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Cambodian Refugees & Health Care in the Inner-City 

Note: Generalizations about Cambodians (Khmer) are about as accurate as generalizations about any other large group. Nevertheless, to better understand Cambodians or other groups or cultures, it is necessary to deal in generalizations to some extent. The following is written in a spirit of respectfully seeking to understand and to serve.

Introduction

Once the dominant military and economic force of Southeast Asia, Cambodia was, by the late 1800's, a part of French Indochina. From the beginning of colonial rule, there was resistance to the French. With the Geneva Convention of 1954, Cambodia became independent with a government ruled by Prince Norodom Sihanouk. Communist and other dissident activities were repressed from that point until the late 1960's when the Khmer Rouge, led by Maoist extremists, in particular a man named Pol Pot, became active. A brutal and complex armed struggle ensued, resulting in many deaths. In 1970, a coup d'état replaced Prince Sihanouk with right wing military rulers. Fighting escalated and on April 17, 1975, a deeply divided Cambodia fell to the Khmer Rouge.

Within days of victory, the Khmer Rouge initiated a radical restructuring of Cambodian society. Liquidation of all non-communist leaders beganGirl with Polio (in Cambodia) immediately and eventually encompassed not only military and political leaders, but also monks, teachers, people who wore glasses, and anyone else judged to be a "new person" or corrupted by capitalism. The cities were totally emptied of all residents, who then were put to work on agricultural communes. Families were separated according the needs of working units and a deliberate effort was made to replace traditional relationships and structures such as family, village, and Buddhism with absolute obedience to the communist party or Angka.

THE SECURITY REGULATIONS (Tuol Sleng Prison)

1. YOU MUST ANSWER ACCORDINGLY TO MY QUESTIONS. DON'T TURN THEM AWAY.
2. DON'T TRY TO HIDE THE FACTS BY MAKING PRETEXTS THIS AND THAT. YOU ARE STRICTLY PROHIBITED TO CONTEST ME.
3. DON'T BE A FOOL FOR YOU ARE A CHAP WHO DARE TO THWART THE REVOLUTION.
4. YOU MUST IMMEDIATELY ANSWER MY QUESTIONS WITHOUT WASTING TIME TO REFLECT.
5. DON'T TELL ME EITHER ABOUT YOUR IMMORALITIES OR THE ESSENCE OF THE REVOLUTION.
6. WHILE GETTING LASHES OR ELECTRIFICATION YOU MUST NOT CRY AT ALL. WHEN I ASK YOU TO DO SOMETHING, YOU MUST DO IT RIGHT AWAY WITHOUT PROTESTING.
7. DO NOTHING. SIT STILL AND WAIT FOR MY ORDERS. IF THERE IS NO ORDER, KEEP QUIET.
8. DON'T MAKE PRETEXTS ABOUT KAMPUCHEA KROM IN ORDER TO HIDE YOUR JAW OF TRAITOR.
9. IF YOU DON'T FOLLOW ALL THE ABOVE RULES, YOU WILL GET MANY LASHES OF ELECTRIC WIRE.
10. IF YOU DISOBEY ANY POINT OF MY REGULATIONS YOU WILL GET EITHER TEN LASHES OR FIVE SHOCKS OF ELECTRIC DISCHARGE.

By 1979, when the Khmer Rouge were overthrown by the Vietnamese army, approximately 1.5 million people out of a population of seven million had been murdered or allowed to die from starvation or disease.

That night Robona, Ton Ny's six-year-old sister, had a dream in which she saw someone very much like an angel who carried an armful of five lotus blossoms and spoke to her, "Don't be afraid my little girl, I'm keeping your Mama with me. But you shall go on living." In fact, one would have said that all the children were hurrying to join their mother. The first to die were the two five- year-old twins, three days apart, lying silently on a bamboo pallet; then two other brothers, Youthevy and Vouthinouk, nine and seven years old, the first at the hospital, the second when he came home from the hospital. Kosol, the four-year-old, and Robona died three months later, on the same day. All of them starved to death. After they died, Mitia Mir dreamed that he saw four columns still standing from a house in ruins. I thought that they were my uncle and his three surviving children, but now I know that the fourth column was myself . . . No one had the strength to work, so we were given no more food . . . from The Stones Cry Out

Like Jews who survived Nazi terror, many Khmer experience significant and long-term effects from the years under Khmer Rouge terror. Many feel that, "For us its too late" (as a man said to me at a recent New Year ceremony) to deal with the long-term effects of these traumas. (See Mental Health page in this site for more detailed information on war trauma and the refugee experience, including information specific to Cambodians. Also see the external site: Cambodian Genocide Project, which explains more about the Cambodian Holocaust and remembering the martyred.)

Beginning in late 1978, Cambodian refugees began fleeing to the relative safety of Thailand. From 1981-1985, approximately 150,000 Khmer were resettled in the U.S. Photo: People about to be killed by Khmer Rouge. Courtesy Christina D'Angelo.

Once in the U.S. the Khmer have tended to follow one of several paths. Some have enjoyed financial success (through salaried jobs as often as entrepreneurship) and have become homeowners in mixed middle-class neighborhoods. Others have scattered to suburban apartments. Still others have stayed in the neighborhoods in which they were originally resettled and have become a generally hidden part of inner-city urban life. In many cases, there has been little assimilation. In most cases, regardless of external appearances, there is great pain related to past trauma and current difficulties. (See Khmer Health Advocates.)

Religion

Most adult Khmer in America are Buddhist (this link is an excellent external resource on Buddhism - click on English). Buddhism is based on the teaching of Siddhartha Gautama, The Buddha. Central to Buddhism is belief in the Four Noble Truths. These are:

  • All sentient beings suffer. Birth, death, and other separations are inescapably part of life.
  • The cause of suffering is desire. Desire is manifested by attachment to life, to security, to others, to being itself, etc.
  • The way to end suffering is to cease to desire.
  • To way to cease to desire is to follow the Eightfold Path: (1) right belief (2) right intent (3) right speech, 4) right conduct (5) right endeavor or livelihood (6) right effort (7) right mindfulness (8) right meditation.

Following the path leads to cessation of desire and to nirvana or emancipation from rebirth and the endless cycles of suffering. The picture is of the Buddha meditating, protected by Naga.

Worship is at a temple or wat, and at altars in individual homes. Worship at temples is usually led by one or more monks, often with assistance by a lay elder or achar. Worship includes monks and congregation chanting in Pali (the liturgical language of Thereavada Buddhism), burning incense, and prayer. Worship may be concluded by the monks eating food (always before midday) brought by the congregation. The congregation then eats and gradually disburses. Overall, there seems to less structure in Buddhist worship or ceremonies than in western religions.

Buddhism teaches tolerance of others, acceptance of life (non-attachment), and lays out a strong moral code. The principle of karma or kamma is central to the practice of Buddhism. Karma is popularly interpreted as a moral precept: Follow Buddhist or other moral teachings and one will be reborn in a higher state; or practice evil and one will be reborn to a lower state. Another view of karma is that it is neither reward nor punishment, but simply cause and effect. Many Buddhists attribute misfortune or accomplishment to actions in this or a past life. Despite assertions to the contrary (by non-Buddhist interpreters of the faith), Buddhism does offer hope to its followers. Hope is leavened with acceptance or passivity, but hope for a better life now, a better next life and hope for a better life for (one's) children is strong. Further, Buddhism is explicitly based on the hope for cessation of suffering; even as the inevitability of suffering is accepted. Readers are invited to read a more in-depth discussion of Buddhism in the section on Religions.

Evangelical Christian churches and The Church of Jesus Christ of Latter Day Saints (Mormon) are active in most Khmer communities. The success of such churches is due in part to the presence of missionaries in refugee camps and the effectiveness and compassion of those missionaries in caring for refugees. Another factor that helps Christian churches is their willingness to go into the community and take an active and ongoing part in the lives and difficulties of refugees. This active outreach and caring is in contrast to the more detached Buddhist groups. Readers should note that many Khmer are comfortable with attending both Christian and Buddhist worship.

Health Beliefs and Practices (focus on Khmer from rural backgrounds)

In Cambodia, "the expected number of years to be lived in what might be termed the equivalent of "full health'" is 43.9 years for men and 47.5 years for women. Cambodia is thus 148th among 181 nations ranked by the World Health Organization (WHO) (WHO, 2000). Among all Americans, this "disability adjusted life expectancy" or DALE is 67.5 years for men and 72.6 years for women.

Background: In general, the Khmer are comfortable with cosmopolitan or western medicine and with traditional or indigenous healing practices, both spiritual and medicinal (and often both). Illness may be attributed to imbalance in natural forces, i.e., a humoural theory of causation. However, many Khmer will not directly express this concept. A common expression of the concept(s) is for people to note the influence of "wind" or kchall on blood circulation and thus on illness. There may also be discussion of body conditions called "cold" or "hot." These are not necessarily temperatures, but rather are body states leading to or caused by illness or other changes such as childbirth.

For a variety of reasons, many Khmer are slow to seek healthcare from western practitioners and traditional measures may be tried first. Reasons for delaying healthcare include:

  • Acceptance of the illness or discomfort
  • Difficulty accessing public or private health providers
  • Difficulty traversing the healthcare system (especially, in our experience, dealing with business/eligibility aspects, appointments, prescription refills, etc.)
  • Other factors related to culture, language, poverty, and the healthcare system itself

The effects of delaying health care are well known, and include increased morbidity and mortality.

Traditional healing or indigenous practices: Some of the following procedures are carried out by family members and some by traditional healers or kruu Khmer. Some kruu Khmer specialize in medicinal practice with a spiritual component, while others specialize in magic with a medicinal component. Regardless of who carries out the below or other procedures, they are often accompanied by prayer and other spiritual activities.

  • Kooí'(rub) kchall (wind) is used to treat a variety of ailments, including fever, upper respiratory infection, nausea, weak heart, and malaise. A coin is dipped in Tiger Balm, Monkey Holding a Peach, Vick's Vapor Rub, or similar mentholated medicine. The coin is rubbed in one direction (away from the center of the body) on the patientís chest, back, and/or extremities. Kooí' kchall is usually referred to in western literature as "coining" or "dermabrasion." We recently encountered a woman with diabetic neuropathy who was coining her feet to treat the pain of the neuropathy!
  • Jup (pinch) kchall is used to treat headache and malaise. The first and second fingers are used to pinch and thus bruise the bridge of the nose, neck, or chest. Jup also refers to the practice of "cupping" or placing a small candle on the forehead, lighting the candle, and placing a small jar over the candle. The flame consumes the oxygen and creates a vacuum, thus causing a circular contusion. As many as three contusions may be seen on a personís forehead.
  • Oyt pleung (known as "moxibustion" in the literature) is used to treat gastrointestinal and other disorders. Oyt pleung is seldom done in the U.S., but many adults will have four to six 1-2 cm round abdominal scars resulting from the procedure.
  • Massage or manipulation is practiced by kruu Khmer and others.
  • Traditional or natural medicines are available in stores and from individuals. Such medicines include a wide variety of plant (leaves, bark, extracts) and other substances. Some are brought to America (or even, occasionally, gathered in America) by individuals. Others are found pre-packaged and imported from Thailand or other Southeast Asian countries. These are often taken or applied topically in some combination of medicines and/or mixed with "wine" (usually vodka). We also sometimes encounter substances that may be classified as "Chinese medicine" such as those medicines/substances sold in Chinese pharmacies worldwide. It sometimes happens that kruu will give medicines (often topical or magic in nature) to hospitalized patients.

Spiritual healing practices: As noted above there are often both spiritual and medicinal elements in healing practices, hence classifying a particular practice as either spiritual or medicinal may not give a completely accurate picture of the practice. However, some illnesses or conditions are viewed as primarily or even only due to spirit problems or possession.

  • Magico-religious articles such as amulets, strings, and Buddha images are common. Katha (amulets or what appears to be a piece of string) are commonly worn around the neck by children or around the waist by adults. Types of amulets include a small piece of metal inscribed with sacred words written in Pali and rolled around string, Buddha images attached to a gold chain, and braided knotted string (with the knots incorporating magical substances. Amulets attain their power from prayers or incantations, from the words inscribed in the metal portion, from the material from which they are made, or from other attributes.
  • Yuan (click to enlarge) are magical pictures/words placed over doors or sometimes folded in pockets. They usually are written in Pali.
  • Buddha images may be seen as above or as statues or pictures in homes. They are found on altars placed high on a wall. Incense, flowers, food, cigarettes, or fetishes such as hair may also be placed on the altar.
  • Tattoos are an older means of protection against harm or illness. Magical designs and/or words written in Pali are found on the chest, back, neck, and arms of some men (see below - also note Oyt pleung scars on abdomen).
  • Other spiritual or magical means of treating illness include blowing on the sick person's body in a prescribed manner and showering or rubbing with lustral or blessed water.

As noted earlier, many Khmer see no conflict in practicing or using traditional or magic means of treating illness simultaneously with western medicine. Many would further see no conflict in adding Christian prayer to the mix.

Response to western or cosmopolitan medicine: Many Khmer take a syncretic approach to health care as well as other issues in life. Often traditional measures will be tried in the home before seeking health care outside the home and/or be used simultaneously with western medicine. Major issues in providing quality care are accurate and complete assessment, compliance with medications and treatment, and a reluctance to be involved in preventive measures.

Communication is a major issue in assessment and all other phases of care. Communication barriers may be due to language or to cultural issues. The latter include attempting to use a translator who, for gender, age, social status, or past relationship incompatibilities, may be rejected or not listened to.

Assessment is complicated first by a reluctance to complain or express negative feelings. It is common for patients to not report or even to deny symptoms or problems. This may be a cultural issue or may be due to past difficulties in obtaining health care. In other cases, symptoms or problems may be reported to several sources or to one source and not another.

Non-compliance may be due to several factors. The patient may not believe that he or she has communicated the problem and thus have little faith in the solution. A common Khmer orientation to symptoms (vs. cause) of illness may result in discontinuation of treatment as soon as symptoms are resolved. Treatment through dietary measures is very difficult because of difficulty in food substitutions, differences in perceptions of foods, and in some cases, financial issues. Often there is an erroneous assumption on the part of health providers that the patient will be able to independently obtain refills or reappointments. At the first of this paper we noted that Khmer (and others) have great difficulty negotiating the business aspects of the health care system. Upon receiving a large bill, some will react by simply not returning to the health facility. Some patients, rather than report a less than efficacious response to treatment, will report "no problem" or "its okay."

Most Khmer are oriented more to illness than prevention of illness. Childhood immunizations are accepted, but adult immunizations (influenza, pneumonia) are of little interest until illness strikes. Most Khmer doe not value early detection or disease screening. We have enjoyed some success in cancer screening (mammograms), but have seen small results from attempts to teach women to perform breast self exam.

Social Roles: Family and Community

Extended families living together or in close proximity are the cultural ideal, but nuclear families are common. Men are the heads of the household, but increasing numbers of households are headed by widowed, divorced, or separated women. In reality, the power in some families is with the wife rather than the husband. Extended families usually are headed by an older parent or grandparent. Because of the inevitable adjustments and changes resulting from living in a foreign land, decision-making may fall to younger family members. However, even when it is clear to healthcare staff that a younger son or daughter is making important decisions, it will benefit all concerned to go out of the way to show respect to the older family members.

Khmer youth are matter of concern to many community leaders and workers. Self-destructive behavior such as involvement in gangs is increasingly common. This is due at least in part to the destruction of much of the Cambodian culture by the Khmer Rouge and the long-term effects of the war and holocaust on individuals and families. Living in poor inner-city neighborhoods is part of the problem, but gangs and related behavior are a problem for many Khmer living in suburbs as well.

In many respects Khmer society in Cambodia and overseas is deeply divided and has been so for more than a quarter of a century. The pressures on individuals and families are profound and have a marked effect on individual and community health. While few Khmer will say to an American, "I am overwhelmed and lost," there is little doubt that many are exactly that.

Dying and Death (From an article by Kemp and Rasbridge in the Journal of Hospice & Palliative Nursing)

For Cambodians in the West (and to some extent, those elsewhere), dying is often accompanied by more "baggage" than other people. Besides the usual physical, personal, interpersonal, and spiritual issues, there also may be issues alluded to above, such as survivor guilt, guilt over decisions made during the Holocaust, unresolved grief, lack of cultural support, lack of family support, and others. As with other persons going through the process, Cambodians may experience a wide range of emotions, but acceptance or resignation are the most commonly displayed.

Most families prefer that discussion of end-of-life issues be with the family rather than the patient. There often are family attempts to "protect" the patient from knowledge of a poor prognosis. In some families there is an almost mystical faith in Western medicine and thus a reluctance to forgo even the most futile treatment. Withdrawal of treatment usually requires extended discussion with all family members and in many cases, repeated explanations.

Pain and other symptoms are often endured with stoicism. This is a critical issue in caring for Cambodians with advanced disease: One must ask very directly and specifically about each symptom that a Cambodian patient (especially older ones) may be experiencing. General or passing questions are meaningless. Equanimity in the face of death is highly valued. One should go into death calmly and mindfully.

Dying at home allows significantly greater cultural/community support than a hospital death. For example, in some locales, with support or intercession from hospice staff, the body may be kept at home for up to 24 hours. This allows for ceremonies and visitation that are very helpful to the family. In any case, hospice staff should assist in preventing the body being rushed out of the home as government agencies may desire.

Family expressions of grief after death may be open and unrestrained; or may be inhibited. We have noticed that persons in acute mourning often are extensively and even severely coined - as if to say, without words, "See my terrible pain."

Ideally, the body should be washed and prepared by the family. The hands are placed in a prayerful position and candles and incense placed in the hands. Some families place a coin in the mouth of the deceased. After the death, neighbors and friends visit in large numbers and are expected to make monetary contributions to the family for the funeral and related ceremonies. Donations are also given at the ceremony.

Cremation is preferred, though some Cambodians in America are buried. Ceremonies are usually held the weekend after the death and again at 100 days after the death. Offerings commemorating the deceased are also made at the New Year in April and at other times as well.

Notes on Interacting with Khmer

As with most other cultures, respect is essential. Older people should be greeted first and last. Communication is often indirect and requests or questions may be couched in seemingly vague terms. It is unusual for older people to make a direct "no" response to a question or request. Responses that may mean "no" include no response, a change in subject, or statements such as "its okay" or "no problem," or even an unconvincing "yes." When an answer is not forthcoming, it is of little value to continue to press for a response.

Paying attention to what others are doing is important. For example, when there is a pile of shoes at a door, visitors should also remove their shoes before going through the door. Offers of food and drink should be accepted as should an offer of the only chair in a room. Note that while Khmer appreciate children as least as much as others, they do not gush over babies or children. In fact, complementing and praising babies and children may bring bad luck to the child. Effusive, loud, or over-familiar behavior toward others is seldom in good form; nor is showing anger or involvement in confrontation.

It is difficult if not impossible to learn and follow all the proper cultural patterns of a culture not one's own. The best one can do is to (1) maintain both an inner and outer respect for others (2) pay attention to what others are doing and how they are reacting to a situation, and (3) learn about the culture attempt to implement that knowledge.

Health Risks in Refugees from Asia (See vastly expanded update in Infectious Diseases Section)

  • Nutritional deficits
  • Hepatitis B
  • Tuberculosis
  • Parasites (roundworm, hookworm, filaria, flukes, amoebae, giardia)
  • Malaria
  • HIV
  • Hansen's disease
  • PTSD

Recommended Laboratory and Other Tests for Refugees from Asia

  • Nutritional assessment
  • Stool for ova and parasites
  • Hemoglobin or hematocrit
  • PPD

VDRL should be considered.

Authors: Lance Rasbridge, PhD & Charles Kemp, FNP, FAAN

References

World Health Organization (2000). Healthy life expectancy rankings. Accessed on the World Wide Web on October 14, 2000 at http://www-nt.who.int/whosis/statistics/dale/dale.cfm?path=statistics,dale&language=english

http://www.btinternet.com/~andy.brouwer/biblio.htm This is a comprehensive listing of available books on Cambodia.

Khmer girl with polio.

Girl in Wheelchair

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