Culture-Sensitive Health Care: Russian Jewish Immigrants
From What Language Does Your Patient Hurt In?: A Practical Guide to Culturally Competent Care.
Russia is the largest country in the world. Its territory runs from eastern Europe to the Pacific shore. It has tremendous geographic and climatic variety. Its lands contain much of the world's gas and oil reserves, as well as diamonds and precious metals. The history of Russia until recent times has been one of political dictatorship, whether by the Tsars or later by the Communist regimes. The birth of the Russian state began in the 13th century in Muscovy. Ruled by dukes, and later by tsars, Russia grew and expanded into the Russian Empire in the 18th century. During World War I, the Bolshevik revolution resulted in the establishment of communist rule under Lenin and his successor Stalin. Russia was renamed the Union of Soviet Socialist Republics. The USSR became isolated from the rest of the world until World War II when it allied itself with England and the US against Nazi Germany and Japan. After World War II the USSR annexed many of its immediate neighbors and the "cold war" began. This period can best be described as a 45 year nuclear stand-off between the two major world powers, the USA and the USSR. The standoff came to an end in the late 1980s when Mikhail Gorbachov and later Boris Yeltsin introduced democratic and free market processes to Russia. While the new freedoms have been beneficial in many ways, the price of freedom has been high. Most of the old ways of doing things have proved unadaptable. Efforts to introduce a market economy have mostly benefited unscrupulous profiteers whom the government, unable to collect tax revenues, is almost powerless to control. This has resulted in economic and social chaos. Some indications of the seriousness of Russia's current problems are that life expectancy has dropped by 5 years to 59 years for men since 1990. 70% of Russians live near or below subsistence level. 40% of children are chronically ill. Food production continues to decline, and environmental pollution is at many times permissible US levels. Cardiovascular diseases, cancer, and trauma (on road, at home, or at work) cause 75% of deaths in Russia. Rates of infectious disease are on the rise since 1990. 100,000 people have contracted Tuberculosis, and rates of hepatitis and dysentery are up sharply in recent years.
Diversity Resources, Inc. Amherst, MA. 2000.During the 20th century, the majority of Russian immigrants to the USA have been Jewish. This has to do with history and politics. Like many European countries, Russia has a history of anti-semitism-- in the 19th century, Jews were required to live within a "Pale of Settlement" in Eastern Russia, and within the pale, were segregated into their own communities or shtetls. In Russia, Jews traditionally could not own property or land. The first major wave of Russian immigration to the USA occurred from 1881 to 1914, when about half were Jews. These Jews continued to practice their faith in the US, as did those who fled the Bolsheviks between 1920 and 1922. The third major wave of immigration occurred after WW2, when many Russians, displaced to Europe by the Nazis during the war, were able to immigrate to the US. The most recent immigration began in the 1970s, when Jews were allowed to go to Israel. Many used this as a stepping stone to come to the US. In the period from 1971-1991, about 181,000 Russian Jews came to the USA. In 1991, 2/3 of all Russian emigrants were Jewish. Of these emigrants, about 20% were over 65, making this one of the oldest immigrant populations. It is important to note that after WWI immigrant Russian Jews were only "nominal Jews." After the Bolshevik Revolution in 1917, Jews as well as other religious denominations were discouraged often forcibly from practicing their religion, and therefore these Jewish immigrants from the USSR have never visited a synagogue and have no knowledge of Yiddish or Hebrew.
Communication
Russian is a Slavic language, which uses the Cyrillic alphabet. Many Russians may have learned English as part of their education in Russia, however, the spoken English of new immigrants may sound very foreign to American ears. Many elderly Jewish immigrants speak Yiddish. Many medical and technical terms that could be used by immigrants have similar sound and meaning to the corresponding American medical terms.
Styles of communication may include speaking loudly when trying to be understood. Nonverbals such as touch are freely used between friends, and are expected and accepted from health care professionals. Feelings are expressed freely when the relationship is one of trust, and Russians have been described as warm, emotional, and with an appreciation of jokes and satire. Until a relationship of trust has been established though, they may appear cautious and shy as they carefully evaluate unfamiliar people and situations. Eye contact may be avoided and affect may be flat. Russians look for sincerity, competence and friendliness in deciding whom they can trust among caregivers. A superficial brightness in the caregiver will not ensure trust. Russians expect to be addressed by "Mr." or "Mrs." with their family name, or by their first name followed by a patronymic (their father's first name with a masculine or feminine ending depending on the person's sex). It is socially unacceptable to address the Russian patient by their first name only, or by any term of endearment such as "hon."
Social Organization and Values
The emigration policy of the USSR has contributed to whole families coming to the USA, since aging relatives were forced to accompany their children if there were no other family members staying in the USSR to take care of them.
The typical Russian Jewish family is very close, and the mother figure is revered. Family structure is very strong, and the divorce rate unusually low. Some background factors other than ethnicity that may have contributed to this closeness are the necessity for several generations to live under the same roof because of housing scarcity in the USSR, their dependence upon one another for such services as child care and management of the household. For example, the necessity of standing in line for hours to buy food and basic necessities, which for decades was the norm in the USSR, meant that grandparents able to do this as well as care for children could allow their adult children to spend their day at work. Emotional closeness is exemplified in much mutual dependence between the generations, as well as the tradition of patriarchy and respect for parents and older persons in the USSR Domestic violence is uncommon among Russian families, even though they may be very expressive in their disagreements. The intense bonds between the generations are inevitably disrupted by the experience of immigration, which leads to separated housing and distancing between the grandparents and their adult children and grandchildren who assimilate into the new culture much more easily and willingly that their elders. Sometimes feelings of guilt on the part of grown children may complicate the caregiver's job especially when nursing home care is needed for an elderly parent. Some values and behaviors are derived from the Soviet era of 'collectivism mentality'. This mind set elevates the needs of a group over the needs of individuals, is intolerant of differing opinions and lifestyles, uses authority and power rather than compromise to resolve conflicts, and distrusts authorities. This can lead to problems for American caregivers trying to negotiate solutions for members of the Russian Jewish family. Behavior that appears unreasonable and manipulative on the part of the adult children appears to be rooted in a difficulty expressing their grief and guilt, as well as a loss of control over the situation. They are no longer able to take the parent home to care for them in old age, as is customary in Russia.
In Russia informal visiting and 'dropping in' on friends and extended family members is more common than in the US, because of geographic proximity and relative lack of mobility. Russian immigrants may miss this easy contact and families may become more dependent on each other. Russian Jewish immigrants who have traditionally not felt fully assimilated in Russia may experience even more isolation as immigrants. In addition, they cannot share the religious Judaic traditions of the American Jewish community. Much has been written about the feelings of isolation, uselessness and depression that afflict especially the elderly Russian Jewish immigrant population.
Traditionally, although Russian women have been liberated in the sense of having equal employment opportunity for many decades (for example, the majority of physicians in Russia are women), their salaries and authority lag behind those of the men. Women, even though they work outside the home, are still expected to take responsibility for all household tasks and the care of children. Russian immigrants tend to have fewer children than other immigrant groups.
Russians Jewish immigrants believe strongly in the value of education--a universal Jewish value for centuries. By the 1970s, Russians between 25 and 34 had on average 16 years of education compared to 12.8 years on average for other European immigrant groups. The motivation to do well among this immigrant population is illustrated by the fact that median family income for Russian Americans in 1970, at $14,000.00, was three to four thousand dollars higher than median family income among other European immigrant groups. Educational levels and job skills are highest among those Russian Jewish immigrants who have arrived since the 1970s. Of these, almost half have had a university education, and more than half have been employed in Russia as engineers, economists, skilled workers, or technicians. Most have been able to find comparable jobs in the US, and have improved their socioeconomic status.
Nutrition
In Russia, there is a shortage of fruits and vegetables. Sausage, potatoes and breads are standard fare for all three meals of the day. In rural districts, cabbage and grains such as buckwheat, millet, and barley may be preferred. Salted meat is more obtainable than fresh meat which is a luxury. Many Russian immigrants may never have had a balanced diet in their homeland, and their diet is a concern for the caregiver.
Health Beliefs and Practices
In the USSR, the health system is organized around regional clinics staffed by medical aides called feldshers. These are the first point of referral for the general population. A Russian who becomes sick could stay in bed and expect a feldsher to make a house call. Since 1990, the Russian health system has become underfunded and may lack the most basic supplies such as disposable syringes. Some traditional medical treatments include "cupping" which is said to draw evil humors out of the body. Cups are heated and applied to the back. These often leave the appearance of bruises which can be mistaken for evidence of physical abuse.
Herbal remedies are widely used. They include Valerian Root and Motherwort for many nervous conditions such as insomnia and headaches, Hawthorn Berries for regulation of blood pressure and cardiac conditions, Coltsfoot for coughs, colds and bronchitis. These are prepared as drinks or enemas. Charcoal in water is also used for stomach acidity. In more recent times, modern medicines equivalent to those available in the US are also used in Russia. It has been noted that there is a high use of benzodiazepines among Russian immigrants.
Other home remedies include hot steam baths for pneumonia and upper respiratory infections, mineral water and plasters. Russian Americans strongly believe in massage as a remedy apparently based on chiropractic ideas or theory. Back pain is sometimes treated with dry heat, with a plaster of raw dough made with rye and honey and placed on the back, or with a pad of coarse wool or animal hair placed next to the skin of the lower back. Headaches may be treated with strong ointment applied behind the ears, on the temples and the back of the neck. Rhinitis may be treated with drops of raw onion juice in the nares. Salt and baking soda are used as a gargle for sore throats. Leech therapy is widely used in Russia.
Factors Affecting Utilization of Health Care among different age groups.
a) Adolescents
Adolescent Russian immigrants, it has been noted, exhibit some unique behaviors when seeking such services as birth control and pregnancy testing, tend to come in groups, having been referred by another Russian teen. They appear skeptical, impatient of any informational sessions or counseling, wanting to just "take the pills" without any further discussion.
b) The Elderly
Elderly Russians have typically suffered hardship from one and sometimes two world wars, from starvation in the USSR after the revolution, from anti-Semitism throughout their lifetimes, as well as from a repressive political regime. An immigrant is quoted as saying "The cause of illness is that we suffered too much" (1). Somatic complaints are frequently noted by healthcare workers, who observe that the health care system is often used by these immigrants for the relief of loneliness and depression. They may magnify aches and pains rather than have to discuss an emotional problem. Complaints such as paresthesia, vertigo, anorexia, hysteria, are linked by the patient to a physical condition or disease. The most common mental health problem diagnosed among Russian immigrants is depression. However, they feel a deep rooted aversion to seeking appropriate psychiatric care for problems of depression and maladjustment, because of their memories of the widespread use of psychiatric medicine as a political tool of repression in the USSR. The chronic, predictable health problems of aging added to the difficulties of adjustment to a new culture prove very daunting for this group. They regard the American healthcare system as a panacea, and tend to overuse it as a result. In their culture, illness is perceived to be caused by social conditions over which they have had no control. The medical system in the USSR was paternalistic and authoritarian, and did not encourage any partnership in care. "In Russia, the doctor gives you medicine and you take it. No questions." Their beliefs are thus at odds with mainstream American health beliefs which espouse a biomedical disease model, and emphasize personal responsibility for wellness and prevention. Many Russian emigrants have the expectation that the American medical system will be able to cure them of their unhappiness born from years of suffering. The paradox is that the US healthcare system may indeed be capable of curing them of many ills, but the behavioral health services that could address their unhappiness and depression are often shunned by those who need it most. Many caregivers become very frustrated with the behavior of this group of patients. It has been noted that where behavioral health services are integrated into the primary medical care setting, there is less reluctance to seek treatment. Another solution for this group has been programs such as adult day programs. Participants have had less depression and fewer requests for medical care.
Attitudes toward Disease
There is a high incidence of hypertension among Russians and Russian immigrants. Many Russians view it as a transient condition rather than a disease. They may take medication sporadically, believing that the efficacy of medication is reduced if it is taken regularly. They also believe that hypertension is symptomatic and therefore if they do not have headaches or "feel" their blood pressure, they do not need medication. Sometimes a patient will discontinue taking his medication so that the doctor can see what his "true" blood pressure is. Russians may also fear that they will develop low blood pressure with long term medication use.
"Serdtsa boleet" or heart pain is a common complaint among Russian immigrants--in fact most over 40 years will say they have some type of chest pain or pressure, which they believe is heart related. In Russia, a diagnosis of angina or ischemic heart disease may be based on a resting EKG. The patient is then likely to relate this diagnosis rather than describing his symptoms. The health system in Russia does not have any tradition of patients being involved or responsible for their own wellness.
Attitudes about cancer commonly involve a great deal of fear and denial. In Russia, a diagnosis of cancer is considered a death sentence, and there is a prohibition against telling the patient their diagnosis. This attitude can be problematic for both Russian immigrants and American caregivers. It is challenging for the caregiver to present a realistic prognosis or enlist the family's cooperation in the treatment plan in the face of this high level of fear and denial.
This fearful attitude also extends to the subject of mental health. Compliance with anti-depressant drugs is poor--side effects are feared and not well tolerated.
Bibliography
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