From fingersticks to chopsticks

Two years at an OB clinic in New York's Chinatown gave this doctor a crash course in cross-cultural medicine

By Debra Gussman, MD
Ob/Gyn/Neptune, NJ

When I arrived at NYU Downtown Hospital on Manhattan's Lower East Side in 1998, I didn't know much about Chinese people or their customs. The little I did know I'd gleaned from Chinese restaurants, Amy Tan novels, movies, and a two-week guided tour of China in 1995. I realized these weren't sufficient credentials for working at a hospital that serves the city's Chinatown district, with a population of more than 160,000. Still, I couldn't resist the opportunity to practice cross-cultural medicine.

The hospital's OB department was a mini melting pot, with a Pakistani chairwoman and staff members from China, Hong Kong, Taiwan, Macao, and Malaysia, as well as Americans like myself. Whatever our origins, most of us needed translators; and not merely a Chinese translator, but one who spoke the patient's dialect. Many times I would listen to a Mandarin translator speaking slowly, loudly, and—as it turned out—incomprehensibly to a Cantonese patient. (It must be a common human attribute to think that if you shout and wave your arms, other people will understand you regardless of linguistic obstacles. Not true.)

The language barrier made for some frustrating exchanges. One day, for instance, a resident told me she was concerned about a patient at 30 weeks who wasn't doing well on her gestational diabetes regimen. The woman was checking her blood sugars six times a day, and they ranged from 30 to 300. We reviewed the options and decided to admit her—but she refused.

The following week the patient returned to the clinic with the same wide-ranging sugar pattern. Again the resident suggested admission, and again the patient refused. I thought it was odd that she would be willing to do fingersticks six times a day but reject our offer of inpatient care. Eventually we discovered the reason: a communication problem.

It turned out that the translator, who spoke Mandarin, and the patient, who spoke Fukienese, had been struggling to converse in Cantonese. When we finally brought in a translator who spoke Fukienese, the patient readily agreed to be admitted. Until then, apparently, she'd thought we were trying to admit her in order to get rid of her baby.

While such misunderstandings can generally be overcome, the flavor of the doctor-patient interaction doesn't always get through a translator. We're used to interpreting body language, and listening for the meaningful tones a patient uses when presenting symptoms. A shrug can mean anything from "I agree" to "I'll think about it" to "I have no idea what you're trying to tell me." That's something a translator may be unable to communicate.

Traditional culture in an immigrant neighborhood

Along with language difficulties, treating Chinese immigrants means confronting infections not typically seen in American hospitals, especially TB and hepatitis B. It also means coping with medical conditions peculiar to Chinese culture. Take the traditional practice of foot-binding. Some of the older women I saw had foot deformities caused by having their feet bound when they were young girls. They also had a higher than normal incidence of osteoporosis and falls.

Some of the women had fake tubal ligation scars, self-inflicted before they left China. In a country that allows only one child per family, they had cut themselves with knives, hoping the scars would fool the "pregnancy police" into believing that they had undergone a failed sterilization procedure. Apparently, the ruse sometimes worked.

I also had to learn the importance of the forces of yin and yang during pregnancy. Yang is the male, active, and positive force associated with heat and light. Yin is the female, negative, and inactive force associated with cold and darkness, and it peaks in women during pregnancy.

Chinese women believe that childbirth causes a marked imbalance between yin and yang forces within their bodies; so during the postpartum period they consume "hot" foods like chicken, liver, yellow wine, hot teas, red dates, and black mushrooms, and avoid "cold" foods such as cabbage, oranges, watermelon, soft drinks, and ice. For physicians treating pregnant women, these preferences mean searching the PDR to find antibiotics and other pills that come in "hot" colors like red, yellow, and orange.

I learned, too, that Chinese immigrants prefer self-treatment and traditional remedies to Western medicine. Fortunately, however, most Chinese women seek prenatal care early. I'd like to think that's because they appreciate the importance of seeing a doctor during pregnancy. But it may have more to do with their concern about eligibility for Medicaid and other state programs.

Some women are illegal immigrants, so they're leery of coming to the hospital because they fear it's part of the government. On the other hand, many of them believe—wrongly—that their baby must be born in the hospital to acquire American citizenship. To promote prenatal care, we don't try to correct this misconception.

Traditional Chinese patients feel that bed rest is essential after delivery in order to straighten the backbone and correct the lordosis caused by pregnancy. That leads to conflicts when you want them to get out of bed soon after a C-section to prevent DVT. The same problem occurs when they go home. In China, these women would be free from housework during their postpartum period. But here they don't have the extensive family support system that exists in China.

Many Chinese women who are illegal immigrants work as indentured laborers in local restaurants or garment industry sweatshops until they can afford to pay back the enormous fees—upward of $20,000—they owe to the smugglers who arranged their transport to the US. Since most of them earn minimum wage or less, this can take years. As a result, few of our patients breast-feed their babies, because they can't get maternity leave. In fact, many women are forced to send their babies back to their families in China.

Cultural background also influences behavior and hygiene. For example, traditional Chinese women don't bathe or wash their hair until one month after delivery. And they're careful to avoid any chill to the body, believing it could result in arthritis, headaches, or lumbago later in life.

Unwanted daughters and "poisonous sex"

Then there's the issue of "poisonous sex." Chinese women believe that sex after childbirth can pollute a new mother's body. Most women, therefore, wait 100 days before resuming sexual relations. This can make postpartum discussions about birth control frustrating, because you're trying to share information on a subject they consider taboo.

The cultural idiosyncrasy I found hardest to accept was my patients' negative attitude toward female offspring. In China, giving birth to a son is considered reason for great joy, because sons will care for their elderly parents and pray for their ancestors. Daughters are seen as an investment with little promise of return.

So I learned that during an ultrasound exam, it's better to say you're not sure of the gender of the fetus than to tell the woman it's female. If she already has a daughter, she might see another as a calamity. In fact, many women seek ultrasounds from neighborhood Chinese doctors before they come to our hospital for prenatal care. If it's a girl, they may opt for an abortion.

I spent just two years in Chinatown, but, looking back, I realize that I enjoyed a rare and wonderful opportunity to learn about another culture. It was an experience I'll never forget.

 

Debra Gussman. From fingersticks to chopsticks. Medical Economics 2002;11:61.