-ea is still widely worn, but some women now wear scarves. Men usually wear Western-style clothing, although traditional robes and turbans are still worn in parts of the country. At home, Iranians may wear loose fitting pajama-type garments. Social gatherings are often segregated by gender. Employment: In general, Iran is divided into urban, market-town, village, and tribal groups. The 1979 Islamic revolution brought many changes to Iran. Clergymen, mullahs, control virtually every aspect of life. Merchants and professionals who sided with the Shah lost influence after Khomeini came to power. Before the revolution, upper-class women living in cities were beginning to enter the workforce, often rising to positions of leadership. Many jobs are not open to women now, and segregation by gender is an important part of the new order. About a third of the people work in agriculture, mostly on small farms. Wool and wool byproducts, such as carpets, are important exports. Most industry is still state-controlled, although privatization began in 1991. Unemploy- ment is a serious problem and is partly the result of population growth as well as a shortage of raw materials and the debilitating war with Iraq. Official estimates put the unemployed at 3.5 million working-age Iranians. The official unemployment rate is 13 percent, but analysts believe more than 20 percent of Iranians are unemployed. The rate among women is twice that of men. The crisis dates back to the 1980s, when large families were encouraged, resulting in a doubling of the country’s population in 25 years. While many of the jobless are unskilled and uneducated, many professionals with college degrees are also out of work; many have left the country, which has the largest “brain drain” of any nation. About 10,000 physicians are among the unemployed, and half of university graduates cannot find work in their own country. Foods and Eating Habits Dietary Practices: Strict Muslims do not eat pork or consume alcohol. This may extend to alcohol in medications. Many Iranians hold the hot-cold theory of foods and strive for a balance between the two to maintain health. Food combinations play an important role in Iranian life. Fresh ingredients are preferred; Iranians use a spoon rather than a fork to eat rice. They avoid cold water during illness. Warm tea sweetened with hard candy may be used. Tea is served after every meal. Everyday Diet: Iranians generally like to eat with the family; three meals a day are common except during Ramadan. The midday meal is largest. Breakfast might include eggs, bread (nan), butter, honey, and feta cheese. Lunch would include plain rice (chelo) or rice mixed with fruits, vegetables, or meat (polo). Lamb and chicken are the most popular meats; beef is considered inferior. In rural areas, goat, camel, and buffalo may be part of the diet. Meat is often served skewered and grilled (kabab) or chopped into a stew (khoresh). Supper is a large meal in the north, but elsewhere it is light and eaten late in the evening. Popular spices include dried limes, pomegranate juice, cinnamon, tur- meric, sumac, and saffron. Dairy products including yogurt, eggs, milk, and feta cheese are commonly part of the diet. Fruit is a popular dessert. Snacks include tea, pastries, fruits, and pistachios. ○○○○○○○○

156 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Iran, cont.

Popular Foods: Chelo kabab, meat with plain rice, is a popular dish, as is khoresh fesenjan, a stew made with poultry, pomegranate juice, and walnuts. Koreshe mast is stew with yogurt; khoresh bademijan is stew with eggplant. Grilled ground meat is called kabab kubideh, and Iranians enjoy dolmeh, grape leaves stuffed with a variety of meats, vegetables, and rice. Beverages: Tea (chai), usually served sweetend after every meal, is the national beverage. Yogurt-based drinks such as sharbat and dug are also popular. Education Status: The government provides free and compulsory education for children ages 6 through 10. Schools are segregated by gender; following the Islamic revolution, schools have compulsory daily religious instruction. The government provides course books for each subject to be used nationwide. Teach- ers discourage discussion and questions. Primary Level: Although five years of primary education are compulsory, children in rural areas may not have access to schools, and urban schools are often overcrowded and operate with two half-day shifts. Students are assigned large amounts of memorization and homework from an early age. The general academic curriculum includes: the Qur’an, religious teaching, Persian composition, dicta- tion, Persian reading and comprehension, social studies, arts, mathematics, and physical education. There are examinations at the end of each year to determine promotion to the next grade. Passing an examination at the end of grade five indicates completion of primary education. Those who fail twice cannot pursue further academic education. Lower Secondary: Secondary school is not compulsory; enrollment is about 60 percent of eligible children. Parents pay fees for textbooks and school heating and maintenance. The lower secondary level is called the Guidance Cycle and covers grades 6 through 8, ages 11 through 13. Curriculum includes both theoretical and applied knowledge. Students who pass a regional exam at the end of grade 8 receive a Certificate of General Education. If a student’s grade is high enough, he/she can continue on to the academic or technical/vocational track in upper secondary education. Upper Secondary: This level covers grades 9 through 11, with students ages 14 to 17. Depending on aptitude shown on the exam at the end of grade 8, students pursue either an academic or a vocational/technical path. The general or academic track has two stages: the first two years cover general curriculum, and the final year allows students to specialize in one of four areas: literature and arts, natural sciences, physics and mathematics, or social sciences and economics. About 80 percent of subjects are required. Students take a national exam following this three-year cycle; those who pass receive the National High School Diploma. The technical-vocational track is either a two-year vocational or agricultural program leading to a Trade Certificate, or a four-year technical program designed to train lower-grade technicians and leading to a Second Class Technician’s Certificate. Pre-University: This one-year phase includes 24 semester credits and prepares students to take the university entrance exam; successful students receive the Certificate of Completion. Higher Education: University education is free to students who have a Certificate of Completion and pass the entrance exams. Applicants also must pass a test in Islamic theology. Most institutions of higher education are run by the government. There are 46 universities, 60 post-secondary technical institutions, 200 colleges and professional schools, and several teacher-training colleges. Religion Status: The nation of Iran is a constitutional theocracy whose official religion is Ja’fari Shi’ism. The constitution provides that other denominations of Islam be accorded full respect and that Zoroastri- ans, Jews, and Christians are the only recognized religious minorities allowed to practice their Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○157

Iran, cont.

religion within the limits of the law. Individuals are not required to register with the Ministry of Islamic Culture and Guidance, but the activities of non-Shi’ite schools and other organizations are closely monitored. The Baha’i religion, which derived originally from Islam, is regarded as a political movement loyal to the former Shah. The government supports anti-Jewish and anti- Baha’i sentiment. Non-Muslim owners of grocery shops must post their religious affiliation on the fronts of their stores. According to the International Religious Freedom Report of 2002, “All religious minorities suffer varying degrees of officially sanctioned discrimination, particularly in the areas of employment, education, and housing.” Islam: Nearly all Iranians practice Islam, the state religion. About 89 percent are Shi’a and the remainder Sunni; the latter are primarily Turkomen, Arabs, Baluchs, and Kurds who live in the southwest, southeast, and northwest sections of the country. Sufi sects like Ahl-Haqq and Naqshbandi are popular. Sufi are considered Muslim for government purposes, but Sufis have some different practices and secret organizations that set them apart and have led to harassment. Shi’ite Muslims practice the five pillars of Islam: professing faith in Allah as the one God and Mohammed as his prophet; praying daily; giving alms to the poor; observing the fast of Ramadan; and making the pilgrimage or hajj to Mecca at least once during a lifetime. Shi’ite has two additional pillars: jihad, the protection of Islamic beliefs; and the requirement to do good works and avoid all evil. Iranian Shi’ites recognize 12 imams, holy leaders, as direct successors of Mohammed. These are the only individuals allowed to interpret the Qur’an (Koran). Shi’ite clergy, called mullahs, play a major role in Iranian life. Zoroastrianism: This was the state religion of Iran prior to the founding of Islam in the 7th century, and is still practiced by as many as 60,000 ethnic Persians primarily in the cities of Tehran, Kerman, and Yazd. Zoroastrians believe that all elements are sacred and pure. For this reason they traditionally do not bury their dead, as this would pollute the earth, and do not cremate them for fear of polluting the air; they leave the dead on towers of silence to be eaten by vultures. Christianity: Most Christians in Iran are ethnic Armenians affiliated with the Armenian Orthodox Church; Protestant denominations are also present. The United Nations Special Representative in 2001 reported some 300,000 Christians in Iran; they are leaving the country in large numbers. Judaism: Judaism is officially recognized, with perhaps 30,000 adherents in Iran, a drop from some 80,000 prior to the revolution. The government is fiercely opposed to Israel. Baha’i: Adherents to the Baha’i faith number about 300,000 throughout the country. Their faith has been declared heretical, and many have been imprisoned, deprived of jobs and pensions, even executed. All Baha’i administrative structures have been banned by the government, and holy places have been confiscated or destroyed. Health and Health Care Health Status: Major causes of illness include parasitic and gastrointestinal diseases caused by lack of clean water and improper sewage disposal. Iran has a surplus of some 10,000 physicians, which means that physicians can take the time to establish personal relationships with patients, explain diagnosis and treatment procedures, and even to make house calls. A news story on April 14, 2005 reported a decision by parliament to allow abortions in the first four months if the fetus is mentally or physically handicapped. Abortion is currently legal only if the woman’s life is in jeopardy; at least 80,000 illegal and unsafe abortions are performed in Iran each year; Traditional Practices: Iranians will generally seek herbal or humoral cures before visiting a physician for Western medical treatment. Unani-Tibb Medicine, one of the three major traditional healing systems, was founded in Persia about 980 AD. In this system, also practiced widely in India and other Asian and Middle Eastern countries, the basic cause of disease is an imbalance in the body’s four humors: blood, ○○○○○○○○

158 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Iran, cont.

phlegm, yellow bile, and black bile. The foundation diagnosis is the pulse, which reveals humoral imbalance in the organ system. Primary treatment modalities are diet, herbs, fasting, cupping, purgation, baths, and attars. The choice of foods and their manner of preparation is key to maintaining or improving health. Each ingredient affects the heat or cold balance of the system and may influence the humoral system. Tastes and aromas—salty, sweet, bitter, pungent, sour—also play a role. Medical System: Health care is provided by government and the private sector. All citizens are entitled to health care. The public health system includes several levels. At the district level, care is provided through some 15,000 health houses, health posts, 4,000 rural and urban health centers, district health centers, and district hospitals. At the provincial level, the Universities of Medical Sciences and Health Services supervise district activities, support health delivery facilities, and manage public health services, pharmacies, and medical education. The Ministry of Health and Medical Educa- tion is in charge of setting national health policy and supervising activities at the lower levels. In 2000, there were 713 hospitals in Iran with 105,716 beds. About 40 percent of health personnel are women. Rural midwives are an important part of the government health system. Tips for Health Care Providers Information on working with Mulsim patients can be found on pages 22 and 23. In addition, health care providers may find the following information helpful when working with clients from Iran. Attitudes: Iranians tend to be sensitive and modest in dress and in sharing personal information. They respect education and authority and so will probably respect the health care provider. In deciding what information to share, the concept of shame (haya) is a guideline. Family Authority: The father, eldest son, eldest daughter, or eldest male family member may serve as the family spokesperson and should be included in medical discussion and decisions. Addressing Clients: Use the client’s last name, at least when first introduced. Handshaking and slight bowing are appropriate. Standing when someone enters the room is a sign of respect. Nonverbal Exchange: Eye contact is accepted between equals and those who know one another well. Iranians generally get closer to one another than is common among North Americans and Northern Europeans. Silence may have many meanings. Verbal Exchange: Iranians generally speak politely to care providers or strangers but may be loud and emotional with family members and friends. Hospitalization: Iranians are generally more comfortable with care providers of the same gender, as they are very modest and like privacy. Foods may be refused based on the humoral theory. Family and friends are an important part of the healing process and should be allowed to stay with the patient if the patient wishes. The family spokesperson may need to assist care providers in controlling noise and number of visitors. Sick Muslims are exempted from the Ramadan fast. Death and Dying: Give a diagnosis of terminal illness to the family spokesperson. For most Iranians, reaching a DNR decision is not difficult as death is seen as a beginning rather than an end. Some patients may prefer warm compresses to pain medication. When a patient has an acute illness, hospital care is preferred; families often prefer to have members with chronic conditions die at home with family care. Family and friends often pray or cry softly by the bedside of a dying person. Organ donation and autopsy are generally accepted if explained fully to the family spokesperson. Religious Practices: Strict Muslims pray five times each day: just before sunrise, just after noon, late afternoon, immediately after sunset, and at bedtime, facing Mecca. Before praying, they wash their hands, face, and feet. Hospital staff should be alert to the possible desire of Muslim patients to observe this ritual. In addition, Muslims do not eat pork or drink alcohol; non-Muslim Iranians may also avoid pork. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○159

Iran, cont. Celebrations and Holidays (Note: Dates are for the year 2005, thanks to the Q++ Studio Diary Publishing System, http://www.qppstudio.net.) January 21 Eid al Adha: Feast of Sacrifice February 10 Islamic New Year February 11 Victory of the Islamic Revolution March 20 Day of Oil Industry Nationalization March 21–25 Naw Roz, Iranian New Year: Celebrations last for 13 days; traditions include spring cleaning, special table settings using seven articles beginning with the Farsi letter “s,” staying out of the house on the thirteenth day, and bonfires. March 30 Ashura: Day of the martyrdom of Hossein, the third Shi’ite imam April 1 Islamic Republic Day April 7 Death of the Prophet/Martyrdom of Imam Hassan April 8 Martyrdom of Imam Reza April 26 Birthday of The Prophet and Imam Sadeq June 4 Death of Imam Khomeini June 5 Anniversary of Overthrow of the Shah July 9 Martyrdom of Fatima August 20 Farsi New Year September 1 The Prophet’s Ascension October 4 Beginning of Ramadan, month of fasting and prayer: Muslims eat a meal before sunrise, fast until sunset, then break the fast with an evening meal. October 24 Martyrdom of Imam Ali October 28 Quds Day November 3 Eid al Fitr: Feast marking the end of Ramadan; Muslims attend special religious services, visit family and friends, exchange gifts. November 28 Martyrdom of Imam Jafar Sadeq Iranians in the United States Before 1978 about 40,000 Iranians were living in the United States; many had come to this country for educational and economic opportunities. Large numbers of immigrants left at the time of the Islamic Revolution in 1979 and the Iran-Iraq War of 1980–1988. By 1986, according to official statistics, 200,000 Iranians were living in the United States. According to the United Nations High Commission on Refugees, in each of the years 1987, 1988, and 1990, more than 1,500 Iranians came to the United States seeking assylum from the Islamic Republic of Iran. Applications have declined since then but still number several hundred annually. According to a report prepared in 2003 by the National Iranian American Council, while the U.S. Census estimates the number of Iranian Americans at about 330,000, the Iranian Interest Section in Washington, D.C., reports holding passport information for some 900,000 Iranians in the United States. Iranian immigrants are well educated; on average, they have six times as many doctoral degrees as their American counterparts. Census 2000 showed that the per capita income of Iranian Americans is 45 percent higher than the U.S. average; their median family income is 38 percent above the national average. California is home to some 159,000 Iranian Americans, representing .469 percent of the population. Iranians are concentrated in the Los Angeles-Beverly Hills area, centered in an area named Little Teheran that stretches from Westwood Blvd. to south of Santa Monica Blvd.; they represent the full gamut of religious groups found in Iran. More Iranians live in California than in the next 20 states combined. Unofficial estimates put the Iranian American population of Southern California at between 300,000 and 600,000. Most of them are from the educated and wealthier segments of the Iranian population. Los Angeles has 10 Iranian newspapers, locally produced Iranian radio and television programs, Iranian Yellow Pages, many Iranian restaurants and businesses, and the largest Persian bookstore outside Iran. ○○○○○○○○

160 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Iran, cont.

Following the terrorist attacks of Sept. 11, 2001, some Iranians suffered persecution because of their Middle Eastern ethnicity. At the end of 2002, immigration officials detained hundreds of Iranians, including Iranian Jews, and other Muslim men, who reported for a mandatory registration. Most were eventually released. Many Iranians responded to the post-9/11 climate by keeping a low profile and not being active in political affairs, not a difficult thing to understand. Language; Useful Words and Phrases Farsi or Persian is the official language of Iran, used for all school instruction, but many Iranians do not speak it, or may speak it as a second language. Other languages and dialects include Turkic (spoken by 26%), Kurdish (9%), and Luri (2%). Educated city dwellers may understand English, French, and/or German. Farsi is an Indo-European language loosely related to English but using Arabic script, introduced when the Arabs invaded Iran in the 8th century. Arabic script is read from right to left. Farsi includes many words from the Arabic language, spoken by 1 percent of Iranians. The Arizona Persian Web Directory, http://www.arizonapersian.com, provides many useful links to resources on Iran, including a number of sites on the Farsi language. The following words and phrases may be helpful to the health care professional seeking to establish rapport with a client who speaks Farsi. Hello. Salam. Goodbye. Khuda hafez. Please. Lotfan. Thank you. Tashaker/Motsha keram/Kelimamnun. You are welcome. Khahesh mikonam. Yes/No Bale/Na Good morning. Rozbakhair. Good afternoon. Rozbakhair. Good evening. Shabakhair. Good night. Shabakhair. How are you? Hale shoma chutor ast? Fine. Khub. Welcome. Khushamadatke. References American Institute of Unani Medicine. Comparison of Healing Systems. http://www.unani.com/comparison.htm (7 Apr. 2005). Ardibili, Nima. 2003. “Iranians in Westwood.” Loyola Marymount University: The Center for the Study of Los Angeles.. Culture and Controversy in Urban Development. 1 May. http://www.lmu.edu/csla/community/students-projects/ westwood/ (8 Apr. 2005). Arizona Persian Web Directory. http://www.arizonapersian.com (8 Apr. 2005). “Construction Sector Makes Recovery.” 2004. Iran Daily. 17 Nov. http://www.iran-daily.com/1383/2141/html/focus.htm (6 Apr. 2005). CountryReports. “Iran—In Their Language.” http://www.countryreports.org/greetings.asp? countryid=116&countryName=Iran (5 Apri. 2005). ———. “Iran—Culture and Customs.” http://www.countryreports.org/customs.asp? countryid=116&countryName=Iran (5 Apri. 2005). ———. “Iran—General Overview.” http://www.countryreports.org/profile.asp? countryid=116&countryName=Iran (5 Apri. 2005). Esfandiari, Golnaz. 2004. “Iran: Unemployment Becoming a ‘National Threat.’” Radio Free Europe. http:// www.parstimes.com/news/archive/2004/rfe/unemployment_threat.html (6 Apr. 2005). Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○161

Iran, cont.

Fata, Soraya, and Raha Rafii. 2003. Strength in Numbers: The Relative Concentration of Iranian Americans Across the United States. National Iranian American Council. September. http://www.niacouncil.org/files/irancensus.pdf (8 Apr. 2005). Grotte, L.B. Unani Medicine. http://www.drgrotte.com/Unani.shtml (7 Apr. 2005). “History of Iran.” Wikipedia. http://en.wikipedia.org/wiki/Iran (5 Apr. 2005). “Iran’s Parliament Votes to Liberalize Abortion Laws.” 2005. Feminist Daily News. 14 Apr. http://www.thruthout.org/ issues_05_printer_041505WC.shtml (16 Apr. 2005). Khorrami, Mohammad M. “Iranians in the U.S.” Islamic Revolution. PBS Online: Beyond the Veil—Iranians in the U.S. http://www.internews.org/visavis/BTVPages/Iranians_in_US.html (8 Apr. 2005). Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. Migration Information Source. Number of Asylum Applicants from Iran, Islamic Republic of in the United States, 1980 to 2002. http://ww.migrationinformation.org/DataTools/asylumresults.cfm (8 April 2005). Orr, Heather C. 2004. “Tehrangeles: L.A. the Iranian Expatriate Capital Abroad.” Raw Story. http://rawstory.com/exclusives/ orr/tehrangles_iran_capital_expatriates_812.htm (8 Apr. 2005). Q++ Studio. Public Holidays and Bank Holidays for Iran. http://qppstudio.net/worldholidays/iran.htm (7 Apr. 2005). “Religious Minorities in Iran.” Wikipedia. http://en.wikipedia.org/wiki/Religious_minorities_in_Iran (5 Apr. 2005). Sanger, David E. 2005. “Victory by Hard-Liner Could Widen Rift with U.S.” New York Times. 26 Jun. http:// www.nytimes.com (26 Jun. 2005). Sedgwick, Robert, ed. 2000. “Education in Post-Revolutionary Iran.” World Education News and Reviews. Vol. 13, No. 3, May/June. http://www.wes.org/ewenr/00may/poractical.htm (7 Apr. 2005). Tavani, Masoumeh E. “Strengthening Reproductive Health and Safe Motherhood Programs in Iran.” Medical Women’s International Association. http://mwia.regional.org.au/papers/papers/05_tavani2.htm (7 Apr. 2005). Turner, Barry, ed. 2002. The Statesman’s Yearbook: the Politics, Cultures and Economies of the World. 2003. New York: Palgrave MacMillan. U.S. Department of State Bureau of Democracy, Human Rights, and Labor. “International Religious Freedom Report 2002: Iran. http://www.state.gov/g/drl/rls/irf/2002/13995pf.htm (28 Feb. 2004). Williams, Emma, and Swarnalatha Vernuri. 2002. Iran. Anti-Racism, Multiculturalism and Native Issues Centre, Faculty of Social Work, University of Toronto, Canada. http://www.settlement.org/cp/english/iran.html (5 Apr. 2005). The World Factbook: Iran. http://www.cia.gov/cia/publications/factbook/geos/ir.html (8 May 2005).

○○○○○○○○

162 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○163 Armenia

Census Figures (2000) United States Residents Born in Armenia: 65,280 (0.2%) California Residents Born in Armenia: 57,482 (0.6%) Quick Facts Country Area: 11,500 sq. miles (slightly smaller than Maryland) Population: 2,982,904 Median Age: 30.07 years Population Growth Rate: -0.25% Life Expectancy at Birth: 71.55 years Below Poverty Line: 50% Literacy Rate: 98.6% Currency: dram (AMD) Population Groups: Armenian 93%, Azeri 1%, Russian 2%, Other (mostly Yezidi Kurds) 4% (2002) Languages: Armenian 96%, Russian 2%, Other 2% Religion: Armenian Apostolic 94%, Other Christian 4%, Yezidi (Zoroastrian/animist) 2% Government: Republic of Armenia: country divided into 10 provinces plus the capital, Yerevan, which has status of a province Climate: hot, dry summers; cold, snowy winters Natural Hazards: earthquakes, droughts Natural Resources: copper, zinc, gold, lead, hydroelectric power, gas, petroleum Arable Land: 17.55% Agricultural Products: fruits, vegetables, wines, dairy, livestock Exports: diamonds, scrap metal, machinery, equipment, brandy, copper ore Industries: chemicals, electronic products, machinery, processed food, synthetic rubber, textiles Labor Force: agriculture 45%, industry 25%, services 30% ○○○○○○○○

164 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Armenia, cont. Brief History Homo sapiens skeletal remains discovered near present-day Bjini, Armenia, are thought to be one to two million years old. Other prehistoric sites include a ca. 90,000 BC settlement in Yerevan, the first signs of the use of obsidian to make knives, spear heads and tools. Traces of stored grain were discovered at the site, indicating mankind moved from a hunter-gatherer society to a collective unit much earlier than previously thought. On the Armenian plateau the domestication of wheat began about 15,000 years ago. Armenia is noted for being the first nation to adopt Christianity as a state religion, in 301 AD, when St. Gregory the Illuminator baptized King Tiridates III. Mt. Ararat, identified by biblical tradition as the mountain on which Noah’s Ark came to rest, is visible from the capital city of Yerevan but now officially in Turkish territory and off limits to Armenians. Armenians settled in the kingdom of Ararat in the 6th century BC, and their empire reached its height under Tigrane the Great, who ruled from 95 to 55 BC. The empire stretched from the Caspian to the Mediterranean seas. Overall, the history of Armenia has been one of invasion and conquest. Conquering armies include the Greeks, Romans, Persians, Byzantines, Mongols, Arabs, Ottoman Turks, and Russians. From the 16th century through World War I, the Ottoman Turks controlled major parts of Armenia. The most brutal of all invaders, the Ottoman Turks massacred thousands of Armenians between 1894 and 1896. During World War I, in 1915, the Turks ordered the deportation of the Armenians to the deserts of Syria and Mesopotamia, where as many as 1.5 million were murdered or died of starvation in the first genocide of the 20th century. Most Californians can make the acquaintance of Armenians whose relatives died during the genocide, which Turkey and Turkish sympathizers deny to this day. When Turkey was defeated at the end of the war, the independent Republic of Armenia was established on May 28, 1918. It survived only until November 29, 1920, when it was annexed by the Soviet Army. In 1936, Armenia became a constituent republic of the U.S.S.R. An earthquake measuring 6.9 on the Richter scale struck Armenia on Dec. 7, 1988, killing some 25,000 people and leaving more than half a million homeless. In that same year, Armenia became involved in disputes with neighboring Azerbaijan over the region of Nagorno-Karabakh. This situation led to a blockade of Armenia by Turkey and Azerbaijan, which continues even though a cease-fire was reached in 1994. These two catastrophic situations have had far-reaching economic consequences for Armenia, which declared its independence from the collapsing Soviet Union on Sept. 23, 1991. Armenians are spread throughout the world—some 60 percent of the estimated 8 million Armenians worldwide live outside the country. Armenians call their country Hayastan and refer to themselves as Hai. Housing, Family, Work, Traditions Housing: In the earthquake zone, 16 years after the 1988 earthquake, thousands of families still live in metal shipping containers called domiks, brought to Armenia as part of the earthquake relief effort. The US Agency for International Development and NGOs including Habitat for Humanity are working to provide adequate housing. Habitat is assisting families to complete houses they had started to construct as well as purchasing apartments and reselling them interest-free to families who renovate them. Through its housing purchase certificate program, USAID has provided new homes for 3,000 families. Family: Generalizations about family structure in present-day Armenia are difficult to make. The devastation of the 1988 earthquake coupled with turmoil following independence from the Soviet Union and economic blockades by Turkey and Azerbaijan have made daily life problematic for many Armenians. According to the United Methodist Committee on Relief, which has been working since 1995 with the United Nations and other agencies on development programs, sustaining a family is very difficult. Many people are reluctant to marry, men are unemployed and depressed or have left the country for employment, and scarce family resources have led to many parents giving their children up to orphanages where they will have adequate food and clothing and receive an education. Of the estimated 10,000 children in Armenian orphanages, international organizations Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○165

Armenia, cont.

estimate that 90 percent of them have families who are unable to care for them. Since the breakup of the Soviet Union, abortion has been widespread. In Yerevan, the capital city, efforts are being made to help street children and provide employability skills to young people. Although the Constitution provides equal rights for women, as in most countries women in Armenia remain subordinate to men in many areas. The Armenian woman traditionally had an accessory role in the family and in society. The way of life, popular rites, social norms, and common mentality have presumed her subordination to her husband. Women often remain economically dependent upon men. The overall average salary for women is less than two-thirds that of men because of the low involvement of women in high-paid activity. Social mobility for women is lower than it is for men. Women bear the burden of the so-called informal sector of the economy, which includes assuring the functioning of the family, educating and caring for the children, and maintaining the household. Daily Life: For interesting observations on daily life in various parts of Armenia, visit the Web site of Califor- nian Andranik Michaelian, a cousin of William Saroyan, and read his monthly Yerevan Journal at http://road-to-armenia.com. In the October 2004 entry he writes: “Far from the bustle of Yerevan, Spitak, as a city, is still recovering from the effects of the 1988 earthquake, with the bulk of the population out of work and many of the youth having left the country to find employment and a future they don’t see in Spitak. . . . Although the economic situation here is showing some movement, it is known that the lives of many here are made easier due to the money being sent by relatives, many now firmly establishing themselves in Europe, Russia, or the U.S., thus increasing the amount of money transferred to their relatives in the homeland.” Employment: In 1993 women accounted for 49 percent of Armenia’s labor force; unemployment among women reached 64 percent that year, whereas the same index among men was 36 percent. Women’s employment in the newly formed private sector was not high, only 45 out of every 1,000 working women were involved in registered small businesses, whereas for men this index was 75. Men take out the majority of bank loans. However, more Armenian women are attaining active economic positions in contrast to men, who are confused with loss of their jobs in the state sector because of low wages. Women have started to make serious contributions to family budgets, sometimes becoming the sole bread providers. Mostly their activity is in unregistered self-employment (cooking for sale, working as housekeepers, engaging in trade outside of Armenia, etc.). Their social and political activity has also increased. In 1995 women accounted for 85 percent of schoolteachers and high percentages in medical, journalistic, judicial, and other professions. The overwhelming majority of NGO members are women. Foods and Eating Habits Dietary Practices: No dietary taboos. Everyday Diet: Breakfast for an Armenian would consist of coffee, bread, and jam, but might include cold meats, fish, pickled vegetables, and eggs. People in rural areas enjoy matsun, yogurt, available in several consistencies. Lunch, nakhajash, is generally a light meal. Dinner, jash, is a heavy meal generally served between 5 and 7 p.m. A full course restaurant meal would begin with appetizers or salads featuring greens, cheese, sliced sausage, basturma and sujukh (dried spicy beef), bean and vegetable salads, and bread. The first course would be soup, and the main course is a meat or fish dish or perhaps both. Fruit and dessert complete the meal along with Armenian coffee. Popular Foods: The Web site Tour Armenia lists a huge variety of popular Armenian foods: htttp:// www.tacentral.com/dining.asp. Appetizers include lobiov pashtet, a paté of red beans and walnuts, and sunk, mushrooms that have been pickled and mixed into a spicy paté. Many Californians are familiar with Armenian foods including dolma, spiced meat and rice wrapped in grape leaves or ○○○○○○○○

166 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Armenia, cont.

cabbage, and pilaf. Desserts are very popular and include the familiar baklava, halvah, and rice pudding as well as cakes, fresh fruits, and ice cream. Armenians eat a a great deal of bread, including the lavash familiar to most Californians. A famous Armenian ham-based soup, khash, is cooked all night and served in the morning with quantities of fresh garlic and lavash. Main dishes feature chicken, beef, and pork, and the most popular is khorovatz, marinated grilled meat. Education Status: When it was part of the Soviet Union, Armenia experienced universal enrollment in basic education from ages 7 to 15. The law requires children to attend school from ages 6 to 17. Literacy is close to 100 percent. Since achieving independence in 1991, Armenia has faced both political and economic challenges to developing a national school system. Financial difficulties have been com- pounded by the 1988 earthquake, which destroyed much of the nation’s infrastructure, and the conflict with neighboring Azerbaijan. State-run schools at all levels are facing problems of inadequate funding that has caused deteriorating services. Non-state institutions are also available. Information is somewhat contradictory, but the most current shows a total of 1,390 state-owned general secondary schools; 83 percent of the teachers are women. Preschool: Children ages 3 through 6 attend preschool, which is intended to develop communication skills in Armenian and lay the groundwork for learning other languages, as well as to lay the foundation for learning in primary school. The state provides day care institutions for children ages 2 to 3 and kindergartens for children ages 3 to 6. Primary School: Grades 1 through 3 form the first level of what is called the general secondary education. Basic/Middle School: This includes grades 4 through 9. High School: Grades 10 and 11. Higher Education: Graduates of basic and high schools can continue their education in two-year vocational schools or universities. Leading institutions include Yerevan State University and the Armenian Academy of Agriculture. Armenia was home to the first universities in Asia Minor during the Middle Ages. Religion Armenian Apostolic: The Armenian Apostolic Church is the national church of Armenia and claims about 90 percent of the population as members. The center of the religion, the Mother See, is the cathedral and monastery at Echmiadzin, 12 miles west of the capital city of Yerevan. Adherents recently celebrated the 1,700th anniversary of the conversion of Armenia to Christianity with bishops from all over the world gathering at the new Cathedral of St. Gregory the Illuminator. His Holiness Karekin II was elected Supreme Patriarch and Catholicos of All Armenians in 1999. As such, he visits Armenian Apostolic churches throughout the world, including California. Active participation in the church is growing since the breakup of the Soviet Union. Other Christian: There are both Roman and Armenian Catholics, Pentecostal, Greek Orthodox, Armenian Evan- gelical, Baptist, Seventh Day Adventist, and other Christian churches in Armenia. Muslim: While most Muslims have left Armenia or been deported to Azerbaijan, small communities remain. In 2002, there were about 1,000 Muslims in Yerevan, including Kurds, Iranians, and temporary residents of various Middle Eastern countries. Other: The presence of Jehovah’s Witnesses in Armenia has caused considerable strife. After many years of being denied recognition as a religion, they received it in 2004. One basis for objection has been the sect’s proscription against military service. Other religions include Mormonism, Baha’i, Hare Krishna, Judaism, and a comparatively large group of practitioners of Yezidi, a Kurdish religion that includes elements of Zoroastrianism, Islam, and animism and claims about 40,000 adherents. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○167

Armenia, cont. Health and Health Care Status: The Library of Congress country study for Armenia states: “The social and economic upheavals that followed the earthquake of 1988 combined with the political collapse of the Soviet Union to create a catastrophic public health situation in Armenia.” The trade blockade imposed by Azerbaijan in response to the conflict in Nagorno-Karabakh meant that basic medical supplies and equipment could not get into the country. United Nations intervention in 1993 eased the situation. A three-year pilot program by the American International Health Alliance in two hospitals in Yerevan focuses on nursing care standards and has resulted in improvements in quality of care. There is virtually no up-to-date information available about the health system or use of traditional medicines in Armenia. Likewise, no information could be found on things for health care providers to keep in mind when working with Armenian clients. Celebrations and Holidays January 1 New Year (Amanor): Celebrated for an entire week with special foods and gifts, visiting, gifts from Santa Claus (Dzmer Papik). January 6 Christmas (Surb Tsnund) January/February Saint Sargis: Festival 63 days before Easter, honors popular saint who brings luck, decides fate. February 14 Purification Day (Trndez) March 8 Women’s Day March/April Palm Sunday (Tsaghkazard), Easter (Zatik) April 7 Motherhood and Beauty Day April 24 Genocide Victims Memorial Day: Armenians worldwide honor the memory of the million or more victims of the 1915 genocide by the Ottoman Turks. May Ascension Day (Hambartsum): Marks the ascent of Christ into Heaven. May 9 Victory and Peace Day: A day to celebrate the end of World War II, remember the dead. May 28 Day of the First Republic: Celebrates the day in 1918 when Armenians gained independence; two years later they were annexed by the USSR. June/July The Transfiguration (Vardavar); festival of water July 5 Constitution Day: Official holiday celebrates adoption of the Constitution of the Republic of Armenia on July 5, 1995. September Holy Cross (Khachverats): Celebrates the cross and is a memorial to the dead. September 21 Independence Day: Celebrates restoration of Republic of Armenia after 70 years as part of USSR. October 12 Holy Translators Day (Targmanchats ton): Dedicated to the creators of the Armenian alphabet and to translators and interpreters of the Bible. December 7 Day of Remembrance of Victims of the 1988 Earthquake Armenians in the United States The geography and climate of California are quite similar to those of Armenia; many of the same crops Armenians grew in their native land thrive here. About half the one million Armenians in the United States live in California, most in Fresno, Glendale, Los Angeles, and San Francisco. Armenians first came to Fresno in the 1870s. They started the fig industry and were instrumental in the production of grapes, raisins, and bulgur in California. Many Armenians settled in the Fresno area following the Turkish massacres in the 1890s and in 1915. Many came to California after first emigrating to other nations including Egypt, Greece, Iraq, and Lebanon. The California Armenian community has strong churches, newspapers, schools, and various cultural organizations. Author William Saroyan is one of the best-known Armenians to make California his home. The greater New York area is home to some 100,000 Armenians, and more than 50,000 live in the Boston area. ○○○○○○○○

168 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Armenia, cont. Language; Useful Words and Phrases The Armenian alphabet was introduced by scholar and monk Mesrop Mashtots in 405 A.D.; he created the 36-character alphabet specifically to translate the Bible. There are at least three different forms of the Armenian language in use today. Eastern Armenian is the official language of the Republic of Armenia; Western Armenian is the form commonly spoken by Armenian Diaspora communities in the United States and other countries, so it is the version most likely to be encountered by U.S. health care providers. Russian is widely spoken in Armenia, and English is becoming increasingly popular along with French and German. The following words and phrases may be helpful to health care professionals: Hello (formal) Barev dzez. Please. Kh’ntrem. Hello (informal) Barev. Thank you. Sh’norhakal em. How are you? (formal) Vonts ek? You’re welcome. Charjhe. How are you? (informal) Vonts es? Pardon me. K’nerek. Very well. Shat lav. Congratulations. Sh’norhavor lini. Not bad. Vochinch. I am sick. Hivand em. Good morning. Bari luis. I want an interpreter. Tarkamanich emuzum. Good evening. Bari yereko. I understand. Haskanum em. Goodbye. Ts’tesityun. I don’t understand. Chem haskanum. Good night. Bari gisher. Yes; No Ayo/Ha; Che/Voch References “About Armenian Food.” Tour Armenia. http://www.tacentral.com/dining.asp (14 Nov. 2004). “Armenia.” Encyclopedia Britannica. 2004. Encyclopaedia Britannica Premium Service. http://www.britannica.com/eb/article Armenian Holidays. http://www.armeniainfo.am/about/?section=holidays (16 Nov. 2004). Discover Armenia. Armenian Embassy. http://armeniaemb.org/DiscoverArmenia/Index.htm (15 Nov. 2004). “Education.” Tour Armenia. http://www.tacentral.com/education.asp (14 Nov. 2004). “Education in Armenia.” Armenian Embassy. http://armeniaemb.org/DiscoverArmenia/armedu.htm (14 Nov. 2004). Habitat for Humanity Armenia. http://www2.habitat.org/intl/countryprofiles.fm (24 Mar. 2004). Krikorian, Onnik. “UMCOR: Assisting the Armenian People through the Process of Transition.” http://gbgm-umc.org/ umcor/caucasus/passingon.stm (15 Nov. 2004). Library of Congress. Country Studies: Armenia. http://countrystudies.us/armenia (16 Nov. 2004). Matiroysan, Karine. Reproductive Health in Armenia. Geneva Foundation for Medical Education and Research. http:// www.gfmer.ch/Endo/Reprod_health/Reprod_Health_Eastern_Eusope/armenia/Armenia (16 Nov. 2004). Michaelian, Andranik. Road to Armenia: The Ancient Land in Words, Music, and Pictures. http://road-to-armenia.com/ index.html (14 Nov. 2004). Rosen, Ruth. 2003. “The Hidden Holocaust.” San Francisco Chronicle. 15 Dec. http://www.groong.com/rosen.html (15 Nov. 2004). University of Pennsylvania. 2004. “Partnerships with Hospitals in Armenia and Russia Lead to Improved Patient Care and Opportunities for Nurses.” http://www/upenn.edu/pennnews/article.php?id=687&print=1 (16 Nov. 2004). USAID Mission to Armenia: Ten Years of Progress. http://www.usaid.gov/locations/europe_eurasia/countries/am/video/ 10_years_progress_transcript (14 Nov. 2004). Useful Armenian Phrases. http://www.cilicia.com (17 Nov. 2004). U.S. Department of State. Background Note: Armenia. http://www.state.gov/r/pa/ei/bgn/5275pf.htm (9 Feb. 2004). ———. Armenia: International Religious Freedom Report 2002. http://www.state.gov/g/drl/rls/irf/2002/13919pf.htm (28 Feb. 2004). Vartanian, Nicole. 2000. “A Fruitful Legacy.” Cobblestone. May. http://www.cilicia.com/armo_article_fruitful_legacy.html (17 Nov. 2004). Viviano, Frank. 2004. “The Rebirth of Armenia.” National Geographic. Vol. 205, No. 3 (Mar.), pp. 28-49. The World Factbook: Armenia. http://www.cia.gov/cia/publications/factbook/geos/am.html (8 May 2005). Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○169 Russia

Census Figures (2000) United States Residents Born in Russia: 340,177 (1.1%) California Residents Born in Russia: 54,660 (0.6%) Quick Facts Country Area: 6,592,800 sq. miles (1.8 times size of U.S; world’s largest country) Population: 143,420,309 Median Age: 38.15 years Population Growth Rate: -0.37% Life Expectancy at Birth: 67.1 years Below Poverty Line: 25% Literacy Rate: 99.6% Currency: Russian ruble (RUR) Population Groups: Russian 81.5%, Tatar 3.8%, Ukrainian 3%, Chuvash 1.2%, Bashkir 0.9%, Belarusian 0.8%, Moldavian 0.7%, Other 8.1% Languages: Russian, Other Religion: Russian Orthodox, Muslim, Other Christian, Buddhist, Other Government: Russian Federation: Moscow is capital; country includes 49 oblasts, 21 republics, 10 autonomous okrugs, 6 krays, 2 federal cities, 1 autonomous oblast Climate: ranges from steppes in the south through humid continental in much of European Rus- sia; subarctic in Siberia to tundra climate in the polar north; winters vary from cool along Black Sea coast to frigid in Siberia; summers vary from warm in the steppes to cool along Arctic coast Natural Hazards: permafrost, volcanoes, earthquakes Natural Resources: oil, natural gas, coal, strategic minerals, timber Arable Land: 7.3% Agricultural Products: grain, sugar beets, sunflower seed, vegetables, fruits; beef, milk Exports: petroleum and petroleum products, natural gas, wood and wood products, metals, chemicals, civilian and military manufactures Industries: mining and extractive industries producing coal, oil, gas, chemicals, and metals; machine building; shipbuilding; communications equipment; agricultural machinery; construction equipment; electric power generating and transmitting equipment; medical and scientific instruments Labor Force: agriculture 12.3%, industry 22.7%, services 65% ○○○○○○○○

170 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Russia, cont. Brief History Today’s Russian people originated in Slavic groups that settled the steppes of European Russia in the 6th century AD. A Scandinavian chief, Rurik, became ruler in the 9th century and established a dynasty. His descendant, Prince Vladimir, established Christianity as the state religion in 988. The Tatars invaded in 1236 and divided the country into small princi- palities, of which Moscow was one. In the late 15th century, Moscow was strong enough to free itself from Tatar control. Russian rulers, called czars/tsars, expanded their empire from the Baltic region of Europe to central and northeastern Asia. Within the empire, the common people worked land owned by the aristocracy. The Russian Revolution of 1917, with the Bolsheviks led by Lenin, ended this feudal system and the reign of the czars and established the first communist country in the world. Russia became part of the Union of Soviet Socialist Republics, the USSR, made up of several European and Asian republics. Beginning in the 1920s, industries were turned over to the state and farming was carried out by large collectives. When Josef Stalin came to power in 1929, many who opposed him were jailed, sent to gulags, or executed. Germany invaded the USSR in 1941. During World War II 20 million Russians died. Following the war relations between the Soviet Union and the other Allies worsened in a period we know as the Cold War, characterized by the amassing of nuclear weapons. At- tempts at restructuring or perestroika began under Gorbachev in the 1980s. In December 1991 the USSR ceased to exist, replaced by 15 independent republics. Russia today is a federation of 21 autonomous republics under elected President Vladimir Putin. Relations with the Islamic Chechen Republic are particularly difficult. Since 1994, more than 200,000 insurgents have been killed in Chechnya. Housing, Family, Work, Traditions Housing: About 75 percent of Russians are city-dwellers, most living in large apartment blocks where va- cancies are scarce and several generations often share an apartment. Apartments are generally small, consisting of a living room, kitchen, bedroom, and bathroom. Country dwellers may live in houses made of wood or bricks. Some Russians have summer country homes, dachas. Family: Russian families have traditionally been very close, possibly because due to limited housing several generations usually live in one house. Under the Soviet Union, when standing in long lines for food and other basic necessities was a fact of life, grandparents played a key role that allowed mothers and fathers to participate in the workforce. Many families have only one child, and children are often cared for by grandmothers, babushkas, and are raised to respect their elders. While Russian families are traditionally patriarchal, women have been part of the workforce for decades. Nevertheless, the women still bear most of the burden of housework and child care, and they are paid less than men in their professional roles. Daily life includes long commutes to work and lines to purchase food that may take considerable time to prepare. Many children attend nurseries and play schools. Russians may use the father’s first name as a child’s middle name, known as a patronym. The first name Ivan would be a middle name of Ivanovich for a son, Ivanevna for a daughter. Employment: Most industries were state-controlled until 1991, and the transition to a market economy has been difficult. In some cases, barter rather than money serves as wages. According to one source, government employees such as doctors and teachers may not receive their salaries until months after they are due. Public welfare funds supplement the wages of most Russian workers by providing free medical services, training, pensions, and scholarships. Workers and professionals receive paid vacations. Wages depend on the type of work as well as working conditions and the importance of the work to the overall economy, with those engaged in such industries as transportation, mining, and construction being paid more than average. More than 90 percent of Russian women work outside the home, doing virtually every job except mining. About 75 percent of Russian physicians are women. Unemployment is increasing: many people can find only part-time or seasonal work. Organized crime is a serious problem in Russia. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○171

Russia, cont.

Sports: Sports have played an important part in Russian culture since the period following World War II. The Soviet Union first participated in the Olympic Games in the summer of 1952 and winter of 1956. Athletes were supported by the state and won competitions in a variety of individual and team events including ice hockey, gymnastics, weight lifting, wrestling, and boxing. Russian athletes still excel in these areas. Jogging, soccer, and fishing are popular, and Russian chess players are some of the world’s best. Foods and Eating Habits Dietary Practices: Russian Jews, Molokan, and Muslims are forbidden to eat pork. They do not like ice in their beverages. When ill, Russians prefer to eat hot soups, bland foods, and plain yogurt. Everyday Diet: Long, cold winters lead to a shortage of fresh vegetables and fruits, and food is relatively expensive. The Russian diet is heavy on carbohydrates, salt, and saturated fats, with starchy root vegetables and bread serving as mainstays of the daily menu. Meats are often dried, salted, or pickled to preserve them; fresh meat is not always available. Sausage, potatoes, and bread are standard daily fare, with cabbage and various grains used as well. A typical meal might begin with zakuski, cold appetizers, including cold meats, smoked fish, pickled mushrooms and cucumbers, spring onions, and perhaps caviar. Zakuski might be followed by a soup such as borsch (beet) or shichi (cabbage), which would be followed by meat or fish with potatoes. Dessert might be stewed fruit or pancakes filled with jam or cream (blini). Popular Foods: The Web site http://www.ruscuisine.com has a wealth of information and recipes for foods and beverages enjoyed by Russian people, as well as information on other aspects of Russian culture. One popular traditional dish, pelmeni, are filled dumplings resembling pot stickers or pierogies. The Russian version is often filled with pork and served with sour cream, soy sauce, and hot mustard. Making the pelmeni may be a family activity for special occasions. Kulich is a popular bread, and borsch, beet soup, is served hot or cold and is probably the most familiar Russian dish. Another variety of filled dumplings, vareniki, are also popular. Beverages: Black tea is a favorite beverage, often prepared in a samovar or self-boiling urn. Kvass, another popular beverage, is a non-alcoholic drink made from dark bread or malted rye flour. This beverage is sometimes added to chopped meat and vegetables to create a cold soup, okroshka. Russians are noted for their high levels of vodka consumption. Made from wheat, Russian vodka runs the gamut from colorless Moskovskaya and Stolichanaya to a variety of bitters with herbs and spices. Education Primary Level: The school year begins in September and concludes at the end of May. Students attend five or six days a week. Students may arrive early in the morning and stay after formal classes for supervised homework. Many Russian children attend kindergartens or creches. Public education is free and compulsory through the 9th form/grade. Primary general education begins at age 6 or 7 and takes four years. Non-Russian children are taught in their native language. Secondary Level: Basic secondary education takes five years. Upon completion of the 9th grade, students receive the Certificate of Incomplete Secondary Education. Graduates who continue on to two years of senior high school receive the complete secondary education. The Russian language is a required subject. Professional Level: Institutions of initial and intermediate professional education train qualified workers and middle- level specialists including technicians and nurses. Students can complete courses in two years if they have completed their secondary education; those who have completed only the five-year basic secondary education can complete the courses in about four years. ○○○○○○○○

172 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Russia, cont.

Higher Education: Higher education in Russia includes three levels: (1) incomplete higher education (at least two years), (2) basic higher education (four years) leading to the first university-level degree, and (3) postgraduate higher education. Admission to higher education is very competitive. Courses are taught almost exclusively in the Russian language. More than 40 percent of Russians have a college or university degree, but this does not necessarily translate to an advantage in the job market, where knowledge of English is more sought-after than an advanced degree. Religion Russian Orthodoxy: While the constitution of the former Soviet Union guaranteed religious freedom, the practice of religion was difficult. Most Russians are members of the Russian Orthodox church, which dates to the close of the 10th century when Russian ruler Kievan Rus was converted to Christianity by missionaries from Byzantium. Prince Vladimir made Christianity the state religion in 988. The monastic movement was an important element of economic and social as well as spiritual life during the Middle Ages. When the Bolsheviks came to power in 1917, they nationalized church property and executed or persecuted many priests. In 1939 the state relaxed restrictions on religious practice; the church supported the country’s efforts under Stalin in World War II. But Kruschev revived restrictions on religious freedom. By the 1980s only 3,000 churches and two monasteries were active. With the collapse of the Soviet Union, churches began opening; more than 8,000 opened between 1990 and 1995. Other Christian: Other Christian religious groups in Russia include the Molokans, a group that separated from the Orthodox in the 17th century; Baptists and other evangelical groups, which experienced growth during the 20th century and now number about 2 million; and about 1.3 million Roman Catho- lics. Molokans maintain strong beliefs in pacifism and communal enterprise. In rejecting Orthodoxy’s rituals, including the veneration of icons, Molokans suffered persecution during the Tsarist era. At one point the number of Molokans reached an estimated 500,000. During the 19th century, Molokan communities developed in Caucasus and Central Asia. Today, Molokans are found around the world, with several dozen communities in the United States including Los Angeles, San Fran- cisco, and the Central Valley as well as Baja California. Islam: In 2004, 20 million Russians were Muslims, most of them concentrated in two regions of the country—the Volga river basin and the Caucasus. During the days of the Soviet Union, most mosques and madrasas were destroyed or closed. With the Soviet Union’s collapse in 1991, Islam experienced a revival. Hundreds of mosques and religious schools were opened with the assistance Muslims in Saudi Arabia, Turkey, and Iran. Efforts of Muslims in the Republic of Chechnya to break away from Russia and form an independent Islamic republic have been the source of ongoing terrorism and bloodshed. Buddhism: Tibetan Buddhism has long been practiced in Russia and was officially recognized by Empress Elizabeth in 1741. When Stalin came to power in the early 20th century, he had most of the temples and monasteries destroyed and many Buddhists killed. With the breakup of the Soviet Union, Buddhism is being reestablished. Most Russian Buddhists live in the autonomous Repub- lic of Buryatia in southern Siberia and belong to the Yellow Hat Sect whose spiritual head is the Dalai Lama. Judaism: Jews were persecuted in Russia both under Stalin and during the Nazi occupation. Emigration to Israel and other countries has been permitted since the late 1980s. The majority of Russian immigrants to the United States are Jewish; the first wave arrived in the late 19th and early 20th centuries. From 1980 to 1991, about 181,000 Russian Jews emigrated to the United States. Because Jews were discouraged from practicing their religion in the Soviet Union, many Jewish immigrants are cultural rather than religious Jews with little knowledge of their religion. Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○173

Russia, cont. Health and Health Care Health Status: Malnutrition is a problem due to the shortage of fruits and vegetables, with many Russians consuming diets high in carbohydrates. Declining food production and increasing environmental pollution have negative health impacts for many Russians. Cardiovascular disease, cancer, and various forms of trauma account for 75 percent of deaths. Rates of infectious disease such as tuberculosis, hepatitis, and dysentery are rising sharply. Both life expectancy and the birth rate continue to decline. Excessive consumption of alcohol and tobacco cause significant health problems. Medical System: The Russian health system is organized around regional clinics. These are often short of basic supplies and are staffed not by physicians but by medical aides. Traditionally, patients are not held responsible for participating in their own wellness. Health care is free. Physicians are plentiful but not paid well; immigrant physicans in the United States report sending money to their Russian counterparts so they can purchase meat and other luxuries. Another source reports that tips or auxiliary payments may be given to ensure good care. The quality of health care has declined due to poor intensive and emergency care, insufficient training of medical personnel, shortages of medicine, and limited development of such specialized services as maternity and hospice care. Traditional Practices: Herbal remedies are used widely and include Valerian root and Motherwort for such things as insomnia and headache, Hawthorn berries for blood pressure and cardiac conditions, coltsfoot for respiratory ailments, and charcoal in water for stomach acid. One traditional medical treatment designed to draw evil humors out of the body, used in many Asian cultures, is called “cupping.” It involves heating cups and applying them to the back, a process that often leaves bruises. Other commonly used treatments include steam baths, massage, and leech therapy. Tips for Health Care Providers Health Status: Hypertension is widespread among Russians, but often they view it as a condition that does not require the regular use of medication. Many Russian immigrants suffer the effects of heavy ciga- rette use, high alcohol intake, environmental pollution, and crowded living conditions in their former homeland. A study published by the American Medical Association reported that Rus- sian-speaking immigrants reported an unusually high frequency of health complaints as compared with other immigrant groups as well as higher than average levels of depression among older immigrants. Attitudes: One source notes that Russian immigrant patients are often seen as loud and complaining, a result of having to go to great lengths to get treatment in their native country. The Soviet medical system was paternalistic and authoritarian and did not encourage patients taking an active role in their health care. Russian patients may not trust care or advice given by nurses, as nurses in the Soviet system had no independent authority. One source suggests that nurses say: “Dr. X instructed me to tell you/do . . . .” Older patients may be suspicious of young health care providers. Russian patients may attempt to give the physician monetary or other gifts, as was the custom in their country to augment the low salaries of physicians. While monetary gifts must be refused, one source suggests accepting other gifts graciously while explaining that they are not necessary. Russian immigrants tend to see the U.S. health care system as a panacea and may use medical services excessively and sometimes inappropriately, a pattern that may be related to the stigma attached to mental illness in their homeland. Rather than discuss emotional troubles, they may report physical symptoms. Physicians and other health care providers need to guard against cat- egorizing their Russian-speaking patients as hypochondriacs. Integrating behavioral health services with primary care is one solution, and researchers note the success of adult day programs that target elderly Russian immigrants with socialization, English-learning, and other services. ○○○○○○○○

174 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Russia, cont.

Family Authority: Patients will generally want to discuss procedures and matters of consent with family members. Decisions makers are the father, mother, eldest son, and eldest daughter. Addressing Clients: They should be addressed by title and family name, not by first name alone, and they may be wary of superficial friendliness. Many recent immigrants will speak English. Russians are very respectful of elders. Nonverbal Exchange: Direct eye contact is usual. When greeting one another, Russians may kiss each other on the cheeks as well as shake hands. In medical situations, the gender of a provider is not generally a concern. Like most patients, they look for a caregiver who is competent and sincere. Once a relationship of trust has been established, Russian patients may be open to expressions such as touch and humor. Verbal Exchange: Russian patients may speak loudly when attempting to make themselves understood. They may be cautious with a health care provider until a relationship has been established. Religious Practices: Due to proscriptions on practicing religion in the former Soviet Union, many Russians may not actively practice their faith and will need no special accommodations. Depending on their religion, Russian patients may ask to see a priest, rabbi, minister, or other religious leader. Hospitalization: Under the Soviet system, hospital stays were often longer than is customary in the United States, and patients may be disturbed by outpatient procedures and shorter hospitalization. Diagnostic tests were not used frequently in the Soviet Union, so health care providers should explain the purpose of such tests without going into great detail. Russians do not like iced drinks. They tend to be stoic and have a high pain threshold; they may not ask for pain medication. Death and Dying: Family members should be notified of a terminal diagnosis and given the choice as to whether or not to tell the patient. According to one source, Russians consider a diagnosis of cancer a death sentence and tend to respond to it with fear and/or denial. Physicians generally do not reveal a diagnosis of cancer. Russians may prefer to care for a dying family member at home rather than use a hospital or nursing home except in cases of acute illness. Depending on religion, family members may want to wash the body or dress it in special clothing. Most do not believe in cremation and are not comfortable with organ donation or autopsy. Celebrations and Holidays January 1 New Year’s Day: A popular holiday which some Russians also celebrate on January 13/14, which corresponds to the first day of the Julian calendar used in Russia until 1918. January 7 Russian Orthodox Christmas February 23 Soldier’s Day, formerly known as Soviet Army Day March 8 International Women’s Day: Women receive flowers and gifts. May 1 May Day, also called Spring and Labor Day May 9 Victory Day: Celebrates victory over the Germans in WWII; flowers and wreaths laid on graves of some of the 20 million Russians who died in the war. June 12 Independence Day: Commemorates the adoption of the Declaration of Sovereignty of the Rus- sian Federation in 1991. August 22 Day of the Russian Federation State Flag November 7 Day of Accord and Conciliation: Anniversary of the socialist revolution of October 1917. December 12 Constitution Day: Celebrates first Constitution of the Russian Federation, 1993.

Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○175

Russia, cont. Russians in the United States Recent Russian immigrants to the United States tend to be older overall than other groups, with 20 percent being over 65 years old. A recent survey of Russian immigrants to Minnesota found that 83 percent were over 50 years old. The first Russians arrived in the United States in the mid-1700s as Russians crossed the Bering Strait into Alaska. Waves of Rus- sians emigrated to this country in the late 19th and early 20th centuries as a result of ethnic and religious persecution, and after World War II when Russians displaced by the Nazis came to the United States. Beginning in the late 1980s, about 50,000 Russian-speaking immigrants have settled in the United States each year. In 2003, some 14,000 Russians emigrated to California, making it the tenth-largest immigrant group. Most Russian immigrants to the United States have been Jews escaping persecution in their native land. A 1999 Los Angeles Magazine article noted that more than 600,000 Russian-speaking immigrants lived in the area that year. Many of the immigrants are not from Russia itself, but from other Russian-speaking countries such as Armenia. Glendale has the largest Armenian population outside the capital of Armenia; 70 percent of these Armenian immigrant speak Russian. A 2003 San Francisco Chronicle article notes that about 20 percent of Russian immigrants living in the Bay Area own their own businesses. Language; Useful Words and Phrases Russian is the country’s official language, but many minority groups speak their own languages. The Russian language uses the Cyrillic alphabet, which has 33 letters. Some of the letters look like those in our Roman alphabet, but they are pronounced differently. The Cyrillic letter “P” is pronounced “R,” for example. Immigrants from Russia would probably be familiar with the following words and phrases: Hello (informal). Preevyet. Hello (more formal). Zdrástvooyte. Goodbye. Dasvidánye. Good morning. Dobraye ootro. Good afternoon. Dobriy den. Good evening. Dobriy vyecher. How are you? Kak pazhivayesh? Fine, thanks. Spaseeba, preekrasna. Do you speak English? Vi gavareetye pa angleeskee? I understand. Ya paneemayoo. I don’t understand. Ya nee paneemayoo. Yes. Da. No. Nyet. Please. Pazhhaloosta. Thank you. Spaseeba. Thank you very much. Bal’shoye spaseeba. You’re welcome. Pazhalooysta. What is your name? Kak vas zavoot? My name is . . . Meenya zavoot . . . Good luck! Shchistíva. Where does it hurt? Shto oo vas baleet?

○○○○○○○○

176 ○○○○○○○○○○○○○○○○○○○○○ Respecting Differences, Celebrating Diversity:

Russia, cont. References Bendersky, Yevgeny. 2004. “Russia and Its Muslim Population: A Balancing Act.” The Muslim News. 15 Sept. http:// www.muslimnews.co.uk/news/print_version.php?article=8101 (19 Oct. 2004). Bettencourt, Elisete. 1999. Russia. University of Toronto, Anti-Racism, Multiculturalism and Native Issues Centre, Faculty of Social Work. http://www.settlement.org./cp/english/russia (10 Nov. 2004). Carney, Thomas. 1999. “Moscow 90210: Russian Immigrants in Los Angeles.” Los Angeles Magazine, March 1999. http:// www.findarticles.com/p/articles/mi_m1346/is_3_44/ai_53980564/print (11 Nov. 2004). Diversity Resources. 2000. What Language Does Your patient Hurt In?: a Practical Guide to Culturally Competent Care. Amherst, MA: Diversity Resources, Inc. Greater Twin Cities United Way. Russian Immigrants in Minnesota. http://www.unitedwaytwincities.org/news/ immigrants_russian.cfm (11 Nov. 2004). Jones, Gareth. 1997. “Russians Find Solace in Buddhism as Monasteries Flourish.” The Asian Age, 19 Aug. http:// www.hvk.org.hvk/articles/0997/0025.html (19 Oct. 2004). Lipson, Juliene G., et al., eds. 1997. Culture and Nursing Care: A Pocket Guide. San Francisco: University of California San Francisco Nursing Press. Margonelli, Lisa. 2003. “Working Hard for the Money: Immigrants Carve Out the American Dream.” San Francisco Chronicle. 1 Oct. http://sfgate.com/cgi-bin/article.cgi?file=/gate/archive/2003/10/01/moneytales.DTL&type=printable (10 Oct. 2004). Master Russian. Basic Expressions. http://masterrussian.com/blbasic.shtml (26 Mar. 2005). ———. Visiting the Doctor. http://masterrussian.com/bldoctor.shtml (26 Mar. 2005). Meyerovich, Mikhail. nd. “Somatic Symptoms among Recent Russian Immigrants.” American Medical Association. http:/ /www.ama-assn.org/ama/pub/category/print/12906.html (11 Nov. 2004). Meyers, Deborah, and Jennifer Yau. 2004. US Immigration Statistics in 2003. Migration Information Source. 1 Nov. http:/ /www.migrationinformation.org/USfocus/print.cfm?ID=263 (11 Nov. 2004). Migration Information Source. Fact Sheet on the Foreign Born: California. http://www.migrationinformation.org?USFocus/ state.cfm?ID=CA (11 Nov. 2004). Robsville, Sean. “Rebuilding Buddhism in Russia: The Threat from Christian Evangelicals and Cultural Imperialists.” http://www.geocities.com/scimah/Russia.htm (19 Oct. 2004). “Russia.” Encyclopaedia Britannica. 2004. Encyclopaedia Britannica Premium Service. 18 Oct. 2004 http://britannica.com/ eb/article?tocid=38602. Russian Brides Cyber Guide. Russian Culture, Traditions, Holidays, Family and Daily Life. http://www.womenrussia.com/ russians.htm (10 Nov. 2004). Russian Embassy. Observed National Holidays. http://www.russianembassy.org/RUSSIA/holid.htm (10 Nov. 2004). ———. Religion in Russia. http://www.russianembassy.org/RUSSIA/religion.htm (10 Nov. 2004). ———. Russian Cuisine. http://www.russianembassy.org/RUSSIA/cuisine.htm (10 Nov. 2004). “Russian Orthodox Church History.” http://atheism.about.com/library/world/KZ/bl_RussiaOrthodoxHistory.htm (10 Nov. 2004). Rychova, Cheryl. 2003. “The Temptations of Pelmeni.” http://www.ruscuisine.com/articles/index.php?article=34 (16 Apr. 2005). “System of Russian Education.” http://www.useic.ru/russian_education/structure.htm (18 Oct. 2004). The World Factbook. Russia. http://www.cia.gov/cia/publications/factbook/geos/rs.html (8 May 2005).

Understanding and Working with Health Care Clients and Students from Other Cultures ○○○○○○○177

Kern Resource Center 5801 Sundale Avenue Bakersfield, CA 93309 (661) 827-3266 (661) 827-3304 (fax) www.health-careers.org