Interpreting Health: Cultural Barriers at New York City Hospitals

Maha Attieh is the health program manager at the Arab American Family Support Center, and she has a constant stream of clients at her small office on Court Street in Brooklyn. Attieh's job is to help new immigrants navigate a daunting and foreign health-care system. But she says she spends a lot of her time educating health providers about what alienates her clients.

"Like in the hospitals, if a Muslim person is dying they're supposed to be facing east. Does the hospital know these things? If a Jewish [person is] dying when they wear their yarmulke, they should leave it on their head because of the religious issues," Attieh says.

The city's public hospital system, which receives the bulk of immigrant patients, established a special department, the Center for Culturally and Linguistically Appropriate Services (CLAS) in 2006. Attieh says she's glad hospitals in the city are becoming more sensitive to the needs of the Arab-American community. But she says there are still cultural hurdles that make medical care an unpleasant ordeal for her clients.

On Christmas Eve, a 31-year-old woman from Yemen, wearing a traditional black robe decorated with red embroidery, walked into Attieh's office for help with a Medicaid application. Halima (who did not want to use her real name because she didn't want her community to know about her struggles), has eight children. The first five were born in her village in Yemen, where it's traditional for women to give birth in their homes while kneeling on a special mat placed on the ground.

"My father's father, he cut the umbilical cord and cleaned everything, he took care of everything," Halima tells Attieh, in Arabic.

But when giving birth to her first American-born child at Kings County Hospital in Brooklyn, Halima found herself lying immobile on her back, hooked up to an IV, feeling helpless and exposed. She wanted to be in her customary position, on her knees. So she asked the nurses, but they refused. "This is our business, not yours," Halima remembers them telling her.

Not knowing hospital rules or her rights as a patient, Halima found childbirth in Brooklyn frightening and traumatic.

Patients refusing medication, requesting specific foods, and preferring home remedies are issues hospitals in New York face daily. And major life events like birth and death are when cultural issues are likely to arise. Even though hospitals in the city are training their staff in cultural competency, they can't always accommodate patients completely.

Surrinder Suri, a nurse at Elmhurst hospital in Queens, says when there are tragedies like still births, some of her patients ask to take the placenta home for burial in their back yards. But the hospital can't allow that because of Department of Health regulations.

"We tell them we can give you a piece of the cord and you can put it in a test tube and you can bury it. So you find an alternative to help them carry their practices," Suri says. To improve relations with the community, Suri says Elmhurst has been training its nurses in cultural sensitivity. They're now open to Muslim women who insist on female doctors, and Chinese and Korean patients who hang numbers in their rooms as signs of good luck. But the line is drawn at what the hospital considers patient safety issues. Touching a newborn's lips with honey is a traditional practice in many parts of the world--but in American hospitals it's forbidden, for fear of botulism. It's times like these when arguments between patients and providers occur.

Dr. David Rubinstein, director of cardiology at Elmhurst, finds that taking the time to find a middle ground with patients is crucial. "You have to be very sensitive to their family and community needs," Dr. Rubinstein says. "The idea that you can just give a pill and think that a person is either going to take it or continue to take it is not correct."

Dr. Rubinstein is trying to forge a relationship with the South Asian community living around Elmhurst hospital, which has a disproportionately high rate of heart disease. But he says it's difficult to communicate -- and not just because of language barriers. Last summer for example, he brought a group of college students to a Sikh temple to give a presentation about heart disease. But one of the students who helped organize the outreach project was upset when he found the older community members, mostly senior men, didn't take him seriously because he was so young. He asked Dr. Rubenstein why they weren't listening to him. Dr. Rubenstein replied, "Because people have to be approached in a certain way if we're going to get the message across."

Cultural differences in how to define illness and treatment also compound the communication problem -- and can have fatal consequences.

Last year, Evens Jean, a language interpreter at Bellevue Hospital, was working with a Haitian patient and her doctor. In the patient's previous appointment, many months earlier, she had been diagnosed with breast cancer.

"So by the time the patient came back to see the doctor it was already too late because the cancer had metastasized. The patient was asking the doctor, ‘Is there any way you can give me some pills or some ointment I can apply over that area because I don't feel any pain.' The doctor was trying to talk to her, saying ‘no,'" Jean says.

Jean, who was born in Haiti, understood the cultural barrier, and decided to step out of his role as an impartial interpreter and explain to the doctor why communication had failed. "I jumped in and told the provider that this is how it is in our culture. If we don't feel the pain, if we don't have an open wound, basically, we're fine."

That's exactly the kind of situation Maha Attieh is trying to avoid at the Arab American Family Support Center. She desperately wants the women in her community to get screened for breast cancer before it's too late. But she says it's been a struggle to even get women to the hospital, and many don't know they can request a female doctor.

"Our women, they don't like to show the whole body in front of the doctor when they do their mammogram. They think it's painful for them to do it, but we assure them that a woman will be doing the mammogram for them," Attieh says.

A few years ago, Dr. Francesca Gany, director of the N.Y.U. Center on Immigrant Health, noticed the same thing. She saw data showing there were almost no Arab-American women getting screened for breast cancer in New York City. In an effort to counter this health disparity, she started an outreach program. It wasn't simple. Many of the women had had negative experiences with the health-care system, and they were reluctant to return. They told her they received high bills they didn't owe, and encountered providers who weren't "sensitive to their needs or who could be racist about having immigrants come in for care." After those experiences with the health-care system, Dr. Gany says "chances are they'll never come back unless it's dire."

Back at the Arab American Family Support Center, Halima tells Maha she not only had a traumatic childbirth experience in the U.S., but she also struggles with the American health-insurance system. Halima's henna-stained hands are clutching a plastic bag that holds eight passports, Social Security cards, birth certificates, old health-insurance cards, and pay stubs. Halima only knows a few words of English, and can't read or write Arabic. Maha Attieh, who is filling out the Medicaid application for her children, asks Halima for a new document every few minutes, and she shuffles through the documents.

Because she didn't understand the Medicaid re-enrollment form that was sent to her home, Halima missed the renewal deadline, and her eight children lost their insurance. Attieh says most of her clients get lost in the American health-insurance system, so they just go without it. Furthermore, she says many avoid public health insurance even if they're eligible for it, because they think it will affect their citizenship applications. That means they don't see doctors until they land in the emergency room, which ends up being more costly to their health, not to mention hospital budgets. For all these reasons, the Arab American Family Support Center started a health advocacy program last year. They trained six bilingual community members to be cultural navigators for the health-care system.

"They are our eyes and ears in the community, they let people know it's okay to get health insurance, it's okay to access health care because we are there to help them out," Attieh says.

These navigators accompany immigrants to hospital visits, advocate for culturally sensitive care, and make sure patient and doctor are truly communicating. Necole Brown of Healthy Families Brooklyn helped train the advocates and says they help new immigrants learn the very basics.

"Okay, you have a health insurance plan, now you have to pick a primary care doctor. What does that even mean to somebody?"

Brown says the Center's program is successful because the advocates come from the community itself, and they're natural leaders that people flock to anyway. Not only is this program highly sensitive to the community's specific cultural needs, it may also be more financially sustainable than hospital led programs.

Back in Queens, Dr. Rubenstein says it's getting harder for him to raise money for his South Asian outreach program as the hospital's budget is squeezed. Especially since Elmhurst doesn't get paid for preventative medicine.

"It's very difficult to find targets to treat and goals to measure with outreach activities. If you bring 1,000 patients into the hospital to get care and follow up, you've probably done a tremendous good to the community, but how do you track that? It's very difficult," Dr. Rubenstein says.

That's why community based health programs run by groups like the Arab American Family Support Center are taking on a bigger role in immigrant health. These insiders are fluent in the cultural language that builds trust with hospitals -- and trust is what's needed to get people in, before there's a crisis.

This series was conceived and produced as a project for The California Endowment Health Journalism Fellowships, a program of USC's Annenberg School for Communication & Journalism.