Socialized medicine

Welcome to the International House of Patients - your local hospital

By Claudia Perry

STAR-LEDGER STAFF

A Jehovah's Witness needs surgery but refuses transfusion because it violates the faith's tenet that using spilled blood is against the teachings of God.

A Muslim is diagnosed diabetic and prescribed insulin to treat the condition. The patient refuses to use the insulin because it's derived from pigs. Muslims do not believe in eating pork or using pork-derived products. The patient is given human insulin instead.

A Spanish-speaking woman comes into an emergency room chattering loudly and scratching herself. The hospital finds an interpreter who tells the assembled medical personnel that the woman says she has little snakes all over her body. Not surprisingly, the hospital wants to admit her for psychological evaluation. Another Spanish speaker points out that "little snakes" is the term used to describe herpes zoster, a skin condition, in that particular dialect of Spanish. The woman is sent to a medical doctor instead.

An orthodox Jewish woman is getting a mammogram. Her religion forbids any man but her husband to see her unclothed body. The mammography center finds a female technician.

Across the state, hospitals and medical practitioners have to deal with the fact that 1 of every 7 people in New Jersey is foreign-born. The documented immigrant population is approximately 1 million. That's the fifth largest immigrant population in the United States, trailing only New York, California, Florida and Texas.

All of those newcomers to the Garden State bring with them religious and cultural practices that are unfamiliar to those of us who have been here longer. Medical practitioners need an understanding of those practices so that they can get the information needed to help the patient.

Reaching out

If you reach Sue Cardona's voice mail at Morristown Memorial Hospital, her outgoing message plays first in English, then in Spanish. Cardona, who lives in Morristown is the outreach coordinator for the Morris County Cancer Screening Project. She's been on the job for a little less than two years, but her enthusiasm for her work is obvious.

"We work very hard to make sure people understand what they're going to do and what's going to happen," Cardona said. "We have videos in English, Spanish and Chinese about breast self-examination."

In recent months, Cardona got a group of Korean women employed at a local nail shop to come in for breast exams. She worked with the owner of the shop to have the women examined at times when they wouldn't have to miss work. She also arranged transportation for people who didn't have a way to get to the hospital.

"When I first got to the shop, people wouldn't make eye contact," Cardona recalled. "I brought the owner some literature in Korean about the program. We got 11 women to come in for first-time screenings."

Cardona also has worked with groups of Chinese women. She is presently laying the groundwork to reach out to a group of South Asian Indian women in Parsippany.

"I met with them at their home and had ginger ice cream, which was great," Cardona said.

Nancy Lee, who is the program coordinator for the project, said they had run into some resistance from women whose exams showed that they would need further treatment.

"We've had a lot of fatalism where women will say that it's God's will they have this," Lee said. "When we run across that, we ask them what will happen to their families if they die."

It's also important to use a translator who is not a family member. Some immigrants use their children as translators, but there are some medical history questions you wouldn't want to ask a child (for example, "How many sexual partners has your mother had?")

In addition to its outreach program, Morristown Memorial has a small library with touch-screen computers that offer cancer information in Spanish. There are also books and pamphlets in other languages, including Chinese and Japanese. The library is in the Carol G. Simon Cancer Center and is open to the public.

Going out into the community and reaching out to different groups is one thing. But what happens when someone becomes a patient? At Saint Peter's Hospital in New Brunswick, there is a trans-cultural committee that has implemented some practices at the hospital." The committee is interdisciplinary," said Alicia Felicia, the hospital's patient education coordinator and the committee's co-chair.

"We have members from dietary, pastoral care, physical medicine and rehabilitation all the areas where there is patient contact. A lot of times, if people are ignorant of cultural practices, they might think they are weird. We do see that here. More and more, people are expressing and verbalizing their culture and religion. So the practices are no longer considered weird.

"We had one of our nurses who was nagging a Chinese patient to take a shower after she had delivered her baby. Their practice is to wait until 7 days after the baby is born before cleaning yourself. Asking them to shower is offensive to them."

Felicia also recalled a case where a Malaysian woman was giving birth and wanted to have four women who were very important in her life in the delivery room. Saint Peter's made it work.

"The delivery rooms only hold a certain number of people, but we made provision for the four extra people to be in there. A blind person requested that their guide dog be present. Although we don't allow pets in the hospital, we made provisions for the seeing-eye dog to be available during delivery. These things that you do to accommodate these patients came about after three years of constant bombardment of information about cultural difference. People finally got it."

My culture, my body

At Englewood Hospital in Englewood, the New Jersey Institute for Bloodless Surgery was started in 1995. Although the Institute was started to accommodate Jehovah's Witnesses who don't believe in transfusion, other patients have also had surgery by this method.

"Blood transfusion has become a public health issue, so we started asking ourselves if this was something we could do for all our patients," said Aryeh Shander, chief of critical care medicine and anesthesiology for the institute. "It became evident that the Jehovah's Witnesses were doing just as well if not better than the rest of the patients. We have performed very complicated surgery without the use of anyone's blood but your own."

Shander said there are many nonreligious reasons for a patient not to be transfused during surgery.

"There are patients who have medical or dietary conditions that prevent them from accepting blood. Someone who is a strict vegetarian might have complications from transfusing."

Dealing with religious and cultural difference is a learning process, Shander said. That process ultimately benefits everyone involved.

"You're dealing with the right of patients to bodily self-determination when it comes to use of blood products, health care or end of life decisions. As you become more sensitive, you learn more. It's a win-win situation."

When in Rome....

Raymond Gora's office at Jersey City Medical Center features a day bed, a map of Puerto Rico and stacks of literature in some 12 languages. Gora is the hospital's patient-care representative. In his office, there are copies of the patient's bill of rights translated into Haitian Creole, Gujarati (a popular South Asian language), Chinese and Arabic.

On Gora's desk is a list of 500 people at the medical center, what shifts they work and the languages they speak. Members of the hospital staff speak 55 languages. If someone comes in and there's no translator available, the hospital uses LanguageLink, a telephone translating service. The patient and the physician get on a conference call with the translator.

"We had someone come through from Somalia and we were able to help them," Gora said.

Gora, who has been at the medical center for close to 20 years, said that Jersey City remains an immigrant entry point.

"Before it was Ellis Island. Now it's Newark Airport," Gora said. "We admitted a group of Austrian tourists who were in an accident on their way to Atlantic City. We had to find someone who spoke German to help them."

Gora also realizes that if patients feel comfortable that the people administering treatment understand them, it can go a long way in helping them get well.

"It can make someone feel better if they hear one or two sentences in their own language," Gora said. "There are certain times when you're likely to use your native language - when you pray, when you're counting money and when you're sick."

Marguerite Pedley, the psychologist who is the program director at Jersey City Medical Center, recalled the time a Hispanic Vietnam veteran came to her for counseling when she lived in Texas.

"He came with 10 people from his family, all of whom expected to be in the office during the session," Pedley said. "I expected he would come in by himself like my other patients. I learned from that."

Pedley said the most common cultures that pass through the Medical Center are Spanish-speaking (Pedley avoids the words "Hispanic" or "Latino" because neither accounts for cultural differences between nationalities), Haitian, Jamaican, Trinidadian, Russian and Polish.

"We are also seeing more and more Koreans and Vietnamese," Pedley said. "It's a pretty broad spectrum. There is a large recent immigrant population so we end up treating people who speak no English at all."

Mental illness in other cultures carries a stigma, just as it does in the United States. Pedley said some immigrant families attempt to handle mental illness internally, only seeking medical attention at the breaking point.

"The question ‘What's a normative behavior?’ may have different answers in different cultures," Pedley said. "If I speak to a patient using an interpreter, the interpreter can't be a family member. You have to ask a lot of personal questions, and you can't have the interview clouded by gender or generational biases intentionally or unintentionally."

Pedley worked with a Latino client whose family kept insisting that she was a good person in spite of her illness.

"While it was good that they knew that her problems didn't detract from her being a good person, you could easily see why it wouldn't be a good idea to use one of the family members as an interpreter. They might leave out crucial information in an attempt to present things in the best possible light."

Pedley said knowing some information about a person's culture and religion can give you a way to approach them about their illness.

"In some Central Asian cultures, you absolutely do not tell a stranger your most intimate problems. In our culture, you would come in and tell the doctors what they needed to know for you to get treatment. Someone might say that for the past three months they have had no appetite, been exhausted. If you were from our culture you might say, "Gee, I wonder if I am depressed.' In some Asian cultures, patients might say they have stomach trouble. They tend to describe psychological problems in physical terms."

But Pedley warns that you can't stop with general cultural assessments, especially when diagnosing psychological illnesses.

"You may know that in some Asian families, the oldest male relative is the family decision-maker and that some Asians describe psychological conditions in physical terms. But you can't stop with that. You have to look at the patient as an individual."

GRAPHIC: Cultural conditions

Cultural and religious practices that may affect health care:

Some sects of Judaism and many Muslims prohibit touching between members of the opposite sex. Buddhist monks may not be touched by a woman or they will have to perform great penance.

Some Native American cultures do not make eye contact out of respect for authority and the belief that it can endanger the spirit of both parties.

In Filipino culture, beckoning with your right index finger is not the way you summon anything but animals. The gesture is considered disrespectful. The proper way to get a person's attention is to motion with the whole hand - palm toward the body, fingers down.

Muslims must pray five times a day using certain passages from the Koran. Nothing can be placed on top of the Koran, as this practice is considered disrespectful. Interrupting prayers is more disrespectful.

Some Southeast Asian cultures place baci (cords) around a child's wrist on important occasions. The cords are believed to "tie in the soul" so it doesn't get lost. They should not be cut during medical procedures. Other religious items include rosaries (Catholics), sacred threads around the neck or arms (Hindu), medicine bundles (Native Americans) and red ribbons (some Mexicans). If these items have to be removed during medical procedures, the reason should be explained to the patient and family. The item should be removed gently and respectfully, and kept in contact with the patient's body if possible.

The Sikh religion forbids cutting or shaving of body hair.

In some Native American cultures, it is taboo to cut a child's hair.