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).

2- 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:

- 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.

3- Arabic Culture and Health Care:

A. Cultural communalities which have an impact on health care delivery may include (10) (17):

- 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.

- 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.

- Arabs are not accustomed to the profession of social workers. They rely on their families, other relatives and close friends for support and help.

- Preferring medical treatment that involves prescribing pills or giving injections, rather than simple medical counseling.

- 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.

- 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.

- Among devout Muslims, praying as many as five times a day, starting before sunrise and ending at night.

- Among devout Muslims, abstaining from alcohol is mandatory.

- 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.

- 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:

- 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).

- 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).

- 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).

- 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).

- 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).

- 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).

- 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).

4- 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.