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Arab-American Culture and Health Care
Najeh M Ahmad, MD
April 15, 2004
1-
Introduction and Objectives:
This chapter is intended to be a
brief resource for health care professionals who are working
with the Arab American community.
It will help practitioners in
providing culturally appropriate health care by addressing some
of the unique characteristics of the Arab-American culture and
the implications of these characteristics on health care access
and delivery; it is not in any way inclusive (17).
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Background:
A.
The definition of the term “Arab”:
The term Arab is often associated
with the region extending from the Atlantic coast of Northern
Africa to the Arabian Gulf in which most people who live in that
area call themselves Arabs. This classification is based largely
on a common language (Arabic) and a shared sense of geographic,
historical, and cultural identity. The term Arab is not based on
race; it includes peoples with widely varied physical features.
The total population of the Arab world is approximately 280
million in 22 nations (2).
There are 10 Arab countries in Africa
(Algeria, Djibouti, Eritrea, Egypt, Libya, Morocco, Mauritania,
Somalia, Sudan, and Tunisia) and 11 countries in Asia (Bahrain,
Iraq, Kuwait, Jordan, Lebanon, Oman, Qatar, Saudi Arabia, Syria,
United Arab Emirates, and Yemen) and includes the Palestinian
people. (Palestinians are presently either living under Israeli
rule, autonomy of partial Palestinian Authority in the West Bank
and Gaza, or dispersed as refugees throughout the world).
Despite the national boundaries dividing the Arabs into nation
states in the post-colonial period, Arabs generally view
themselves as a unified entity (17). Arab countries are diverse
with respect to religious beliefs. They include Christians,
Jews, and Muslims. The large majority of Arabs are Muslim (92
percent), however, in total Arabs comprise only about 17 percent
of the Islamic population worldwide. The majority of non-Arab
Muslim populations live in Central Asia, Indonesia/Malaysia,
Iran, South Asia, Sub-Saharan Africa, and Turkey. The religion
of Islam is closely associated with Arab identity because of the
origin of Islam in the Arabian Peninsula and the fact that the
language of Arabic is the sacred language of the Holy Qur'an
(17). Ethnic minority groups live in many Arab countries. These
include Persians, Turks, Armenians, Kurds, Berbers, and other
minorities. Differences within Arab culture also exist between
people living in urban and those in rural areas, and among
countries. For example, only 29 percent of Yemen’s population
lives in cities, while in Lebanon, 84 percent of the population
is urban. These varied backgrounds must be kept in mind when one
tries to apply the cultural norms described in the following
paragraphs. No practice is universal, and behaviors and
attitudes, while they may follow certain trends or have a common
influence, may vary greatly (17).
B.
Language: An important
aspect of the Arabic culture, 51 % of Arab Americans speaks
language other than English at home.
The Arabic language
can be divided into three categories:
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Classical Arabic, the language of the Qur’an; Modern Standard
Arabic, used in newsprint and newscasts throughout the Arab
World. While most
people understand it, Modern Standard Arabic is not used in
conversations. (3)
- Local dialects, which vary among
countries and regions and are not easily understood by those who
speak another dialect. (3)
- Other languages spoken in the Arab
World include Aramaic, an ancient language of Mesopotamia, which
is still used in Chaldean and Assyrian church services. Berber
is commonly spoken in North Africa, and Kurdish is spoken in
regions of Syria and Iraq.
Figure 1: Map of the Arab countries
C.
Arab Americans:
There are an estimated 2 to 3 million
Arab Americans living in United States (1) (6), including
individuals who are ethnically Arab or have emigrated from one
of the approximately 22 countries that compose the contemporary
Arab world (1).
Figure
2: Arab ancestry, from census 2000
The exact number of Arab Americans is
not known, because often they are reluctant to identify
themselves as being of Arabic descent out of a general fear of
authority or out of concern about possible negative social
reactions (1). There are also problems with the ways Arab
immigrants to the United States have been classified. For
example, before 1920 Arab immigrants were classified as Turks;
later they were classified as Syrian, Asian, or African; and
Palestinians who have emigrated since 1948 have been classified
as nationals of the country from which they came, including
Israel (5). Federal government doesn’t consider Arab Americans
an ethnic minority and they are classified as white when it
comes to race.
Approximately two thirds of Arab
Americans were born in the United States (1). As of 1990, more
than 80% were Christian (5), although this figure is expected to
have decreased in recent years given that recent immigrants tend
to be more often Muslim than were earlier immigrants. Arab
Americans tend to have more education than other U.S. ethnic
groups in part because educational achievement and economic
advancement are encouraged within Arab cultures (1) and also
because of immigration patterns, because recent U.S. immigration
policies favor educated professionals (6). Because of their
tremendous diversity, one way of classifying Arab Americans has
been with regard to the period of, and reason for, their
emigration to the United States. There have been three major
waves of Arab immigration to the United States, each with
distinct demographic characteristics and adjustment experiences.
The first wave of Arab immigrants
came mainly from Greater Syria, the geographic region now known
as Syria, Lebanon Israel and Palestine, arriving in the United
States between the late 1800s and World War I (1). These
immigrants were mainly Christian or Muslim minorities, mostly
merchants and farmers, and emigrated primarily for economic
reasons (6). These immigrants settled mainly in urban areas in
the Northeast, including Manhattan, Brooklyn, and Boston, and
industrialized cities in the Midwest. These immigrants tended to
blend in with the general population without many difficulties
(1).
The second wave of Arab immigrants
began coming to the United States in 1948 following the creation
of Israel and included many professionals and university
students who remained in the United States after their
education. This wave consisted of many more Muslims, including
Palestinian refugees displaced from their land after the
creation of Israel in 1948 (1). By the 1950s, the Arab world was
breaking free of European colonial rule and experiencing a surge
of Arab consciousness, thus immigrants in the second wave were
able to retain more of an Arab identity once they arrived in the
United States (1) (5).
These immigrants also settled in
urban areas in the Northeast, as well as in Midwestern
industrial cities, including Chicago and Cleveland (in Ohio) and
Dearborn and Detroit (in Michigan).
The third wave of Arab immigration
began after the Arab defeat in the Arab–Israeli war of 1967.
This wave is still occurring and is expected to continue for
some time. These immigrants often come to the United States to
escape war or political instability or in search of economic
opportunities (1), and they have settled in a broader geographic
pattern across the United States, including the West Coast.
Today, the largest Arab American community in the United States
is in Detroit, which has an Arab American population of more
than 80,000 (1). These new immigrants tend to be with a high
education. Experiencing a more negative reception in the United
States than earlier immigrants, members of the third wave have
assimilated into mainstream society less and been active in
creating Muslim schools and charities and providing
Arab-language classes (1).
More than two-thirds of Arab
Americans are employed. Of those, 73 percent hold managerial,
professional, technical, or service positions. Seventy-two
percent work in private sector, and 12 percent work in the
public sector. Arab Americans have a higher median income than
the average American family. About 11 percent of Arab Americans
live in poverty, a number slightly higher than the overall
population. (6)
Arab Americans are one of the most
diverse ethnic groups in the United States in their cultural and
linguistic backgrounds, political and religious beliefs, family
structures and values, and acculturation to Western society (1).
Originating from many different countries with tremendous
regional and national differences in language, politics,
religion, and culture (1), in many ways Arab Americans are only
a loosely connected ethnic group. Because of this, there are a
number of important national differences among Arab Americans
that must be considered. For example, individuals from Saudi
Arabia are more likely to be Muslim, hold more conservative
values, and have a higher standard of living than individuals
from Lebanon or Syria who are more likely to be Christian, or
non committed Muslims, and more likely to hold liberal or
“Westernized” values, and have a lower standard of living.
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Arabic Culture and Health Care:
A.
Cultural communalities which have an
impact on health care delivery may include (10)
(17):
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Preferring to be treated by a medical provider of the same sex:
this is especially true for female patients. That also applies
when interpreting services are needed.
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Nurses
are perceived as helpers, not health care professionals, and
their suggestions and advice are not taken seriously. Doctors
may need to explain the nurse's role to the patient.
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Arabs
are not accustomed to the profession of social workers. They
rely on their families, other relatives and close friends for
support and help.
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Preferring medical treatment that involves prescribing pills or
giving injections, rather than simple medical counseling.
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Among
orthodox Muslims, following a halal (Muslim Diet), which
prohibits some types of meat like pork and medications/foods
that contain alcohol. For example you might have a diabetic
Muslim patient refusing to take insulin or hospital pre prepared
meals that contain Pork or pigs products.
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Among
orthodox Muslims, strictly secluding women from men; in these
societies, women may have little contact outside of the home.
This is changing rapidly with women getting their rights in many
Arab countries.
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Among
devout Muslims, praying as many as five times a day, starting
before sunrise and ending at night.
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Among
devout Muslims, abstaining from alcohol is mandatory.
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Among
devout Muslims, fasting during the holy month of Ramadan, with
no food or drink consumed between sunrise and sunset, is
required. The ill are supposed to be exempt from fasting, but
among people who are fasting, oral medication and IV solutions
are prohibited. Muscular injections are permitted. Women are
exempt from fasting during menstruation and 40 days post partum.
Despite their illness the Muslim patient may try to fast during
Ramadan.
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When
serving food or drink to Muslim patients in hospital, allow for
receipt in the right hand. Muslims consider the left hand
unclean since it is use to cleanse oneself after going to the
toilet.
B.
Some Health Care Issues in the
Arab-Americans communities:
A major stressor for Arab Americans
is stereotyping of the Arab people, which has been exacerbated
by recent world events. Arab-Americans are classified as “White”
by the US census (9), but they face discrimination that European
Americans may not:
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Honor:
Honor (sharaf) is an important
social aspect of the family. Under (sharaf), the actions of an
individual can bring shame to the entire family. Thus, an
individual might choose to ignore a potential health concern
such as drug addiction, mental illness, venereal disease, or a
pregnancy out of fear that the family would consider the
condition to be shameful. Confidentiality of the
patient-provider relationship and diagnosis and treatment of a
potentially “shameful” condition could be of particular concern
to the client in this type of situation, no matter what his or
her age. Adolescents and unmarried women may be particularly
vulnerable in this type of situation—for example, if a bill for
services is sent to the home and opened by other family members.
Another example: if unmarried woman is on contraceptives. Health
care professionals must have high sensitivity to these issues
(10) (17).
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Lack of experience with the US health system:
This is especially true with recent
immigrants: Many Arab countries provide free universal health
care and private health care at costs much below those in the
United States. Therefore, new immigrants generally do not
understand the complicated US healthcare system characterized by
third-party insurance and managed care. Also, these new
immigrants may not take advantage of the free or low-cost
services offered by federally supported community health
programs such as Medicare and Medicaid, because the programs may
be unfamiliar with their language and culture.
Many Arab immigrants may not place a priority on
preventive care and may not seek those services. They may stop
taking the medicines once their symptoms improve, and may not
return for a follow-up visit. It is clinically advisable to
actively follow up with these patients to assure adherence to
treatment regimens. Understanding the culture and language of
these patients will certainly increase adherence to medical
advice. Among Arabic patients, many may be used to receiving a
variety of medications, including antibiotics and pain
relievers, from the pharmacist without a prescription. In
addition, they may be surprised or disappointed if they are not
treated with a variety of medications for an illness (11).
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Mental Health is often considered a stigma:
Mental illness is often stigmatized in Arab communities,
may be more than other societies. A person with mental distress
may not seek advice from professionals, or even family members.
Male family members are the major bread winners for their
families, and male unemployment can affect the mental health of
men more than women.
In addition to posttraumatic stress disorders resulting
from war, dislocation, oppression, and torture, many new Arab
immigrants face other stressful events such as economic
hardship, assimilation into a new culture, racism, and other
forms of discrimination. Many immigrants may have held
professional occupations in their home countries but are unable
to find comparable employment in the United States. Stressors
related to loss of previously held social and economic status
may precipitate some forms of depression. Some conservative Arab
immigrant women may be more isolated from the wider society than
are Arab men. Isolation may be one of the factors to precipitate
depressive illness (17).
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Access to Health care:
Many recent Arab Americans immigrants
have language barriers, although many of them may hold part-time
jobs that may prevent them from getting timely access to health
care when needed. In addition, many part-time jobs do not
provide health insurance or provide sick leave. Many recent
immigrants don’t speak English fluently and that will limit
their ability to seek medical care (11).
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Family, Marriage, Natality and Parenting:
Arabic societies was traditionally
organized and governed by families or tribes, and the family
remains an important institution. Families are generally
patrilineal. This means that children strongly identify with the
lineage of the father, and the paternal relatives hold primary
responsibility for the children. In traditional Arab society,
Christians prefer to give their children a Biblical name,
followed by the father’s first name, then by the family name.
Muslims commonly use the names of Mohammed and others in his
family as well as “servant of God names” (Abdul-Rahman
“Servant of the Compassionate”, Adbul-Aziz “servant of
the Beloved”). Names may also carry secular meaning (e.g.,
Najeh, “successful”, Laila “night”). Ibn (bin)
or bint means son or daughter of, respectively, and may
follow the middle name. Last names may denote a person’s
profession or their city of origin. (4)
Marriage is a highly stressed
objective in the Arab culture, from the youngest age, people
often wishes the child “farhatek”, your happiness on your
wedding day. Premarital sex, though tolerated in secrecy with
males, is totally shameful for the female and it can carry grave
consequences on the individual female and her extended family.
Natality is highly respected within the immediate family and
infertility often considers a shame rather than a medical
condition. Birth is considered a strictly feminine experience
and the lack of male participation in the birth room should be
expected. Children in the Arab family are often get a great deal
of love and expectation. In Arab norm, light physical discipline
of the child is considered proper parenting. In general, the
general well being of the child is not neglected (17).
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Care for the elderly:
The elderly in the community are
regarded with deep respect. They are given priority in all walks
of life. An Arabic saying: “Heaven would be found under the feet
of one's mother”. Therefore, the care of the elderly is regarded
as an avenue to Heaven, another expression of worship. Whether
they live together with their children or separately, parents
are usually consulted in all decision making processes (17).
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Death, Dying and communicating bad news:
Arabic culture in general, regardless
of being Christian or Muslim, believes in death as “the will of
God” and nobody can stop it or delay it.
So many Arabs are fatalistic where diseases are God
punishment and only God can cure it. The words death, dying and
cancer should be used with sensitivity and a feeling for others.
Cancer is often referred to as “that” disease.
This is usually followed by the sentence “God keep it
away”. Arabs
usually avoid discussing death, dying and how long a person is
likely to live. In some Arab families, communication of
diagnosis/prognosis is first given to the family – the closest
member to the patient. The next of kin will advise the rest of
the family. Euthanasia is forbidden.
Autopsies are often considered disrespectful and get
refused. Burying the dead as quickly as possible is expected.
For a patient who just died, the face and body of the
deceased must be covered by a sheet, the body must be handled as
little as possible, and because Arabs in general believe that
the body of the deceased feels the pain until burial (17).
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Some Arab Americans resources:
Arab
American Institute
918 16th Street, NW, Suite 601
Washington, DC 20006
(202) 429-9210
www.arab-aai.org
American Arab Anti-Discrimination Committee/ National
Association of Arab Americans
4201 Connecticut Avenue, NW, Suite 300
Washington, DC 20008
(202) 244-2990
www.adc.org
Council on American-Islamic Relations
453 New Jersey Avenue, SE
Washington, DC 20003
(202) 488-8787
www.cair-net.org
Washington Report on Middle East Affairs
P.O. Box 53062
Washington, DC 20009
(202) 939-6050
www.washington-report.org
Arab Community Center for Economic and Social Services
2651 Saulino Ct.
Detroit, MI
(313) 842-7010
www.accesscommunity.org
References:
1-
Abraham, N. (1995). Arab Americans. In R. J. Vecoli, J. Galens,
A. Sheets, & R. V. Young (Eds.),
Gale encyclopedia of multicultural America
(Vol. 1, pp. 84–98). New York: Gale Research.
2-
United Nations Development Program (UNDP) Human Development
Report. Investing in Health. Oxford University Press, New
York: 1993.
3-
Detroit Free Press. 100 Questions and Answers
about Arab Americans: A Journalists’s Guide. Detroit:
Detroit Free Press, 2000 Available from
http://www.freep.com
4-
3. Douglass, Susan L. An Introduction to Islam and Arabs.
In Resources on Islam and Arabs. Washington:
AMIDEAST, 2002
Available from
http://amideast.org/news_and_events/sept11/free_resources_islamarabs.htm
5-
Naff, A. (1980). Arabs. In S. Thernstrom (Ed.),
Harvard encyclopedia of American ethnic groups
Cambridge, MA: Harvard University Press.
6-
Arab American Institute, 2003
www.aaiusa.org.
7-
Census Tract 2000.
www.census.gov
8-
El-Badry, Samia. "The Arab-American Market." American
Demographics. 16:22-30. 1994
9-
Census 2000,
www.census.gov
10-
Hammad, Adnan.
Effectiveness and Efficiency in the Management of Palestinian
Health Services.
Manchester, UK: University of Manchester. 1989.
11-
Laffrey,
Shirley C., et. al. "Assessing Arab-American Health Care Needs."
Social Science and Medicine. 29(7):877-883.1989.
12-
Central Intelligence
Agency (2003) World fact book.
www.cia.gov
13-
Said, E W (1979),
Orietalism, New York random house.
14-
Simon, J. P. (1996).
Lebanese families. In M. Mc-Goldrick, J. Giordano, & J. K.
Pearce (Eds.), Ethnicity and family therapy.
15-
American Arab anti
discrimination committee.
www.adc.org.
16-
Washington Report on
Middle East affairs.
www.washington-report.org.
17-
This chapter also used
several books and articles about Arabic culture which are
written in the Arabic language only. For list in Arabic please
email the author at
Najeh.ahmad@case.edu.
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