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Background

The vast majority of the approximately 700,000 Vietnam-born persons living in the U.S. arrived here as refugees from 1975 to the present. While there are many shared cultural traits among all the Vietnamese-Americans, such as the Vietnamese language and strong emphasis on the extended family, there are also marked differences. This heterogeneity is represented largely by the refugee "wave" in which the individual or family arrived.

The first group of refugees to come to the U.S. in 1975 were educated and urban professionals (and their families) who were airlifted directly from Saigon. They were closely associated with American interests in Vietnam, so many spoke English and were familiar with American culture. This group has for the most part gone on to resume their professional lives in the United States, including serving as staff members of social service agencies which assist more recently-arrived Vietnamese.

In contrast, the second wave of Vietnamese refugees, arriving from the late 1970's through the mid 1980's, included a much higher proportion of merchants, farmers and other rural Vietnamese who escaped Communist Vietnam in small boats. These "boat people" suffered extreme hardship and loss through the refugee process, often remaining in harsh refugee camps for years. Many who came from rural origins or limited educational backgrounds have had a more difficult time adapting to urban U.S. life - while others from rural backgrounds found that intelligence and persistence are stronger than 100 generations of rural deprivation. The photograph is of a woman and children shortly after being picked up in the South China Sea in 1979. Lady, where are you now?

Finally, the third wave, continuing to arrive to the present, come to the U.S. under more "orderly" programs, typically on the basis of their statuses as political prisoners in Vietnam, or offspring of Vietnamese women and American fathers ("Amerasians"), two groups who faced serious discrimination in Vietnam. They come with their families; in the case of Amerasians, more often than not the father is unknown or otherwise out of the picture.

Because of their experience as refugees, Vietnamese-Americans on the whole are at high risk for many communicable diseases like tuberculosis, hepatitis B and parasitism as they arrive to the U.S. Over time, as many face accessibility barriers to medical care because of such factors as limited English skills, transportation difficulties, and cultural misunderstandings, they are at risk for more chronic problems like hypertension, heart disease, cancer and diabetes. In addition, many Vietnamese refugees also suffer mental health problems like post-traumatic stress disorder (PTSD), a result not only of the horrors they experienced as refugees but also due to the adjustment difficulties in attempting to retain their traditional values in the face of the dominant American culture.

Buddhism and Health

Although some Vietnamese refugees are Catholic or have been converted to other branches of Christianity, most Vietnamese follow Buddhist concepts. Buddhism on the whole is best understood not as a religion in the Western sense but more a philosophy of life, and it impacts profoundly on the health care beliefs and practices of Vietnamese. For example, Buddhists profess profound respect for elders and those in authority. This means that many Vietnamese in this country will rarely be confrontational with their American counterparts; in disagreement, a "face-saving" measure of avoidance or superficial acceptance is preferred to questioning or defiance, especially of those in positions of superiority, such as doctors and teachers. Even direct eye contact or physical positioning of elevation over one's superior is considered forward and impolite by some traditional Vietnamese.

Buddhism also teaches that life is a cycle of suffering and rebirth; if one lives life in adherence to the Buddhist path, one can expect less suffering in future existences. Buddhism stresses disconnection to the present, especially materialism and self-aggrandizement. Hence pain and illness are sometimes endured and health-seeking remedies delayed because of this belief in fate. Similarly, preventive health care has little meaning in this philosophy.

Another tenet of Buddhism holds that the family unit is more important than the individual, with less emphasis on the "self." Accordingly, health care decision-making is frequently a family matter. Concordantly, the family would typically be involved in treatment.

Respect for and veneration of ancestors is associated with Buddhism and Confucianism. The prospect of burial away from ancestral burial sites is a source of significant distress to older Vietnamese. Difficulty visiting burial sites in Vietnam is also distressful.

Health Care Beliefs and Practices

Spiritual

The diagnosis of illness is frequently understood in three different, although overlapping, models. The first, the least common, is what could be considered supernatural or spiritual, where illness can be brought on by a curse or sorcery, or nonobservance of a religious ethic. Traditional medical practitioners are common in Vietnamese culture, both here and in Vietnam; some are specialists in the more magico-religious realm. This specialist may be called upon to exorcise a bad spirit, for example, via chanting, a magical potion, or consultation from and recitation of ancient Chinese texts.

The use of amulets and other forms of spiritual protection are also commonly employed by Vietnamese. For example, babies and children commonly wear bua, an amulet of cloth containing a Buddhist verse or is blessed by a monk, worn on a string around the wrist or neck. For spiritual illness of a more Buddhist etiology, religious practices may be intensified, such as the burning of incense at the home altar to appease the ancestors, or a Buddhist monk may be consulted for prayer.

Vietnamese traditionally do not have a concept of mental illness as discrete from somatic illness, and hence are very unlikely to utilize Western-based psychological and psychiatric services. Instead, most mental health issues such as depression or anxiety fall into this spiritual health realm and are treated accordingly. Similarly, physical expression of spiritually-based illnesses (known as somatization) is common, and treatments overlap with the realms of health understanding which follow below.

Balance

Secondly, a very widespread belief is that the Universe is composed of opposing elements held in balance; consequently, health is a state of balance between these forces, known as "Am" and "Duong" in Vietnamese, based on the more familiar concepts of yin and yang in China. Specific to health, these forces are frequently translated as "hot" and "cold," although it is important to understand that these concepts are not necessarily referring to temperature. Illness results when there is an imbalance of these "vital" forces. The imbalance can be a result of physiological state, such as pregnancy or fatigue, or it can be brought on by extrinsic factors like diet or over-exposure to "wind," one of the body forces or "humors." Balance can be restored by a number of means, including diet changes to compensate for the excess of "hot" or "cold," western medicines and injections, and traditional medicines, herbs and medical practices. These practices and medications include:

  • Coining (Cao gio). "Catch the wind." A coin dipped in mentholated oil is vigorously rubbed across the skin in a prescribed manner, causing a mild dermabrasion. This practice is believed to release the excess force "wind" from the body and hence restore balance.
  • Cupping (Giac). A series of small, heated glasses are placed on the skin, forming a suction that leaves a red circular mark, drawing out the bad force.
  • Pinching (Bat gio). Similar to coining and cupping, the dermabrasion formed by pinching the skin allows the force to leave the body. (It should be noted that many of these practices are performed on young children, even infants, and the temporary dermabrasions they produce should not be confused with abuse or injury.)
  • Steaming (Xong). A mixture of medicinal herbs is boiled, the steam is inhaled, and the body bathed.
  • Balm. Various medicated oils or balms, like Tiger balm, are rubbed over the skin.
  • Acupuncture. Specialized practitioners insert thin steel needles into specific locations known as vital-energy points. Each of these points has specific therapeutic effects on the corresponding organs.
  • Acupressure or Massage. Fingers are pressed at the same points as with acupuncture, and together with massage, stimulate these points to maximize their therapeutic effects.
  • Herbs. Various medicinal herbs are boiled in water in specific proportions or mixed with "wine" and consumed, for example, in the postpartum, to restore balance.
  • Patent Medicines. These powdered medicines come packaged usually from Thailand or China and are mixed or boiled with water and taken for prescribed ailments.

Western

Thirdly, most Vietnamese-Americans also recognize the more "western" concepts of disease causation, like the germ theory. There is widespread understanding, for example, that disease can come from contaminants in the environment, even if full concepts of microbiology or virology are not grasped. Concomitantly, through decades of French occupation and more recently the American influence, even the most rural Vietnamese has come to know the life-saving power of antibiotics.

When Vietnamese enter the American health care setting, they do so frequently with the goal to relieve symptoms. In general, the Vietnamese patient expects a medicine to cure the illness immediately. When a medication is not prescribed initially, the patient is likely to seek care elsewhere. In addition to the myriad of traditional healers and other traditional medicines and practices available to resettled Vietnamese, Western pharmaceuticals, especially vitamins and even antibiotics, are obtainable, either through specialized "injectionists," or from relatives in other countries such as France where some of these medicines are available without prescriptions.

Vietnamese frequently discontinue medicines after their symptoms disappear; similarly, if symptoms are not perceived, there is no illness. Hence preventive, long-term medications like anti-hypertensives must be prescribed with culturally-sensitive education. It is quite common for Vietnamese patients to amass large quantities of half-used prescription drugs, even antibiotics, many of which are shared with friends and even make their way back to family in Vietnam.

Western medicines, especially oral medications, are held in general to be "hot" medicines, in their effect on the balance of the body. When medicines are prescribed for a condition like skin irritation, which is understood traditionally as a hot illness, the excess force erupting through the skin, a compliance issue may result. In this case, alternatives like a balm or poultice may better meet the patient's understanding of balance. Similarly, Vietnamese commonly believe that Western pharmaceuticals are developed for Americans and Europeans, and hence dosages are too strong for more slightly built Vietnamese, resulting in self-adjustment of dosages.

As mentioned above, Vietnamese hold great respect for those with education, especially physicians. The doctor is considered the expert on health; therefore, the expectation is that diagnosis and treatment should happen at the first visit, with little examination or personally-invasive laboratory or other diagnostic tests. In fact, a doctor who probes a great deal into symptoms may be held incompetent by some traditional Vietnamese for not being able to diagnose readily.

Commonly, laboratory procedures involving the drawing of blood are feared and even resisted by Vietnamese, who believe the blood loss will make them sicker and that the body cannot replace what was lost. Surgery is particularly feared for this reason. Overall, as health is believed to be a function of balance, surgery would be considered an option only of last resort, as the removal of an organ would irreparably alter the internal balance.

In sum, Vietnamese view health and illness from a variety of different perspectives, sometimes simultaneously. In other words, it is not uncommon for a sick person to interpret their illness as an interaction of spiritual factors, internal balance inequities, and even an infective process, for example. Accordingly, Vietnamese will combine diagnostic and treatment elements from all three models in order to get the maximum health benefits. This broad perspective suggests an understanding of mind-body interactions and predisposing factors to illness that Western medicine is only beginning to fully appreciate.

Health Risks in Refugees from Asia (Also see the Infectious Diseases web site for updates and details)

  • 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.

Author: Lance A. Rasbridge, PhD

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