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Ethiopians & Eritreans culture health refugees immigrants


Background on Country of Origin

Ethiopia is an arid country located on the Horn of (East) Africa at the Red Sea.Ethiopia was never colonized, but in 1935 suffered terribly at the hands of Italy's army as a prelude to WWII. The country was ruled from 1930 until 1973 by the Emperor Haile Selassie. In 1973, the Emperor was overthrown by a group of army officers who established a repressive marxist military regime. Along with the repression came drought, famine, a secessionist movement in Eritrea, and other conflicts.

Ethiopia and Eritrea are now separate countries, but culturally are similar, and considered the same by some sources. Major cultural groups living in Ethiopia include the Amhara and in western Ethiopia, the Oromo. In Eritrea, Tigreans are the most common group. Other groups living in Ethiopia/Eritrea include the Afad-Isas, Somalis, Wolaitas, Sidamas, Kimbatas, and Hadiyas.

History of Immigration

Prior to the 1973 coup, there were very few Ethiopians living in the West. Out-migration began immediately after the coup. A common experience was for a small group of 5-20 people to travel across the desert by night and hide by day. The journey to the country of first asylum was dangerous and many died on the way. Migration to the West began in 1980, with the greatest number of Ethiopians coming to the U.S. from 1983-1993. Estimates of the number of Ethiopians in North America range as high as 250,000 (Hodes, 1997). This probably is inflated. There were major airlifts of more than 55,000 Ethiopian Jews to Israel in 1985 and 1991 (Operations Moses and Solomon). Most of these were illiterate farmers.

Ethiopians/Eritreans living in the West are most often from urban backgrounds and many came with or obtained college degrees in their host countries. Most live in large urban areas on the East and West coasts as well as in Houston and Dallas. As noted in the section on families, Ethiopians/Eritreans living in the West are disproportionately male and young.

Culture

Influences operational to varying degrees in the lives of Ethiopians/Eritreans include traditional thinking (especially among the Ormoro and those from rural backgrounds), the Coptic Church, and Islam.

Foods are spicy and tend to be "heavy" and served in large portions, especially late in the day. A thin spongy bread is served and is used in place of utensils. Ethiopians tend to be very conscious of the need for hand washing before meals (and perhaps at other times as well).

Communications

Amharic is the national language of Ethiopia (the Amhara people) and Tigrinya the language of Eritrea (the Tigrean people) - though both languages may be used in either country. A third language, Oromigna is used by the Oromo people living mostly in western Ethiopia. Most Ethiopians/Eritreans prefer translations and other assistance be provided by persons from their own ethnic or linguistic group - thus translation by an Amhara person for a Tigrean will not be as effective as a Tigrean translating for a Tigrean.

Communication tends to be direct, with most people usually speaking softly. Among those who live in the West, eye contact is usually direct. Little emotion or affect is shown to strangers, but physical affection is common between friends.

Religion

Most Ethiopians/Eritreans are Coptic Christians (or Ethiopian Orthodox). Some are Muslim and some Jewish - with many of the later immigrating to Israel 1985 & 1991. As discussed in the section on Religions this branch of Christianity views the spiritual and physical worlds as similarly sacred and makes wide use of icons. Intercessory prayer is used to obtain God's healing in physical and mental illness.

Both Muslims and Coptic Christians practice restriction of some foods. Muslims are forbidden pork and other flesh not properly killed. Muslims also do not eat from vessels in which pork may have been served or cooked. Coptic Christians do not consume meat or dairy products for more than half of each year. The latter is probably more closely followed in the homeland than in the West.

Social relations

The ideal family structure and living arrangement is the extended family. However, there are few truly extended Ethiopian/Eritrean families living in the West. Ethnomed notes that the divorce rate is high and that is particularly difficult for single female head-of-household parents to raise children.

In most families, men are dominant, although the roles of some Ethiopian/Eritrean women are changing rapidly in the West. At least in the early days of out-migration, there were many more men than women coming to the U.S. and other countries of refuge. The imbalance of men and women has changed somewhat (now 65% male and 35% female), but single Ethiopian/Eritrean males are more common than among other refugee groups. This is particularly a problem when single men become ill and do not have the social support of family and wife.

Ethiopian/Eritrean women are perceived as needing protection by their husband or male family members. Men make most of the decisions, especially those in relation to the outside world. The emancipation of Ethiopian/Eritrean women in the West is changing family and interpersonal dynamics - including this decision-making. Factors promoting women's emancipation include (1) the power of Western culture and the women's movement and (2) the lack of Ethiopian/Eritrean women living in the West, i.e., with an abundance of men, women do not have to tolerate being dominated.

Traditionally, disputes are settled by community (male) elders. Originally in the West there were few such men, but leaders and elders have emerged in the Ethiopian/Eritrean communities in host countries.

Health Care Beliefs and Practices

Traditional Ethiopian/Eritrean belief is that health results from equilibrium between the body and the outside world; and illness from disequilibrium. The external world may be either the physical (sun, temperature, foods, etc.) or the spiritual world. The relationship between the person and the supernatural world is very important in maintaining health and happiness. Those who live in the Western world are more likely to understand biomedical principles of causation.

Traditional herbal medicine is highly developed and widely used in Ethiopia/Eritrea. Analyses of extracts/fractions taken from traditional herbal medicines show that many such substances have significant activity against disorders for which they are used, e.g., parasites, infections, and other medical problems. There are at least 21 specialized traditional healers operating in Ethiopia/Eritrea. These include tooth extractors, cuppers (i.e., suctioning or cupping - sometimes large amounts of blood), amulet writers, seers, herbalists, and uvula cutters.

As with many others from the Third World, Ethiopians/Eritreans put great stock in medications, with injections more valued than oral medications. Many patients are dissatisfied if medications are not given while diagnostic tests are pending or the illness does not necessarily call for medication.

Several resources note that Ethiopians/Eritreans tend to take less fluids than is healthy. Fluids are preferred at room temperature. Fluids are particularly a problem when a patient is in the hospital where hydration is most important and drinks are often offered with ice.

Ritual female genital cutting (FGC) is practiced by Ethiopians/Eritreans from all three major religions (Coptic, Muslim, Jewish). Cutting usually is done in infancy or childhood and is classified by the WHO as Type I, the removal of the prepuce and/or part or all of the clitoris; Type II, the removal of prepuce and clitoris together with the partial or complete excision of the labia minora; Type III (or infibulation), the removal of the clitoris, the adjacent labia (majora and minora), followed by the pulling of the scraped sides of the vulva across the vagina and securing with thorns or sewn with catgut or thread except for a small opening to allow passage of urine and menstrual fluid; or Type IV Unclassified. 90-95% of women from Eritrea and Ethiopia have had FGC performed, mostly Types I or II. In some cases, FGC may consist of slight ritual scarring. See the section on Refugee Women and Health Issues.

Magico-religious practices are common in Ethiopia/Eritrea, and some continue among refugees in the west. Amulets (kitab) are worn by some, usually under clothing.

A person's mental condition is thought to play an important role in her or his physical health, hence shocking or potentially traumatic news should be given with care and with family or friend support at hand. Many will prefer that a poor prognosis or other such news be given first to a (male) family member. Open discussion of terminal illness is not desired by most; and acceptance of a poor prognosis is unusual.

Mental illness is attributed to evil spirits by both Muslims and Christians. Mental illness is sometimes attributed to possession by the Zar spirit, especially among newer refugees or immigrants. Zar possession is more common among women in Ethiopia/Eritrea and among men in refugees and immigrants living in the Western world. Harm can be inflicted on others by persons with buda or the power of evil eye. Spirit possession is treated with prayer and herbal preparations or holy water depending on whether the patient is Muslim or Christian. Some people may utilize different sources of religious and medical help for mental disorders, with the reputation of the healer of greater importance than his religious orientation.

Somatic complaints as a manifestation of emotional distress are common. These complaints are often vague and/or difficult to treat. Therapy in mental illness or distress should be more active and include the family. Hodes (1997) suggests low doses of antidepressants as especially helpful.

Hospitalized or sick patients take on a passive and dependent role. Physicians are expected to know and convey to the patient what is best for the patient. As with many others from third world countries (especially those with less education), large amounts of information and frequent decision-making by the patient or family may induce anxiety. Health care providers are expected to be warm and friendly (but not act as partners in the health relationship). In Ethiopia/Eritrea the extended family plays a significant role in the care of hospitalized patients, but in the West, few Ethiopian/Eritrean families are of sufficient size to take on such a role and the health care system does not accommodate extensive involvement in care. As among other refugees and immigrants, being in a sick role intensifies whatever difficulties an Ethiopian patient may have in adjustment to a different culture.

Most Ethiopians/Eritreans are stoic with respect to physical (and emotional) pain. Pain medications may be refused and pain control in advanced disease such as cancer is difficult to achieve.

Specific Ethiopian/Eritrean Beliefs About Health and Illness (Hodes, 1997)

  • Excess sun (especially if sun strikes a part of the body that is sweating or unclean) causes mitch which is translated as sunstroke, but causes rash, itching, or herpes.
  • The heart is thought to regulate other organs by producing heat and not involved with blood. Complaints of a "heart problem" (vs. complaints of cardiac symptoms) may be related to dyspepsia or other GI problem.
  • The uvula is believed to put infants at risk for suffocation, hence is excised in many Ethiopians/Eritreans.
  • Eye problems may be treated with incisions of the eyelids or eyebrows.
  • Amulets to treat or prevent disease are called kitab.
  • Diarrhea in infants may be treated by extracting the milk teeth.
  • The evil eye is called buda and infants are especially vulnerable.
  • Menopause that leads to increase in abdominal girth may be attributed to pregnancy which "stays bone."
  • Moygnbaggen or "get a fool" is a traditional disease with symptoms of syncope, fever, headache, abdominal cramps, or stiff neck. The disease is treated by bloodletting (brachial vein).
  • Wind (cold) may cause pleuritic chest pain or wugat. Treatment is with cupping.
  • The stomach is believed to be an inert organ in which ascaris worms live and process food.
  • Sexually transmitted diseases may be attributed to urinating under a full moon, urinating on a hot stone, contact with an infected dog, or other means. HIV infection is increasing in Ethiopia.
  • Having sex weakens tuberculosis medicines. Responses to this belief may include divorce, ceasing sex, or discontinuing the medications (R. Hodes, personal communication 1/2000).

Pregnancy and Childbirth

Among rural people, pregnancy is thought to be a time of increased vulnerability for the mother. The fetus is also at risk for harm from evil spirits and sorcery. In Ethiopia/Eritrea, most deliveries are performed by a midwife or female family members. In the West, Ethiopians/Eritrean women prefer female physicians. Some feel that Western physicians are too quick to perform Cesarean sections and attempt to prevent such intervention by waiting as long as possible to go to the hospital for delivery.

Some women practice a brief symbolic rejection of the infant for the discomfort and pain caused by pregnancy and delivery. After delivery, the mother may stay in the home for two-six weeks. Breast-feeding (for up to three years) is the norm in Ethiopia and also is practiced in the U.S., but for a shorter time. Many mothers introduce other foods at about four months.

Family planning was not widely available in Ethiopia/Eritrea, but is well-accepted by many Ethiopians/Eritreans in the West.

Health Problems

Although the drought has eased and the famine far less dramatic than in the 1970s, malnutrition remains a widespread problem in rural and, to a lesser extent, urban Ethiopia/Eritrea.

Few Ethiopians/Eritreans arrive in the West with the dramatic health problems and malnutrition seen in the early days of displacement. Nevertheless, health problems are common, and may include the long-term effects of malnutrition, war trauma (physical and psychological), and a variety of infectious diseases. The prevalence of hepatitis B is high among Ethiopians/Eritreans and other sub-Saharan Africans. In one study, more than half of children >10 years have serological markers for past HBV infection (Bisharat, Elias, Raz, & Flatau, 1998).

Medical problems most commonly seen in newly arriving refugees from Ethiopia/Eritrea and other East African countries (Ackerman, 1997; Gavagan & Brodyaga, 1998) are listed below. Also see the Infectious Diseases site.

  • Malnutrition
  • Intestinal parasites (Enterobius, Trichuris, Strongyloides, and Ascaris)
  • Filariasis
  • Leishmaniasis
  • Hepatitis B
  • Tuberculosis
  • Low immunization rate
  • Dental caries
  • Typhoid fever
  • Malaria
  • Trachoma
  • Syphilis
  • Dengue fever
  • HIV infection
  • Diarrheal illnesses
  • Hansen's disease

Recommended laboratory and other tests include:

  • Nutritional assessment
  • Stool for ova and parasites
  • Hepatitis B surface antigen
  • Hemoglobin or hematocrit
  • VDRL
  • HIV
  • PPD
  • Peripheral smear for malaria should be considered

Other problems that practitioners should be especially alert to are cervical cancer, ectoparasites, and post-traumatic stress disorder.

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Author: Charles Kemp, FNP, FAAN

References

Ackerman, L. K. (1997). Health problems of refugees. Journal of the American Board of Family Practice, 10(5), 337-348.

Bisharat, N., Elias, M., Raz, R., & Flatau, E. (1998). Familial pattern of infection with hepatitis B virus among immigrating Ethiopian Jews to Israel. European Journal of Epidemiology, 14(1), 89-91.

Ethnomed

Gavagan, T. & Brodyaga, L. (1998). Medical Care for immigrants and refugees. American Family Physician, 57(5), 1061-1068.

Hodes, R. (1997). Cross-cultural medicine and diverse health beliefs: Ethiopians abroad. Western Journal of Medicine, 166(1), 29-36. Readers are encouraged to obtain a copy of this article.