Galore International Journal of Health Sciences and Research Vol.2; Issue: 3; July-Sept. 2017 Website: www.gijhsr.com Review Article P-ISSN: 2456-9321

Approach to the Chinese Patient

Domingo Ly-Pen1,2

1 Emergency Department, Hospital Universitario “Ramón y Cajal”, Ctra. de Colmenar Viejo km. 9,100, 28034, . 2 Emergency Department, Royal Glamorgan Hospital, Ynysmaerdy. Llantrisant, CF72 8XR. Wales, UK. ______

ABSTRACT About 92% of ’s population is . There remaining 8% is Background: The number of Chinese people is divided among Zhuang, Uygur, Yi, Miao, increasing every year all over the world. Mongolian, and Tibetan ethnicities. [3] The Chinese ethnicity is the sixth most common vast majority of Chinese in the UK are Han, ethnic group in the UK. Even Chinese patients are not the most frequently attended in most which represents the oldest Chinese Western countries, they might be one of the community in Western and the groups with the most difficulties to second or third largest group of overseas communicate with, mainly because of the Chinese in Europe (after France and extreme differences in culture and language. Russia). Objective: The main objective of this review Traditionally, Chinese immigrants in article is to give all doctors working in Western the UK arrived from the British colony countries (above all family physicians / general (from 1841 to 1997) in China, namely, practitioners), a brief introduction about main . In recent years, plenty of customs and behavior of Chinese patients. In Chinese immigrants arrived from Mainland this way, they can get a realistic idea of Chinese China as students. [2] patients´ thinking and ideas about diseases. This should be very helpful in their clinical approach. Medical aspects and clinical interview: In this Sociocultural Aspects review article, we explain (among others) In all provinces of China, the Chinese´s sociocultural aspects, their general surname (first syllable or character) is medical problems and ideas about disease and named first, followed by the first name, their clinical peculiarities of clinical interview. which may be of one or two characters. Most frequent diseases: At the end of the Second-generation Chinese, or first- article, a practical review of the literature about generation Chinese who have spent many the most frequent diseases in Chinese ethnicity, years living in the UK, have adopted our with their clinical implications. customs, so they may have Christian names

(or associated with their Chinese name) KEY WORDS: Chinese Ethnicity, Frequent Diseases before their last name. There are numerous languages and BACKGROUND dialects in China. Nonetheless, the official Chinese ethnicity is the sixth most Chinese language or common language common ethnic group in the UK. (“Putonghua”) is Mandarin, which is the [1]Although the Chinese are one of the UK’s most spoken language worldwide. There are smallest minorities (only 379,503 people: eight main languages in China (Wu, Hakka, 0.72% of England’s population), [2] they , Minan, Minbei, Gan, Xiang and might be one of the groups with the most Mandarin), with different pronunciations difficulties to communicate with, mainly that do not allow understanding among because of the extreme differences in them; nonetheless, the written language is culture and language. [3] the same for all of them, being fully understood by all literate Chinese. Chinese

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immigrants from Hong-Kong, and along with what they are doing and will not Canton speak Cantonese. Chinese from cause any trouble. Mainland China and Taiwan speak If you receive a gift from a Chinese Mandarin, as well as their own local person, the item must be handled with both language. The phonetic transcription of hands (even if of small size) and must never Chinese phonemes to Western language or be opened in his/her presence. romanisation is called “pinying”. Chinese food is known for its Compared with other ethnicities, the variety. Chinese people usually eat more Chinese retain a socio-familiar structure and vegetables than the average Briton. Other cultural activities, with little contact with ingredients that are seldom used in the UK social activities of the country they are but are consumed by the Chinese include living. [4] The family is the main nucleus of soybeans (and all its derivatives), bamboo, their social life; it is the essential, basic, fish and monosodium glutamate. traditional and strongest institution. First- Tea is the most popular brew in generation Chinese immigrants value China, even more than in the UK; it is also responsibility in their children, so they are consumed before meals. The Chinese drink taught this value early in life, such as by very hot tea without milk, lemon or sugar. It going alone to school at an early age. For is also used when cooking numerous dishes. young people, respect for parents, older Tealeaves are composed of water, tannin people and authority figures, such as (7%–15%), caffeine (1%–4%) and other teachers, monks, doctors and nurses, [4] are a alkaloids, such as theophylline. The very important part of their attitude to life. presence of tannin implies some diaphoretic Unfortunately, such practices are not always effects by dilating the superficial vessels, observed nowadays in the society in which causing perspiration and astringent they are transplanted. [4] properties. Although the content of The Chinese are usually very theophylline per cup of tea is about 1mg, diplomatic, especially when speaking to a great tea drinkers can achieve plasma Westerner. When addressing a Chinese concentrations close to the therapeutic level. individual, we should always refer to We should remember that it’s therapeutic him/her as “Mr.” or “Ms.” with his/her range is very narrow (10–20mg/ml). surname; never call him/her by his/her first Irritability, nervousness, insomnia, name. They always greet by shaking hands headaches and seizures can be assign of or with simply a bow. overdose. Simultaneous administration of Britons might stereotypically believe some substances (coffee and erythromycin) that the Chinese people possess the may increase serum theophylline levels, following characteristics: first-generation whereas administration of some enzyme- Chinese run a self-employed takeaway inducing drugs, such as Phenobarbital, will restaurant. They are business oriented and decrease theophylline levels. These types of family focused, hardworking, thrifty, interactions are generally not clinically friendly but very insular, inscrutable, relevant among moderate consumers of tea socially conservative, apolitical and non- but should be considered in patients threatening; they do not try to impose their simultaneously treated with theophylline. [5] values but keep to themselves. Second- Westernfoodsthatdonotusuallyhavem generation Chinese students are quiet, shy, uchacceptanceamongtheChinesepopulation usually “light drinkers”, non-smokers, (not acclimated to Western flavors) are as outstanding students and easy-going follows: cured (hard) cheese, milk (thrifty individuals who never get into trouble; if lactose intolerance), jam (raw meat) and they are international students, most likely legumes (peas and lentils). Western food is they only blend with other Chinese, will get generally considered too salty, and desserts are too sweet. Rice in China is usually

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cooked well done, softer than in Western environment or macrocosm. Both are countries. constantly changing and formed of matter In Chinese cuisine (especially and energy; the interactions between these Cantonese), sugar is added to plenty of two are the basis of vital phenomena, and dishes (beware diabetics). A condiment that energy is what gives life to the matter and is wide lyused, especially in urban areas of the body. [5] China, is monosodium glutamate (vetsin, The second idea is the “Tao”, which ajinomoto). Therefore, by introducing low- is defined as “the unchangeable course of sodium diets, we must remind our Chinese Nature” or “what happens by itself”. This patients not only to avoid salt but also idea is manifested mainly in two aspects, the monosodium glutamate and soysauce. “yin” (representing the dark, the moon, The native wine in China is made femininity, passivity, what yields, etc.) and from rice (probably the world’s oldest “yang”(representing the clarity, the sun, the alcoholic beverage) and generally has a high masculine, activity, what resists, etc.). They alcoholic content. “Medicinal” wines, which are neither opposites nor contraries, but are prepared with lizards or snakes complementary and interdependent macerated in brandy, reportedly possess principles. [5] The yin is as important as the healing and invigorating properties. Ginseng yang, and the total absence of one cancels wine is also widely celebrated by those out the other. The light is not the opposite of same properties. The Chinese believe that the shadow, nor what gives in, it is the cold drinks can induce bad digestion, so opposite of what resists. In a healthy person, some spirits and wines are served hot. [3] yin and yang are in a continuous dynamic Families and relatives of admitted patients balance. Both contribute to vital energy, will typically bring special food that will which adequately circulates throughout the help with recovery according to traditional body through a network of circuits or Chinese medicine (TCM). meridians, each of which is directly China has no official religion. Most connected to an internal organ or function, Chinese from the People’s Republic of and all organs are interconnected. The state China profess no religion. Under the of health depends on the balance of energy influence of the communist regime, religion flow, which must be harmonious, rhythmic was tolerated and not encouraged. Unlike in and proportional to the needs of an the West, where different religions are individual. Obstruction (deficit) or overflow clearly differentiated from each other, (excess) in the circulation of that energy mestizo religions exist in China. The produces an imbalance that results in minority that professes some religion is disease. [5] usually a Buddhist, Taoist or Christian. Confucianism, rather than a religion, is a General Medical problems doctrine or a catalogue of rules of social Usually, Chinese immigrants use function, which has been the basis of all life medical or social community services much in China for centuries. Such rules have not less frequently than immigrants from other been easy to eradicate in a generation of ethnic groups and the British people. This communist rule. [5] disparity may be because the Chinese The Chinese theory of the process of patient generally employs auto-dispensable getting sick is difficult to summarize, as this natural remedies, including Chinese herbal would lead us to the philosophical medicine and massage therapy (cultural foundations of Nature itself, and the human factors). As they are usually working most being is only one component in it. [5] The of the day, they have little time to see a first idea that we should retain is that of doctor (labor factors). However, perhaps the globalism: every human being is a greatest obstacle to seeking healthcare microcosm that is inseparable from its might be the language barrier. [4] This seems

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logical if we consider that most of the will TCM usually solves the problem and does have serious difficulties in making not only relieve the symptoms: therefore, it themselves understood when explaining is not suitable for urgent and ill-defined their symptoms, and they may even be very conditions. In exchange for a faster result or worried about understanding the a specific and well-defined pathology (acute information given to them by the doctor, febrile infectious disease or appendicitis), and how to follow the treatment correctly. [4] they prefer WM. For example, a patient In the case of undocumented with insomnia may prefer WM to alleviate patients, the problem is even more the problem with drugs if the patient will be accentuated. These patients usually only go leaving for a weeklong trip; however, in to private and recommended doctors by their usual environment, they will surely other friends who know their situation, prefer TCM to combat the problem even if because they are afraid that the National several weeks are needed. [5] Health System (NHS) will report them to In recent decades, people in China the police (extrapolation of president have been bombarded by the media with Trump´s deportation policies). Similar to healthcare products from both the TCM and what occurs with patients of other the WM. The former emphasizes the ethnicities, absolute ignorance about the absence of adverse effects, and the latter linguistic difficulty to communicate health focuses on the speed of the results. In this and social services is crucial when accessing battle, WM presents an advantage in the such services. sense that many more headlines and front For the reasons explained above, one pages are targeted (e.g. new treatments such may easily understand why a Chinese as gene therapy and monoclonal antibodies). patient, before going to a Western physician Chinese urban environments will be more or to emergency department, would have supportive of WM than other inhabitants already tried home treatment or medication from rural environments, where the charge dispensed by the pharmacist. If the patient to relieve their ailments will be a ‘barefoot knowledge staking Chinese herbal medicine doctor’ (not trained in medical school but an (recognized as the largest pharmacopoeia in expert of TCM remedies, although they the world), doctors do not need not waste might have some notion of WM). [5] their valuable time into figure out the active Studies in which the above ingredients in such medications. Such herbs statements are based have been made in should all be written in Chinese, and only in China, but the question that remains is rare cases are the names soft he plants whether these results can be extrapolated to written in English or in Latin: they are the Chinese immigrant population in the native herbs that are not found in common UK. Currently, we have no available Western formulas. [5] evidence to answer this question. In the Chinese patients usually prefer modest opinion of the author of this article, remedies of TCM to treat less serious the answer is “no”: the Chinese immigrant diseases. In situations in which fast relief is population in the UK is not at all required or when the causative organic representative of the general Chinese pathology is clearly defined, they will population. It is a biased, more open-minded probably choose Western Medicine (WM). population, which is closer to the Chinese of In China, both medicines have coexisted for the great city than in rural areas. Therefore, over two centuries, and both have their in general, the Chinese immigrants we see advantages depending on certain conditions, in our daily practice will be less influenced speed of results, accessibility and type of by the idea soft CM than the average patients. [5] Chinese of a local Chinese population, The perception is that TCM has as except in older patients from rural areas or low erection and fewer adverse effects. living a shorter time in the UK. [5]

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Chinese immigrants generally have Overall, the Chinese patient is very no problem in receiving treatment via oral respectful of authority figures, such as contraceptives, intrauterine devices, doctor, teacher or monk. Even if they do not abortions, blood transfusions or organ agree with certain medical advice, they will transplants. not manifest it openly. Usually old male Chinese patients Some Medical Myths and Medical Ideas are more comfortable in dealing with a male of Many Chinese doctor, especially in the case of surgical They are summarized in Table 1. specialties. Chinese women, except in very young patients, do not usually have Table1. Main medical myths and ideas of many Chinese problems when being physically explored patients Droppers. by male doctors or doctors of the same sex. They are regarded as a panacea for treatment of any disease. As in all cases, it is always prudent to Many sick Chinese patients (in emergency department) request ‘to put IV fluids’. explain to the patient (or the interpreter) Medicines. how the examination will be performed and Like many other patients of other ethnic groups, Chinese patients usually consider German or American manufactured its purpose. medicines more effective than drugs made elsewhere. Secularly, Chinese women have Predilection for presentations. Broadly speaking, they prefer parenteral administration, except been discriminated against in society, younger patients or patients with try pan phobia (needle phobia). especially in rural environments. Today Traditional Chinese Medicine. This term encompasses the whole of TCM practices developed Chinese women in the 21st century, at least over millennia. They include acupuncture and its variants, in theory, have been equaled to male, herbal medicine, dietetics, “tui na”, “tai chi” and “chi kung”. In herbal medicine, the most famous and precious plant is enjoying a social situation, that even quite ginseng (Panax ginseng). Its qualities of panacea (aphrodisiac, improvable, never reached before. tonic and rejuvenator) have been extensively discussed. Its use and acceptance are widespread. [5] Chinese women in the UK, above all Acupuncture. the self-employed, can work even more time Usually preferred by older patients who have lived in China for many years and/or young patients who have had favorable than men, if we add the time working at experience with it. For centuries, millions of people have been own home. They even have to scarify their treated with this technique (and variants, mentioned below) for various conditions, although the most frequent is chronic pain. own careers and prioritize the interest of the [2] Variants of acupuncture are acupressure (the action of the family. needles is replaced by finger pressure on the same energy points), auricular acupuncture (auriculotherapy), (the field of Elderly Chinese people think that all needles is reduced only to the patient’s ear, which is supposed to kind of food is divided into “heating” and reflect all points of the body) and moxibustion (the needles are replaced by burning mug wort leaves, resembling cigar snuff). [5] “cooling” food. Some techniques such as “gua sha”, with residual purpura and Pregnancy is a heating condition, ecchymoses, must not be confused with physical abuse. [6] Blood tests. and that is the reason why pregnant women Chinese patients dislike repeated blood tests, as they believe that should reduce the intake of heating food blood withdrawal “weakens” health. [4] Teeth. (i.e.: red meat, fat, etc.), and increase Most immigrants of Chinese origin have little or no dental cooling food intake (i.e.: vegetables, fruits, culture. In the elderly, tooth decay is inevitable with age. Another reason for the infrequent visits to the dentist is the huge etc.). difference in prices of dental services in the UK compared with It is an ancient custom that after [7] the rates in their country of origin. giving birth, a Chinese mother traditionally Diet. In general, Chinese patients have difficulty in following their stays for a month at home doing nothing but diet strictly according to tradition. eat, rest and sleep. [8] During this time Feeding in fants. Inmanyfamilies(especiallyinthosewithbothparentsworking,andch should not take cooling food (fruits and ildren vegetables), but on the contrary, should eat areraisedbythegrandparents),childrenfrom9months(ifnotbefore)s tarteatingthe most varied food, such as eggs, meat, fish, fruits foods rich in protein and calories (typically and vegetables, regardless of the GP’s or pediatrician’s advice. braised chicken in sesame oil and rice wine, However, they usually strictly follow their immunization schedule.[6] soup and peach seeds, Chinese herbs and rice wine). [5] Clinical Peculiarities of Clinical Interview In China, it is common breastfeeding for many months; however, many Chinese

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immigrants cannot breastfeed their children Table2. Most prevalent diseases in Chinese children due to work. Pediatric age Lactose intolerance [3,4] Similar to patients of other Thalassemia syndromes [10-13] nationalities who do not understand English, Glucose 6-phosphate dehydrogenase deficit for additional tests or aggressive treatments Mongolian spot (congenital dermal melanocytosis) [14] that require informed consent, we must Table3. Most prevalent diseases in Chinese adults. ensure that the patient is aware of the Adults [3,4] dangers and possible consequences. Lactose intolerance For Chinese people, life is a Due to lactase deficit. About 80% of Chinese populations have a certain degree of lactose intolerance. continuous process and death is accepted as Hepatitis B [15,16] the end of the road. Children are the The high prevalence of HBV carriers in the Chinese prolongation four life times. For first- population (15%) is due to mother-to-child transmission generation Chinese patients, when asked during child birth. Hepato carcinoma (hepatocellular carcinoma) [17-19] their age, they always add on year (relative Usually associated with chronic hepatitis B. to the age as counted in the West). In China, Nasopharyngeal carcinoma [20] birth is not the beginning of life; we began Squamous cell carcinoma. The Epstein–Barr virus is involved in its genesis. to live in the moment of conception, and Esophageal carcinoma [21] when we are born, we are already a year The most common type is squamous cell carcinoma. More old. common in males and the elderly. [22,23] Whenever a Chinese patient is Gastric carcinoma Mainly adenocarcinoma. Gastros copy is often conducted diagnosed abroad with a deadly disease in in Chinese patients aged 55 years or more and in patients the short to medium term, the first course of expressing a feeling of fullness and/or heartburn. The [21] action taken is to consult a native doctor, cancer spreads via the lymphatic system, with three time’s lower incidence of liver metastases compared with with whom he/she can communicate other ethnicities. [22] directly in their language. Very often, they Cholelithiasis [24] will strongly consider the possibility of Taiwan has an extremely high prevalence (53.5%) compared with Hong Kong (3.1%) and Singapore (1.7%). returning to China to be assessed by a trusty hospital, usually in Beijing or Shanghai, or Least Prevalent Diseases seek a second opinion. When the diagnosis Chinese patients have also lower prevalent is confirmed, the classic defense diseases, compared with Caucasians. mechanisms of the human mind play a decisive role, just like in Western patients. Table4. Least prevalent diseases in Chinese

An old Chinese proverb says, “A tree may [25] Obesity grow a thousand feet tall, but when its Coxartrosis [26] [27] leaves fall, they return to its root” (people Leukoplakia in oral cavity residing far from home will eventually Giant cell arteritis [28] [9] Hodgkin´sdisease [29] return to their native soil). This is the Follicularlymphomas [30] [31] main reason why the vast majority of Paget’sdisease elderly Chinese patients (older than 65) Melanoma [32] [33] prefer to die in their native village, Dermatitisherpetiformis Psoriasis [34] surrounded by their elderly parents (if still alive) or other family members (brothers, Miscellany, Other Diseases/Clinical uncle sand nephews). If these family ties characteristics were of little weight, the patient may opt to stay and die in his British family In Table 5, we summarize other clinical atmosphere. characteristics or varied diseases, clinically

relevant. Most Prevalent Diseases They are summarized in Table 2 (for pediatric patients), and Table 3 (adults)

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Mediators between the Chinese Table5. Other prevalent diseases or clinical characteristics in Chinese communities and local social services would be most desirable, so that Chinese Epicanthus [3] immigrants have equal access to health This feature is normal not only in the Chinese, but also in Asians. Pseudo strabismus can be difficult to distinguish from systems like other immigrants and native true strabismus (differential diagnosis: cover test), especially in patients. children. The incidence of strabismus in Chinese children is not more prevalent than in other ethnic groups. “Chinese restaurant” syndrome [35-3737] STATEMENTS This syndrome consists of posterior cervical numbness radiating to both arms and back, general weakness and palpitations that Contributorship statement appear about 15–20 Domingo Ly Pen is the only author: conceived minafterintakeofChinesefoodpreparedwithmonosodiumglutamat the paper, looked for the references and wrote e.Suchsymptomslastfor about 2 h, with no hangover. Alcohol metabolisation [3] the manuscript. Alcoholis metabolized in the human body mainly through the Conflict of Interest of Financial Disclosure isoenzymes alcohol dehydrogenase (ADH) and cytochrome None p450 2E1 (CYP2E1). They metabolize ethanol to acetaldehyde, which is oxidized to acetate by aldehyde dehydrogenase Competing Interests (ALDH2). When the activity of this enzyme decreases, None acetaldehyde accumulates in the liver and into the circulation. Symptom so facet al dehyde accumulation in clued flushing, tachycardia and circulatory collapse. About half of the Chinese ACKNOWLEDGEMENTS population is deficient in aldehyde dehydrogenase. The author is indebted to Dr. Diana Ly- Acetylation [3] A number of drugs (e.g. isoniazid, hydralazine and Liu for her help in redacting, organizing and procainamide) are metabolized by acetylation of a hydrazino or writing the manuscript. amino group. The enzyme N-acetyl-transferase in the liver, which transfers an acetyl group from acetyl-coenzyme-A., catalyses this REFERENCES reactionTherateofacetylationisgeneticallycontrolledandslowacet 1. http://www.ons.gov.uk/ons/rel/census/2011- ylationisinherited as autosomal recessive. A majority of Chinese people are slow-acetylators. census/key-statistics-and-quick-statistics- Tuberculosis (TB) [38] for-local-authorities-in-the-united-kingdom- Although plenty of effective measures to control TB are being th done, China is still a country with high TB prevalence. The --part-1/rft-ks201uk.xlsAccessed30 Jan characteristics in terms of presentation and forms of treatment 2017. do not differ substantially from those we find in our environment. The Mantoux test must be performed on every child adopted and 2. Knowles C. Who are the new Chinese brought in from China. migrants in the UK? Runnymede. In Malaria [39] Equality, Culture, Employment, News, In China, malaria exists only in remote rural communities (1500 m below the Southeastern regions of the country). The disease Featured, Identity. Published 2nd Apr 2015. occur north of 33° N, from July to November; 33° to 25° N from th May to December and S 25° N throughout the year. Accessed 30 Jan 2017 Plasmodiumvivax is usually resistant to Chloro quine and Me at:http://www.runnymedetrust.org/blog/who floquine. However, malaria by Plasmodium falciparum is prevalent in Yunnan province (border with Vietnam, Laos and -are-the-new-chinese-migrants-in-the-uk Myanmar). 3. Ly Pen D. Patologías prevalentes en pacientes de etnia china. (Prevalent diseases CONCLUSIONS of Chinese people in Spain). Medifam Given the increasing number of 2001;11: 34-44. Accessed30th Jan 2017 at: immigrants in the and the UK, http://scielo.isciii.es/pdf/medif/v11n7/hable every doctor (and above all, GPs) should mosde.pdf have an updated version of the most 4. Black J. Chinese and Vietnamese families. prevalent diseases in different ethnicities. BMJ 1985;290:1063-5. Although, Chinese patients are not the most 5. Ly-Pen D. Manual de Atención al common race in our daily practice, they can Inmigrante (Manual of immigrant care). be the most challenging and difficult to Chapter25. Ed Ergon 2009. pp: 411-25. ISBN: 978-84-8473-755-1. communicate with. Extensive knowledge 6. Ly-Liu D, Ly-Liu JD. Multiple ecchymoses and understanding of their customs and in a female patient of Chineseorigin. IJCAR most common diseases will be most helpful th in the clinical approach, diagnosis and 2015; 9: 352. Accessed30 Jan 2017 at: http://journalijcar.org/sites/default/files/issu management of these patients. e-files/0202.pdf

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