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* About 150,000 Laotians live In the United States * When the US withdrew from the Southeast Asian conflicts in 1975, some 13,000 Mien fled the rural highlands of Laos for Thailand * In 1980, asylum in the US was granted the Mien in camps In Thailand
Cross-cultural Medicine A Decade Later Use of Traditional and Modern Health Services by Laotian Refugees STUART C. GILMAN, MD, MPH, Long Beach; JUDITH JUSTICE, PhD, MPH, San Francisco; KAOTA SAEPHARN, San Pablo; and GERALD CHARLES, MD, San Francisco, California
Although refugee health care emerged as a special interest in the United States following the influx of almost a million Southeast Asians since 1975, few studies have been done of the influence of refugee traditions on the use of Western medical services. The illness patterns, medical beliefs, and health care behavior of a Southeast Asian refugee group, the Mien from Laos are described in this study. A cohort of 1 19 Mien refugees living in Richmond, California, was observed for a 6-month period. In-home interviews were undertaken about all episodes of ill health, including treatment and health care decisions. This study shows that the Mien integrate traditional healing beliefs and practices with the use of American health services. Such findings are important because the increasing cultural diversity in the United States, particularly in Western states, necessitates that health care professionals understand the importance of cultural factors for access to and the use of health care by all patients including refugees and other immigrant groups. (Gilman SC, Justice J, Saepharn K, Charles G: Use of traditional and modern health services by Laotian refugees, In Cross-cultural Medicine-A Decade Later [Special Issue]. West J Med 1992 Sep; 157:310-315) Refugee health care has emerged in the United States as an area of special interest following the influx of almost a million Southeast Asians since 1975. Because the largest number of Southeast Asian refugees resettled in the US West, health care professionals, particularly in California, Washington, and Oregon, have confronted numerous challenges in providing medical care to this population. Earlier articles focused on new refugees and the need for "health screening" for infectious and other tropical diseases.1'2 Reports providing brief, general descriptions of Southeast Asian cultures, including traditional practices, beliefs, and attitudes towards health and medical care, appeared in medical journals with the early arrival of refugees.3-5 For example, a photo of a Mien family in full traditional dress was on the cover of THE WESTERN JOURNAL OF MEDICINE'S initial special issue on cross-cultural medicine in December 1983.4 Few articles have been published, however, about the influence of refugee traditions on the use of Western medical services in US communities.
Research Methods Most physicians and other health care professionals meet refugees only in clinical settings and thus do not have access to information about factors influencing Southeast Asian patients' definition of illness and treatment-seeking behavior. The present study was designed to help fill this gap in current medical knowledge about the refugee community by describ-
ing the illness patterns, medical beliefs, and health care behavior of one Southeast Asian refugee group, the Mien from Laos. A research team of two physicians (S.C.G. and G.C.), a Laotian university student (K.S.), and an anthropologist (J.J.) collaborated on a community-based study in 1988 to 1989, observing a cohort (randomly selected from telephone book listings) of 17 Mien refugee families with 119 household members. The first six-month phase of this two-part study consisted of ethnographic in-home interviews of Mien families, healers, and religious leaders and interviews of health care professionals at voluntary agencies and medical facilities providing services to Mien. Traditional and Christian Mien religious ceremonies were observed in Mien homes and in the Mien church. Phase two consisted of biweekly surveys of all episodes of ill health and treatment during the subsequent six-month period. One member of each household served as the principal informant on health for all persons in the household, aided by other family members who were usually present during the in-home interviews. The Mien researcher conducted interviews in the refugees' own language. The findings of this study provide insight into how refugees integrate traditional healing beliefs and practices with the use of American health services. The Mien This study of Mien in Richmond, a city in the San Francisco Bay Area of California, is one of the few community-
From the Regional Medical Education Center and Western Region Special Studies Group, Veterans Affairs (VA) Medical Center, Long Beach (Dr Gilman); the Medical Anthropology Division, Department of Epidemiology and Biostatistics, University of California, San Francisco (Dr Justice); the Ethnic, Asian-American Studies, Center for Southeast Asian Studies, University of California, Berkeley (Mr Saepharn); and the Medical Service, VA Medical Center, San Francisco, California (Dr Charles). Mr Saepharn is currently with the Ethnic and Bilingual Sciences Program, Roosevelt Junior High School, Oakland, and Dr Charles is also Chief of Staff at the VA Medical Center, San Francisco, California. Research support for this study was provided by the Department of Veterans Affairs and the Robert Wood Johnson Foundation Clinical Scholars Program at the University of California, San Francisco, School of Medicine. Eric Crystal, Program Coordinator, Center for Southeast Asian Studies, University of California, Berkeley, assisted in the development of this project. Appreciation is extended to the Richmond, California, Mien community for their generous hospitality and cooperation. Reprint requests to Judith Justice, PhD, MPH, Medical Anthropology Division, Department of Epidemiology and Biostatistics, University of California, San Francisco, 1350 Seventh Ave, Box 0850, San Francisco, CA 94143.
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based cohort studies of refugee use of health services to consider traditional health practices. Richmond's Mien population is estimated to number between 1,200 and 1,500. Although there are many Southeast Asian groups in the San Francisco Bay Area, the Mien were selected for study for several reasons: * Mien are identifiable at the community level because of naming practices. The Mien naming convention in the United States places the prefix "Sae" on all clan names. Only six clan names-which serve as the second or family name in the United States-are used in the research area: Saepharn, Saeteurn, Saelee, Saechao, Saefong, Saeliaw, and their spelling variants; * The Mien refugees are similar in educational and economic status because they came from a homogeneous highland rural culture in Laos. They were one of the most geographically isolated groups before emigration and, therefore, had greater difficulties adjusting to this country than did other Southeast Asian refugee groups who are from lowland and urban areas; * The Mien were accessible to the research team because one team member is a Mien refugee who lived in Richmond with his family. He was the first member ofthe Mien community to attend the University of California at Berkeley where he was a third-year undergraduate student at the time of this study (1988 to 1989). Data about Mien use of health services are not easily compared with those of other Americans because of economic, family structure, and demographic factors. Strand and Jones's cross-sectional study found that Hmong refugees, another highland Lao group with many cultural similarities to the Mien, were infrequent users of Western medical services compared with other Southeast Asian refugees.6 Unfortunately, the authors did not address the use of indigenous healing practices. Brainard and Zaharlick sampled ethnic lowland Lao from a voluntary agency roster in Ohio and found little traditional healing activity among this population.7 Buchwald and co-workers, however, found the frequent practice of traditional healing among Southeast Asians in Washington State.8
Background The Mien, also called "Iu Mien" or "Yao," are a highland people who inhabit the hills of Vietnam, Thailand, Laos, Burma, and China.9 The Mien migrated to Southeast Asia from southern China over several hundred years and still retain many features of Chinese tradition. Mien religion includes aspects of animism, ancestor worship, and Chinese Taoism. A Chinese dialect is used for the Mien's religious language, and written records are recorded in Chinese characters. Other hill people in Laos, such as the Hmong, do not keep written records. Life in the highlands of Laos consisted of slash-and-bum agriculture, frequent religious rituals, and war that extended for a period before World War II through 1975.10 Westernstyle medical services available in Laos were poorly developed, especially in the hills, and Mien and other hill tribes relied primarily on traditional healing before emigrating from Laos.11 The Mien who lived in Laos sided with the United States and other allies against Communist forces in the region from 1959 to 1975 during the war in Southeast Asia. When the
United States withdrew from Southeast Asia, approximately 13,000 Mien living in Laos fled to Thailand."2 In 1980 the US made asylum widely available to the Mien who were in refugee camps in Thailand.13 Although the Mien initially were settled throughout the United States, their sense of family, village structure, and religion, in addition to differences in public assistance benefits among the US states,12 contributed to a second migration and resettlement to the West. About 15,000 Mien are currently living in the US, although accurate demographic information is impossible to obtain because the Mien are counted as Lao, a category that also encompasses the culturally distinct Hmong, other hill tribes, and the lowland or urban Lao. The Mien who settled in Richmond reside in poor urban neighborhoods in this city of approximately 92,000 people. Study participants generally live in poorly maintained rental apartments and small houses on streets with decaying and abandoned buildings. Households usually comprise an extended family consisting of two and three generations and, on average, seven people. Most Mien families are poor and receive welfare benefits. Several families supplement this income with day work as manual laborers, gardeners, house cleaners, babysitters, and so forth. For most, a lack of formal education and fluency in English are barriers to other employment. Among the 17 families participating in the study, only 2 were comfortable speaking English, and even these families resorted to Mien for the discussion of any complex issues. Children attend the local public schools where they learn English, but most adults still use the Mien language, especially in the home.
Findings The combination of home visits, interview schedules, and observation of relevant Mien traditional ceremonies provides a comprehensive picture of health problems and treatment practices of the 17 households with 119 family members. Study participants ranged in age from 2 months to 74 years, with a skewed age distribution, 69% being younger than 18 years. Their average age was 20.3 years, and the median age was 10 years. Just over half (52%) of the sample was female. Religion is a factor influencing Mien health beliefs and practices. Of the participants in the study, 72% practiced Mien religion and 28% were Christian (Baptist). Some Mien converted to Christianity in the Thai refugee camps because of a rumor that only Christians could immigrate to the US. Others converted in Thailand or the United States because family members no longer knew the traditions or the loss of the family's written religious records containing the spirit names of ancestors prevented them from conducting traditional ceremonies. Some Mien converted because they thought it would help cure illnesses.
Illness Symptoms During the study, 66 people reported 174 episodes of illness. Some illnesses had constellations of several symptoms and, therefore, the occurrence of 232 symptoms for the 174 illnesses was reported. As expected, the incidence of symptom reports varied by age group, the highest incidence occurring among the youngest and oldest age categories, shown in Table 1.14 Respiratory symptoms were the most common, accounting for 45% of the total symptoms and 5 1 %
of the symptoms in the youngest age group.
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Symptom categorization was open-ended to include everything participants classified as a symptom of illness. For example, "soul fright" was reported once for an infant. Soul fright is a cause of "soul loss," which is a symptom complex of sleeplessness, distractability, and listlessness believed to indicate that the soul has been frightened from the body. Mien experience more symptoms of headaches and musculoskeletal complaints than might be expected from the general population. These two symptom categories are frequently attributed to a somatization of depression or post-
traumatic stress disorder and are responsible for many refugee visits to health professionals."5 The study only collected information on reported symptoms and did not attempt to assess physical or mental health. Mien find it hard to understand mental illness; in fact, the Mien language does not have a word for mental illness. When consulting a physician, Mien expect to receive physical treatment-that is, medicine or injections-and therefore generally do not perceive psychotherapy as treatment.
which facilitates communication during consultation with the Chinese physicians and provides a more culturally familiar context. Some Mien traveled as far as 50 miles to consult the Chinese physicians in Sacramento and other cities. Although public health care services in Richmond are available, patients reported problems with long waiting times and difficult and costly travel to reach services. In addition to other cultural differences, language posed a major problem. Richmond's two public clinics both have Mien language interpreters but only on a limited, scheduled basis. Mien patients who come to the clinics for urgent or walk-in care may not find interpreters available. If patients were not able to attend the clinic when interpreters were available, they often relied on a school-age child who spoke English. Health care professionals interviewed at the public clinics reported that language difficulties and misunderstandings about treatment were barriers to the optimal use of health services for the Mien and other Southeast Asian patients."6 Treatment was obtained from physicians for 77 of the 174 episodes of illness, from physicians in public clinics and neighborhood health centers for 60% of these illnesses, in a physician's private office for 27%, and 13% were treated in a hospital emergency department. Only seven admissions to hospital occurred during the study. Treatment was not sought by 9% of the participants reporting illnesses. Medications were a frequently used treatment, 65% of the participants saying they used some medication, and many reported using more than one drug to treat the same illness. Medications were obtained from a variety of sources, including pharmacies, physicians' offices, grocery stores, and medicines already in the home. Mien often sought medical advice from Asian-American shopkeepers and purchased over-the-counter medication, several illegally imported from Thailand, Hong Kong, and Canada. A visit to an Asian shop in the Richmond area revealed several products either not approved for use in the United States or that should be dispensed at a pharmacy by prescription only. Health professionals in both public and private medical facilities treating the Mien were unaware that patients might be taking unapproved and controlled medications that could have notable side effects.
Treatment Practices Western Medical Treatment General medical treatment was available from several sources. The two public clinics in Richmond include a county-supported clinic and a neighborhood health center. Public medical specialty clinics and inpatient care are available at the county hospital 20 miles away-a long trip on public transportation. Private sources for medical care include a local hospital and any community physician who accepts Medi-Cal (California's Medicaid program). Many private physicians in California do not accept Medi-Cal because of the low reimbursement rates. Most study participants were covered by medical insurance, 86% by Medi-Cal and 10% by private insurance; 4% were medically uninsured. Most of the private Western-trained physicians used by the Mien were described by them as ethnic Chinese. Mien said they consulted private Chinese physicians because, unlike public clinics, they would provide antibiotic injections on request. Injections are a popular form of treatment among Southeast Asians and other populations in developing countries. In addition, many Mien read and write some Chinese,
Traditional Treatments Several types of traditional care are used by the Mien, including self-care and home remedies, herbal medicines, and healing ceremonies. These non-Western treatments are selected based on the perceived causation of the illness: physical, humoral imbalance, or spiritual. Religious preference for either Mien religion or Christianity also influences the use of traditional treatments. Most Mien healing practices involve appeals to traditional spirits and ancestors, the exception being the use of home remedies and herbal medicines and of interventions related to humoral theory. Examples of these healing practices and descriptions of the more important healing ceremonies provide insight into the integration of traditional and modem medical practices. Traditional therapies for illnesses attributed to a physical cause. Traditional therapies for symptoms that are thought to have physical rather than spiritual causation include home remedies, herbal medicines, and humoral-related treatments. Religion is not a factor here. Many home remedies are related to diet-for example, drinking a special tea or abstaining from certain foods.
TABLE l.-Primary Symptom Type in a Mien Community (n=66) by Age Group Symptom Type'
64
0 0 2 1 0 2 1 0 8 0 0 14 33 8
6 1 1 8 3 5 5 13 14 5 0 61 44 35
0 0 0 1 0 1 1 3 8 6 0 20 6 11
Total
9 1 4 15 5 10 14 17 78 20 1 174 119
'Categories adapted from National Center for Health Services Research.14
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Herbal medicines are popular. In Laos they were prescribed mostly by older women with special knowledge about their use. In the US the use of herbal medicines is limited by the availability of herbs, although some people in Richmond keep herb gardens. Some traditional Mien herbs are obtained from friends or relatives in Thailand. Herbs obtained from vendors in San Francisco's Chinatown, although different from Mien herbs, can be adapted for use. Herbal medicines were used by the study population to treat 12% of reported illnesses, often for respiratory symptoms. They obtained the medicine from another Mien in 17 of 21 of the cases (81%), which suggests that the dispensing of herbal substances by an expert continues in this country. Herbal ingredients were grown by three of the patients (21%), and only one (5%) obtained herbal medicines in Chinatown. Traditional treatment ofsar conditions. Traditional therapies are used for sar conditions, which are attributed not to ancestors or other spirits but to humoral imbalance. Physical interventions used for sar are common throughout Southeast Asia. There are several forms of sar treatment. One is "cupping": A cup filled with burning paper is placed over the affected area, and the fire burns off the oxygen, leaving a circular red mark on removal. In a second form, pinching or "catch sar," pinches are made on the skin over the affected area, chest, neck, or back. In a third method, fine scratches are used for some specific illnesses. Mien believe these treatments will remove "hot blood" from an area and cure certain musculoskeletal and abdominal complaints. Most Richmond Mien do not use sar treatments-only five people in the study group used it to treat 9% of the reported illnesses. Wick burning was used in six cases, cupping in five, and skin pinching was used twice. Sar can be disfiguring and may be misinterpreted as physical abuse.'7 Many Mien said they would not use this treatment on their children, even if it was thought to be beneficial. They feared accusations of child abuse by medical and school personnel who observed the bruises and other marks from sar treatments. Among the five patients who had sar treatment, however, two were children ages 5 and 10. The 10-year-old child lived in the household of a frequent sar user. Traditional therapies for illnesses involving spiritual causes. Traditional religious healing ceremonies are an important dimension of Mien culture. Several traditional ceremonies are used for healing and other purposes, such as for protection from evil spirits, disasters, and bad dreams. Although Chinese and Mien New Year ceremonies are nonhealing ceremonies, they are healing related because they confer health benefits on all family members. Sip mmien. The sip mmien is both a healing and protective ceremony. In the Mien language the word "mien" means "people" and the word "mmien" means "ancestor spirits." Sip mmien is a general name for more than 14 different ceremonies used by the Mien for healing. The types of ceremonies vary widely, and each can be used for a variety of purposes. Sip mmien ceremonies were used in 19% (33/174) of all reported illnesses. Mien practicing the traditional religion performed sip mmien for healing illness in only 25% of cases. Ceremonies frequently were performed in succession, and second ceremonies were carried out in 46% (15/33) of the cases. A brief description of the sip mmien is presented here because it explains the important role of ancestors in illness causation and curing and the need to perform placating cere-
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monies to ensure good health. During sip mmien ceremonies, ancestor spirits are called to protect living family members, or evil spirits are called to appease them. These ceremonies are an essential part of Mien traditional religion. Some sip mmien ceremonies require a written record of the family's genealogy for as many as ten generations. Common ceremonies can be conducted by the male head of household, but Mien specialists are needed to perform the more complicated ones. Family members may watch the ceremony but do not have an active role. The ceremonies are usually conducted midmorning and are conducted annually for the family, for the birthday of all household members, and for illnesses, distress, and so forth. A sip mmien ceremony usually involves offering an animal to the ancestor spirits. Only domesticated animals can be used as offerings. A chicken is used for minor ceremonies, a pig for more important occasions, and occasionally a cow is offered. The killing of the animal is not ritualized, and large animals are often slaughtered at farms or packing houses before being purchased by the Mien. The manner of butchering is important, however, and large animals must be carefully dismembered to "reassemble" the animal temporarily at the location of the sip mmien ritual. After the ceremony, the animal is cooked and eaten by the household. Phat. Phat is another form of Mien traditional healing in which ancestor spirits are invoked. Phat differs from sip mmien in several important ways: Phat calls the ancestor spirits or the spirit master of the healer rather than of the afflicted; it is performed only by priests versed in the ceremony. Phat is now used only for healing and other beneficial purposes, although elder Mien recall some practitioners casting evil spells in Laos. For healing purposes among the study participants, phat was performed for 6% (10/174) of reported illnesses. Phat was used primarily for respiratory symptoms and also to treat the child who had soul fright. Traditionally phat also is used for physical illnesses such as sprains or broken bones. Christian Mien healing practices. Mien who have converted to Christianity do not use phat or sip mmien because these ceremonies call on Mien ancestor spirits. Christian Mien are unable to call the ancestors because they no longer have the written records with the necessary information to perform these ceremonies. Christian Mien ministers explained that conversion to Christianity requires a family to destroy the written family records and the paraphernalia required for sip mmien ceremonies. The loss of these items makes it almost impossible for a family to convert back to Mien traditional religion. Altogether, 28% of study participants were Christian. Of this group, 14 people experienced 24% of the illnesses. Christian prayer was offered for 20% of all illnesses and for 83% (35/42) of illnesses among Christians. Christian prayer was both a social and private intervention. People from the church assisted with the prayers in 63% of the cases. This assistance was offered at the church for half of the cases, at private homes (5/22), and in both home and church (6/22). Figure 1 presents the treatment choices available to Mien depending on whether the cause of illness is perceived as
being physical or spiritual. Multiple treatment practices. Mien used more than one therapy for most diseases, including a combination of Western medical, Mien traditional herbal and sar treatments, and spiritual rituals. The study participants did not have an ideal
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treatment for all illnesses. Even the elder priests of Mien traditional religion thought that both Western medical and traditional practices were needed. The largest category of single treatment for all illnesses comprised visits to a Western physician or the use of American medication (prescription or over-the-counter drugs). Almost half of these visits were for respiratory illnesses. Western treatment was used in combination with Christian or Mien religious rituals (sip mmien orphat) and Mien physical treatments (sar or the use of herbal medicines) for 72% of total treatments. Traditional methods (sip mmien, phat, sar, or herbal medicine) were used exclusively to treat only 10% of illnesses. Of the total number of illnesses, 9% had no reported treatment. There was wide variation by symptom in type of treatment used. Several factors influence the choice between traditional and Western self-care or professional care. Most Mien reported little philosophic difference between Western medical
Physical
Physical Physician Sar Herbal
Spiritual
Prayer*
Treatment Type
Illness Cause Spiritual None
Sip mmien Phat Prayer*
Figure 1.-The diagram shows the Mien illness classification and treatment scheme. *Prayer is used if the patient is Christian.
care and the Mien traditional interventions of herbal medication or sar. Mien believe that both Western and Mien methods of treatment address physical aspects of illness. When spiritual causes for illness are suspected, this aspect must be addressed separately. Determining spiritual causation of a given illness has less to do with specific symptoms than with recent experiences or dreams. The following case demonstrates the integration of traditional and Western medicine treatments. Case Example: Illness with spiritual causation treated with multiple methods. A young woman had dysuria and increased frequency of urination develop, both signs of an infection of the urinary bladder. When she was waiting for a medical evaluation in the emergency department of a local hospital, she recalled recently reading a letter sent from Thailand about deceased relatives. She suspected that reading this letter caused the spirits of relatives to become unhappy and led to her symptoms. She phoned her father from the emergency department, who agreed with this assessment. He then performed a healing ceremony at home on his daughter's behalf while she waited for treatment at the hospital. The woman waited for the medical evaluation and the prescription of antibiotics, explaining that even if the spiritual cause of the ailment was placated, the physical infection was best treated by oral antibiotics. After taking the prescribed medication, she reported a rapid resolution of the symptoms. She attributed treatment success to the efforts of both the physician and her father.
Discussion and Conclusion The findings show that the Mien use medical services from many sources. Both private and public health care pro-
viders are used, as well as traditional healing practices. The ease with which Mien combine multiple healing systems results from their explanation of disease causation. In Western medicine, a differential diagnosis is based on symptoms described by the patient and signs found by the health professional's examination. Mien take a different approach to assessing illness causation. They believe that illness is a state of physical dysfunction, and the origin of this condition must first be determined before undertaking treatment. The emphasis is on what caused the symptom and why it started, not on an identification or diagnosis of the condition itself. Several methods are used for determining illness causation, including patient introspection, the recollection of dreams and events, and consultation with a senior family member or a priest. For more complicated conditions, religious ceremonies may be performed to invoke and query the patient's ancestors about the possibility of angry spirits causing the illness. All cases of spiritual causation must first be addressed by the patient and family to ensure a resolution of the symptoms. If there are no indications of spiritual involvement, illnesses may be treated only with physical remedies such as medical interventions or sar. Western and traditional remedies may be used at the same time, as in the above case example of the woman with dysuria. A key factor in determining treatment choice for the Mien is their perception of illness causation. Such information, however, is often unavailable to Western health care practitioners, who may be unaware that the patient's explanatory model is an integral component to patient compliance. In the case discussed, only a short course of antibiotic treatment was needed. Sensitivity to patients' belief about the cause of illness is particularly important for chronic illnesses (such as hypertension or diabetes mellitus) and acute illnesses requiring intervention such as an operation, transfusion, or organ transplantation for health practitioners to communicate effectively with patients about the risks and benefits of prescribed treatments. The Mien community's easy access to prescription drugs over the counter (OTC) raises concern. For example, penicillin was self-prescribed for such common conditions as colds and heartburn. Mien patients were unaware of the risk in taking these medications and frequently shared medication among household members. Although physicians and nurses are aware that over-the-counter drugs can be associated with side effects and serious reactions, it is important to recognize that Mien and other Southeast Asians may have access to a wider variety of OTC products than other patients. This suggests that health professionals need to take careful medication histories, in addition to supporting the medical recommendation that they request patients bring in all medicines for review during visits. Because the pharmaceutical industry is unregulated in many developing countries, the use of OTC medication without consulting a physician or pharmacist is common. For Mien and other immigrant groups, the use of OTC medication, therefore, represents another example of combining traditional and modern health behavior. Economic pressures shape behavior. Choosing Western medical care did not place Mien at financial risk because most Mien have Medi-Cal health insurance coverage, which eliminates out-of-pocket expenses. Provider choices were limited, however, because of Medi-Cal's low reimbursement to private physicians. Other reported barriers to care included the long waiting time at public clinics, geographic
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distance and inaccessibility by public transportation, and limited access to trained medical interpreters at health clinics. 16 Barriers were also encountered in seeking traditional medical treatments. As discussed earlier, herbal products are not readily available in the US, which contributes to the high price and paucity of many substances required for herbal treatments. Traditional ceremonies also may involve a substantial investment oftime and money. If the religious head of household is not skilled in the required ceremony, a priest with adequate skill must be located and compensated. The animal offering must be purchased. A live chicken is not expensive, but a pig may cost more than $200. Traditional ceremonies involve a large investment of time and effort. A ceremony must be scheduled at the convenience of the priest; the animal to be slaughtered must be located, obtained, butchered properly, and transported; and the home and food must be prepared for the ceremony. Just as the costly nature of finding a physician who will accept Medi-Cal limits the use of Western medical practices, the costly nature of some traditional ceremonies limits their use. This study demonstrates that Mien have not abandoned traditional methods of healing, although they have accepted Western medical care, consult physicians, and use modern pharmaceuticals simultaneously. Most medical symptoms were treated with Western medical care or with both Western and traditional care, and only 6% of all reported illnesses were treated solely with traditional methods. Mien incorporation of Western causes into traditional illness models has not required the replacement of beliefs. Mien do distinguish between "physical" and "spiritual" causes of illness but integrate the treatment of illnesses with these dual causations. Health care professionals in Richmond perceived longterm Mien refugee patients in the 1980s to be more insular and more likely to use traditional treatments than other Southeast Asians. In contrast, Brainard and Zaharlick's cross-sectional study of long-term refugees in Ohio found that ethnic or lowland Lao who had access to physicians before migration eschewed traditional treatments in favor of
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Western medical care in the United States.7 Such contrasts in study findings support the argument that cultural and historical factors play a significant role in how people choose among healing options in a new country and may influence the interaction between health care professionals and refugee patients. Mien are but one of many Southeast Asian refugee groups who share similar practices, although most beliefs and practices are culture specific."1 Health practitioners and planners, therefore, need to be sensitive to the specific cultural issues of each ethnic group they serve and not make sweeping generalizations. REFERENCES 1. Barrett-Connor E: Latent and chronic infections imported from Southeast Asia. JAMA 1978; 239:1901-1906 2. Borchardt KA, Ortega H, Mahood JD, et al: Intestinal parasites in Southeast Asian refugees. West J Med 1981; 135:93-96 3. Muecke MA: Caring for Southeast Asian refugee patients in the USA. Am J Public Health 1983; 73:431-438 4. Muecke MA: In search of healers-Southeast Asian refugees in the American health care system, In Cross-cultural Medicine. West J Med 1983; 139:31-36 [835-
8401 5. Thao X: Southeast Asian refugees of Rhode Island: The Hmong perception of illness. Rhode Island Med J 1984; 67:323-330 6. Strand PJ, Jones W Jr: Health service utilization by Indochinese refugees. Med Care 1983; 21:1089-1098 7. Brainard J, Zaharlick A: Changing health beliefs and behaviors of resettled Laotian refugees: Ethnic variation in adaptation. Soc Sci Med 1989; 29:845-852 8. Buchwald D, Panwala S, Hooton TM: Use of traditional health practices by Southeast Asian refugees in a primary care clinic. West J Med 1992; 156:507-511 9. Lemoine J: Yao Ceremonial Paintings. Bangkok, Thailand, White Lotus, 1982 10. Habarad JK: Spirit and the Social Order: The Responsiveness of Lao Iu Mien History, Religion, and Social Organization-Dissertation. Berkeley, University of California, 1987 11. Cohon JD Jr: Southeast Asian refugees and school health personnel. J Sch Health 1983; 53:151-158 12. Habarad J: Refugees and the structure of opportunity: Transitional adjustments to aid among US resettled Lao Iu Mien, 1980-1985, In Morgan SM, Colson E (Eds): People in Upheaval. New York, NY, Center for Migration Studies, 1987 13. Habarad J: Five villages: Culture and resources among Lao Iu Mien. Kroeber Anthropol Soc Papers 1986; 65-66:83-100 14. National Health Interview Survey-Advance Data #129. Hyattsville, Md, National Center for Health Services Research, 1987 15. DeLay PR, Faust S: Depression in Southeast Asian refugees. Am Fam Pract 1987; 36:179-184 16. Faust S, Drickey R: Working with interpreters. J Fam Pract 1986; 22:131,134138 17. Yeatman GW, Dang VV: Cao Gio (coin rubbing): Vietnamese attitudes toward health care. JAMA 1980; 244:2748-2749 18. Kleinman A, Gale JL: Patients treated by physicians and faith healers: A comparative outcome study in Taiwan. Cult Med Psychiatry 1982; 6:405423
* About 150,000 Laotians live In the United States * When the US withdrew from the Southeast Asian conflicts in 1975, some 13,000 Mien fled the rural highlands of Laos for Thailand * In 1980, asylum in the US was granted the Mien in camps In Thailand
Cross-cultural Medicine A Decade Later Use of Traditional and Modern Health Services by Laotian Refugees STUART C. GILMAN, MD, MPH, Long Beach; JUDITH JUSTICE, PhD, MPH, San Francisco; KAOTA SAEPHARN, San Pablo; and GERALD CHARLES, MD, San Francisco, California
Although refugee health care emerged as a special interest in the United States following the influx of almost a million Southeast Asians since 1975, few studies have been done of the influence of refugee traditions on the use of Western medical services. The illness patterns, medical beliefs, and health care behavior of a Southeast Asian refugee group, the Mien from Laos are described in this study. A cohort of 1 19 Mien refugees living in Richmond, California, was observed for a 6-month period. In-home interviews were undertaken about all episodes of ill health, including treatment and health care decisions. This study shows that the Mien integrate traditional healing beliefs and practices with the use of American health services. Such findings are important because the increasing cultural diversity in the United States, particularly in Western states, necessitates that health care professionals understand the importance of cultural factors for access to and the use of health care by all patients including refugees and other immigrant groups. (Gilman SC, Justice J, Saepharn K, Charles G: Use of traditional and modern health services by Laotian refugees, In Cross-cultural Medicine-A Decade Later [Special Issue]. West J Med 1992 Sep; 157:310-315) Refugee health care has emerged in the United States as an area of special interest following the influx of almost a million Southeast Asians since 1975. Because the largest number of Southeast Asian refugees resettled in the US West, health care professionals, particularly in California, Washington, and Oregon, have confronted numerous challenges in providing medical care to this population. Earlier articles focused on new refugees and the need for "health screening" for infectious and other tropical diseases.1'2 Reports providing brief, general descriptions of Southeast Asian cultures, including traditional practices, beliefs, and attitudes towards health and medical care, appeared in medical journals with the early arrival of refugees.3-5 For example, a photo of a Mien family in full traditional dress was on the cover of THE WESTERN JOURNAL OF MEDICINE'S initial special issue on cross-cultural medicine in December 1983.4 Few articles have been published, however, about the influence of refugee traditions on the use of Western medical services in US communities.
Research Methods Most physicians and other health care professionals meet refugees only in clinical settings and thus do not have access to information about factors influencing Southeast Asian patients' definition of illness and treatment-seeking behavior. The present study was designed to help fill this gap in current medical knowledge about the refugee community by describ-
ing the illness patterns, medical beliefs, and health care behavior of one Southeast Asian refugee group, the Mien from Laos. A research team of two physicians (S.C.G. and G.C.), a Laotian university student (K.S.), and an anthropologist (J.J.) collaborated on a community-based study in 1988 to 1989, observing a cohort (randomly selected from telephone book listings) of 17 Mien refugee families with 119 household members. The first six-month phase of this two-part study consisted of ethnographic in-home interviews of Mien families, healers, and religious leaders and interviews of health care professionals at voluntary agencies and medical facilities providing services to Mien. Traditional and Christian Mien religious ceremonies were observed in Mien homes and in the Mien church. Phase two consisted of biweekly surveys of all episodes of ill health and treatment during the subsequent six-month period. One member of each household served as the principal informant on health for all persons in the household, aided by other family members who were usually present during the in-home interviews. The Mien researcher conducted interviews in the refugees' own language. The findings of this study provide insight into how refugees integrate traditional healing beliefs and practices with the use of American health services. The Mien This study of Mien in Richmond, a city in the San Francisco Bay Area of California, is one of the few community-
From the Regional Medical Education Center and Western Region Special Studies Group, Veterans Affairs (VA) Medical Center, Long Beach (Dr Gilman); the Medical Anthropology Division, Department of Epidemiology and Biostatistics, University of California, San Francisco (Dr Justice); the Ethnic, Asian-American Studies, Center for Southeast Asian Studies, University of California, Berkeley (Mr Saepharn); and the Medical Service, VA Medical Center, San Francisco, California (Dr Charles). Mr Saepharn is currently with the Ethnic and Bilingual Sciences Program, Roosevelt Junior High School, Oakland, and Dr Charles is also Chief of Staff at the VA Medical Center, San Francisco, California. Research support for this study was provided by the Department of Veterans Affairs and the Robert Wood Johnson Foundation Clinical Scholars Program at the University of California, San Francisco, School of Medicine. Eric Crystal, Program Coordinator, Center for Southeast Asian Studies, University of California, Berkeley, assisted in the development of this project. Appreciation is extended to the Richmond, California, Mien community for their generous hospitality and cooperation. Reprint requests to Judith Justice, PhD, MPH, Medical Anthropology Division, Department of Epidemiology and Biostatistics, University of California, San Francisco, 1350 Seventh Ave, Box 0850, San Francisco, CA 94143.
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based cohort studies of refugee use of health services to consider traditional health practices. Richmond's Mien population is estimated to number between 1,200 and 1,500. Although there are many Southeast Asian groups in the San Francisco Bay Area, the Mien were selected for study for several reasons: * Mien are identifiable at the community level because of naming practices. The Mien naming convention in the United States places the prefix "Sae" on all clan names. Only six clan names-which serve as the second or family name in the United States-are used in the research area: Saepharn, Saeteurn, Saelee, Saechao, Saefong, Saeliaw, and their spelling variants; * The Mien refugees are similar in educational and economic status because they came from a homogeneous highland rural culture in Laos. They were one of the most geographically isolated groups before emigration and, therefore, had greater difficulties adjusting to this country than did other Southeast Asian refugee groups who are from lowland and urban areas; * The Mien were accessible to the research team because one team member is a Mien refugee who lived in Richmond with his family. He was the first member ofthe Mien community to attend the University of California at Berkeley where he was a third-year undergraduate student at the time of this study (1988 to 1989). Data about Mien use of health services are not easily compared with those of other Americans because of economic, family structure, and demographic factors. Strand and Jones's cross-sectional study found that Hmong refugees, another highland Lao group with many cultural similarities to the Mien, were infrequent users of Western medical services compared with other Southeast Asian refugees.6 Unfortunately, the authors did not address the use of indigenous healing practices. Brainard and Zaharlick sampled ethnic lowland Lao from a voluntary agency roster in Ohio and found little traditional healing activity among this population.7 Buchwald and co-workers, however, found the frequent practice of traditional healing among Southeast Asians in Washington State.8
Background The Mien, also called "Iu Mien" or "Yao," are a highland people who inhabit the hills of Vietnam, Thailand, Laos, Burma, and China.9 The Mien migrated to Southeast Asia from southern China over several hundred years and still retain many features of Chinese tradition. Mien religion includes aspects of animism, ancestor worship, and Chinese Taoism. A Chinese dialect is used for the Mien's religious language, and written records are recorded in Chinese characters. Other hill people in Laos, such as the Hmong, do not keep written records. Life in the highlands of Laos consisted of slash-and-bum agriculture, frequent religious rituals, and war that extended for a period before World War II through 1975.10 Westernstyle medical services available in Laos were poorly developed, especially in the hills, and Mien and other hill tribes relied primarily on traditional healing before emigrating from Laos.11 The Mien who lived in Laos sided with the United States and other allies against Communist forces in the region from 1959 to 1975 during the war in Southeast Asia. When the
United States withdrew from Southeast Asia, approximately 13,000 Mien living in Laos fled to Thailand."2 In 1980 the US made asylum widely available to the Mien who were in refugee camps in Thailand.13 Although the Mien initially were settled throughout the United States, their sense of family, village structure, and religion, in addition to differences in public assistance benefits among the US states,12 contributed to a second migration and resettlement to the West. About 15,000 Mien are currently living in the US, although accurate demographic information is impossible to obtain because the Mien are counted as Lao, a category that also encompasses the culturally distinct Hmong, other hill tribes, and the lowland or urban Lao. The Mien who settled in Richmond reside in poor urban neighborhoods in this city of approximately 92,000 people. Study participants generally live in poorly maintained rental apartments and small houses on streets with decaying and abandoned buildings. Households usually comprise an extended family consisting of two and three generations and, on average, seven people. Most Mien families are poor and receive welfare benefits. Several families supplement this income with day work as manual laborers, gardeners, house cleaners, babysitters, and so forth. For most, a lack of formal education and fluency in English are barriers to other employment. Among the 17 families participating in the study, only 2 were comfortable speaking English, and even these families resorted to Mien for the discussion of any complex issues. Children attend the local public schools where they learn English, but most adults still use the Mien language, especially in the home.
Findings The combination of home visits, interview schedules, and observation of relevant Mien traditional ceremonies provides a comprehensive picture of health problems and treatment practices of the 17 households with 119 family members. Study participants ranged in age from 2 months to 74 years, with a skewed age distribution, 69% being younger than 18 years. Their average age was 20.3 years, and the median age was 10 years. Just over half (52%) of the sample was female. Religion is a factor influencing Mien health beliefs and practices. Of the participants in the study, 72% practiced Mien religion and 28% were Christian (Baptist). Some Mien converted to Christianity in the Thai refugee camps because of a rumor that only Christians could immigrate to the US. Others converted in Thailand or the United States because family members no longer knew the traditions or the loss of the family's written religious records containing the spirit names of ancestors prevented them from conducting traditional ceremonies. Some Mien converted because they thought it would help cure illnesses.
Illness Symptoms During the study, 66 people reported 174 episodes of illness. Some illnesses had constellations of several symptoms and, therefore, the occurrence of 232 symptoms for the 174 illnesses was reported. As expected, the incidence of symptom reports varied by age group, the highest incidence occurring among the youngest and oldest age categories, shown in Table 1.14 Respiratory symptoms were the most common, accounting for 45% of the total symptoms and 5 1 %
of the symptoms in the youngest age group.
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Symptom categorization was open-ended to include everything participants classified as a symptom of illness. For example, "soul fright" was reported once for an infant. Soul fright is a cause of "soul loss," which is a symptom complex of sleeplessness, distractability, and listlessness believed to indicate that the soul has been frightened from the body. Mien experience more symptoms of headaches and musculoskeletal complaints than might be expected from the general population. These two symptom categories are frequently attributed to a somatization of depression or post-
traumatic stress disorder and are responsible for many refugee visits to health professionals."5 The study only collected information on reported symptoms and did not attempt to assess physical or mental health. Mien find it hard to understand mental illness; in fact, the Mien language does not have a word for mental illness. When consulting a physician, Mien expect to receive physical treatment-that is, medicine or injections-and therefore generally do not perceive psychotherapy as treatment.
which facilitates communication during consultation with the Chinese physicians and provides a more culturally familiar context. Some Mien traveled as far as 50 miles to consult the Chinese physicians in Sacramento and other cities. Although public health care services in Richmond are available, patients reported problems with long waiting times and difficult and costly travel to reach services. In addition to other cultural differences, language posed a major problem. Richmond's two public clinics both have Mien language interpreters but only on a limited, scheduled basis. Mien patients who come to the clinics for urgent or walk-in care may not find interpreters available. If patients were not able to attend the clinic when interpreters were available, they often relied on a school-age child who spoke English. Health care professionals interviewed at the public clinics reported that language difficulties and misunderstandings about treatment were barriers to the optimal use of health services for the Mien and other Southeast Asian patients."6 Treatment was obtained from physicians for 77 of the 174 episodes of illness, from physicians in public clinics and neighborhood health centers for 60% of these illnesses, in a physician's private office for 27%, and 13% were treated in a hospital emergency department. Only seven admissions to hospital occurred during the study. Treatment was not sought by 9% of the participants reporting illnesses. Medications were a frequently used treatment, 65% of the participants saying they used some medication, and many reported using more than one drug to treat the same illness. Medications were obtained from a variety of sources, including pharmacies, physicians' offices, grocery stores, and medicines already in the home. Mien often sought medical advice from Asian-American shopkeepers and purchased over-the-counter medication, several illegally imported from Thailand, Hong Kong, and Canada. A visit to an Asian shop in the Richmond area revealed several products either not approved for use in the United States or that should be dispensed at a pharmacy by prescription only. Health professionals in both public and private medical facilities treating the Mien were unaware that patients might be taking unapproved and controlled medications that could have notable side effects.
Treatment Practices Western Medical Treatment General medical treatment was available from several sources. The two public clinics in Richmond include a county-supported clinic and a neighborhood health center. Public medical specialty clinics and inpatient care are available at the county hospital 20 miles away-a long trip on public transportation. Private sources for medical care include a local hospital and any community physician who accepts Medi-Cal (California's Medicaid program). Many private physicians in California do not accept Medi-Cal because of the low reimbursement rates. Most study participants were covered by medical insurance, 86% by Medi-Cal and 10% by private insurance; 4% were medically uninsured. Most of the private Western-trained physicians used by the Mien were described by them as ethnic Chinese. Mien said they consulted private Chinese physicians because, unlike public clinics, they would provide antibiotic injections on request. Injections are a popular form of treatment among Southeast Asians and other populations in developing countries. In addition, many Mien read and write some Chinese,
Traditional Treatments Several types of traditional care are used by the Mien, including self-care and home remedies, herbal medicines, and healing ceremonies. These non-Western treatments are selected based on the perceived causation of the illness: physical, humoral imbalance, or spiritual. Religious preference for either Mien religion or Christianity also influences the use of traditional treatments. Most Mien healing practices involve appeals to traditional spirits and ancestors, the exception being the use of home remedies and herbal medicines and of interventions related to humoral theory. Examples of these healing practices and descriptions of the more important healing ceremonies provide insight into the integration of traditional and modem medical practices. Traditional therapies for illnesses attributed to a physical cause. Traditional therapies for symptoms that are thought to have physical rather than spiritual causation include home remedies, herbal medicines, and humoral-related treatments. Religion is not a factor here. Many home remedies are related to diet-for example, drinking a special tea or abstaining from certain foods.
TABLE l.-Primary Symptom Type in a Mien Community (n=66) by Age Group Symptom Type'
64
0 0 2 1 0 2 1 0 8 0 0 14 33 8
6 1 1 8 3 5 5 13 14 5 0 61 44 35
0 0 0 1 0 1 1 3 8 6 0 20 6 11
Total
9 1 4 15 5 10 14 17 78 20 1 174 119
'Categories adapted from National Center for Health Services Research.14
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Herbal medicines are popular. In Laos they were prescribed mostly by older women with special knowledge about their use. In the US the use of herbal medicines is limited by the availability of herbs, although some people in Richmond keep herb gardens. Some traditional Mien herbs are obtained from friends or relatives in Thailand. Herbs obtained from vendors in San Francisco's Chinatown, although different from Mien herbs, can be adapted for use. Herbal medicines were used by the study population to treat 12% of reported illnesses, often for respiratory symptoms. They obtained the medicine from another Mien in 17 of 21 of the cases (81%), which suggests that the dispensing of herbal substances by an expert continues in this country. Herbal ingredients were grown by three of the patients (21%), and only one (5%) obtained herbal medicines in Chinatown. Traditional treatment ofsar conditions. Traditional therapies are used for sar conditions, which are attributed not to ancestors or other spirits but to humoral imbalance. Physical interventions used for sar are common throughout Southeast Asia. There are several forms of sar treatment. One is "cupping": A cup filled with burning paper is placed over the affected area, and the fire burns off the oxygen, leaving a circular red mark on removal. In a second form, pinching or "catch sar," pinches are made on the skin over the affected area, chest, neck, or back. In a third method, fine scratches are used for some specific illnesses. Mien believe these treatments will remove "hot blood" from an area and cure certain musculoskeletal and abdominal complaints. Most Richmond Mien do not use sar treatments-only five people in the study group used it to treat 9% of the reported illnesses. Wick burning was used in six cases, cupping in five, and skin pinching was used twice. Sar can be disfiguring and may be misinterpreted as physical abuse.'7 Many Mien said they would not use this treatment on their children, even if it was thought to be beneficial. They feared accusations of child abuse by medical and school personnel who observed the bruises and other marks from sar treatments. Among the five patients who had sar treatment, however, two were children ages 5 and 10. The 10-year-old child lived in the household of a frequent sar user. Traditional therapies for illnesses involving spiritual causes. Traditional religious healing ceremonies are an important dimension of Mien culture. Several traditional ceremonies are used for healing and other purposes, such as for protection from evil spirits, disasters, and bad dreams. Although Chinese and Mien New Year ceremonies are nonhealing ceremonies, they are healing related because they confer health benefits on all family members. Sip mmien. The sip mmien is both a healing and protective ceremony. In the Mien language the word "mien" means "people" and the word "mmien" means "ancestor spirits." Sip mmien is a general name for more than 14 different ceremonies used by the Mien for healing. The types of ceremonies vary widely, and each can be used for a variety of purposes. Sip mmien ceremonies were used in 19% (33/174) of all reported illnesses. Mien practicing the traditional religion performed sip mmien for healing illness in only 25% of cases. Ceremonies frequently were performed in succession, and second ceremonies were carried out in 46% (15/33) of the cases. A brief description of the sip mmien is presented here because it explains the important role of ancestors in illness causation and curing and the need to perform placating cere-
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monies to ensure good health. During sip mmien ceremonies, ancestor spirits are called to protect living family members, or evil spirits are called to appease them. These ceremonies are an essential part of Mien traditional religion. Some sip mmien ceremonies require a written record of the family's genealogy for as many as ten generations. Common ceremonies can be conducted by the male head of household, but Mien specialists are needed to perform the more complicated ones. Family members may watch the ceremony but do not have an active role. The ceremonies are usually conducted midmorning and are conducted annually for the family, for the birthday of all household members, and for illnesses, distress, and so forth. A sip mmien ceremony usually involves offering an animal to the ancestor spirits. Only domesticated animals can be used as offerings. A chicken is used for minor ceremonies, a pig for more important occasions, and occasionally a cow is offered. The killing of the animal is not ritualized, and large animals are often slaughtered at farms or packing houses before being purchased by the Mien. The manner of butchering is important, however, and large animals must be carefully dismembered to "reassemble" the animal temporarily at the location of the sip mmien ritual. After the ceremony, the animal is cooked and eaten by the household. Phat. Phat is another form of Mien traditional healing in which ancestor spirits are invoked. Phat differs from sip mmien in several important ways: Phat calls the ancestor spirits or the spirit master of the healer rather than of the afflicted; it is performed only by priests versed in the ceremony. Phat is now used only for healing and other beneficial purposes, although elder Mien recall some practitioners casting evil spells in Laos. For healing purposes among the study participants, phat was performed for 6% (10/174) of reported illnesses. Phat was used primarily for respiratory symptoms and also to treat the child who had soul fright. Traditionally phat also is used for physical illnesses such as sprains or broken bones. Christian Mien healing practices. Mien who have converted to Christianity do not use phat or sip mmien because these ceremonies call on Mien ancestor spirits. Christian Mien are unable to call the ancestors because they no longer have the written records with the necessary information to perform these ceremonies. Christian Mien ministers explained that conversion to Christianity requires a family to destroy the written family records and the paraphernalia required for sip mmien ceremonies. The loss of these items makes it almost impossible for a family to convert back to Mien traditional religion. Altogether, 28% of study participants were Christian. Of this group, 14 people experienced 24% of the illnesses. Christian prayer was offered for 20% of all illnesses and for 83% (35/42) of illnesses among Christians. Christian prayer was both a social and private intervention. People from the church assisted with the prayers in 63% of the cases. This assistance was offered at the church for half of the cases, at private homes (5/22), and in both home and church (6/22). Figure 1 presents the treatment choices available to Mien depending on whether the cause of illness is perceived as
being physical or spiritual. Multiple treatment practices. Mien used more than one therapy for most diseases, including a combination of Western medical, Mien traditional herbal and sar treatments, and spiritual rituals. The study participants did not have an ideal
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treatment for all illnesses. Even the elder priests of Mien traditional religion thought that both Western medical and traditional practices were needed. The largest category of single treatment for all illnesses comprised visits to a Western physician or the use of American medication (prescription or over-the-counter drugs). Almost half of these visits were for respiratory illnesses. Western treatment was used in combination with Christian or Mien religious rituals (sip mmien orphat) and Mien physical treatments (sar or the use of herbal medicines) for 72% of total treatments. Traditional methods (sip mmien, phat, sar, or herbal medicine) were used exclusively to treat only 10% of illnesses. Of the total number of illnesses, 9% had no reported treatment. There was wide variation by symptom in type of treatment used. Several factors influence the choice between traditional and Western self-care or professional care. Most Mien reported little philosophic difference between Western medical
Physical
Physical Physician Sar Herbal
Spiritual
Prayer*
Treatment Type
Illness Cause Spiritual None
Sip mmien Phat Prayer*
Figure 1.-The diagram shows the Mien illness classification and treatment scheme. *Prayer is used if the patient is Christian.
care and the Mien traditional interventions of herbal medication or sar. Mien believe that both Western and Mien methods of treatment address physical aspects of illness. When spiritual causes for illness are suspected, this aspect must be addressed separately. Determining spiritual causation of a given illness has less to do with specific symptoms than with recent experiences or dreams. The following case demonstrates the integration of traditional and Western medicine treatments. Case Example: Illness with spiritual causation treated with multiple methods. A young woman had dysuria and increased frequency of urination develop, both signs of an infection of the urinary bladder. When she was waiting for a medical evaluation in the emergency department of a local hospital, she recalled recently reading a letter sent from Thailand about deceased relatives. She suspected that reading this letter caused the spirits of relatives to become unhappy and led to her symptoms. She phoned her father from the emergency department, who agreed with this assessment. He then performed a healing ceremony at home on his daughter's behalf while she waited for treatment at the hospital. The woman waited for the medical evaluation and the prescription of antibiotics, explaining that even if the spiritual cause of the ailment was placated, the physical infection was best treated by oral antibiotics. After taking the prescribed medication, she reported a rapid resolution of the symptoms. She attributed treatment success to the efforts of both the physician and her father.
Discussion and Conclusion The findings show that the Mien use medical services from many sources. Both private and public health care pro-
viders are used, as well as traditional healing practices. The ease with which Mien combine multiple healing systems results from their explanation of disease causation. In Western medicine, a differential diagnosis is based on symptoms described by the patient and signs found by the health professional's examination. Mien take a different approach to assessing illness causation. They believe that illness is a state of physical dysfunction, and the origin of this condition must first be determined before undertaking treatment. The emphasis is on what caused the symptom and why it started, not on an identification or diagnosis of the condition itself. Several methods are used for determining illness causation, including patient introspection, the recollection of dreams and events, and consultation with a senior family member or a priest. For more complicated conditions, religious ceremonies may be performed to invoke and query the patient's ancestors about the possibility of angry spirits causing the illness. All cases of spiritual causation must first be addressed by the patient and family to ensure a resolution of the symptoms. If there are no indications of spiritual involvement, illnesses may be treated only with physical remedies such as medical interventions or sar. Western and traditional remedies may be used at the same time, as in the above case example of the woman with dysuria. A key factor in determining treatment choice for the Mien is their perception of illness causation. Such information, however, is often unavailable to Western health care practitioners, who may be unaware that the patient's explanatory model is an integral component to patient compliance. In the case discussed, only a short course of antibiotic treatment was needed. Sensitivity to patients' belief about the cause of illness is particularly important for chronic illnesses (such as hypertension or diabetes mellitus) and acute illnesses requiring intervention such as an operation, transfusion, or organ transplantation for health practitioners to communicate effectively with patients about the risks and benefits of prescribed treatments. The Mien community's easy access to prescription drugs over the counter (OTC) raises concern. For example, penicillin was self-prescribed for such common conditions as colds and heartburn. Mien patients were unaware of the risk in taking these medications and frequently shared medication among household members. Although physicians and nurses are aware that over-the-counter drugs can be associated with side effects and serious reactions, it is important to recognize that Mien and other Southeast Asians may have access to a wider variety of OTC products than other patients. This suggests that health professionals need to take careful medication histories, in addition to supporting the medical recommendation that they request patients bring in all medicines for review during visits. Because the pharmaceutical industry is unregulated in many developing countries, the use of OTC medication without consulting a physician or pharmacist is common. For Mien and other immigrant groups, the use of OTC medication, therefore, represents another example of combining traditional and modern health behavior. Economic pressures shape behavior. Choosing Western medical care did not place Mien at financial risk because most Mien have Medi-Cal health insurance coverage, which eliminates out-of-pocket expenses. Provider choices were limited, however, because of Medi-Cal's low reimbursement to private physicians. Other reported barriers to care included the long waiting time at public clinics, geographic
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distance and inaccessibility by public transportation, and limited access to trained medical interpreters at health clinics. 16 Barriers were also encountered in seeking traditional medical treatments. As discussed earlier, herbal products are not readily available in the US, which contributes to the high price and paucity of many substances required for herbal treatments. Traditional ceremonies also may involve a substantial investment oftime and money. If the religious head of household is not skilled in the required ceremony, a priest with adequate skill must be located and compensated. The animal offering must be purchased. A live chicken is not expensive, but a pig may cost more than $200. Traditional ceremonies involve a large investment of time and effort. A ceremony must be scheduled at the convenience of the priest; the animal to be slaughtered must be located, obtained, butchered properly, and transported; and the home and food must be prepared for the ceremony. Just as the costly nature of finding a physician who will accept Medi-Cal limits the use of Western medical practices, the costly nature of some traditional ceremonies limits their use. This study demonstrates that Mien have not abandoned traditional methods of healing, although they have accepted Western medical care, consult physicians, and use modern pharmaceuticals simultaneously. Most medical symptoms were treated with Western medical care or with both Western and traditional care, and only 6% of all reported illnesses were treated solely with traditional methods. Mien incorporation of Western causes into traditional illness models has not required the replacement of beliefs. Mien do distinguish between "physical" and "spiritual" causes of illness but integrate the treatment of illnesses with these dual causations. Health care professionals in Richmond perceived longterm Mien refugee patients in the 1980s to be more insular and more likely to use traditional treatments than other Southeast Asians. In contrast, Brainard and Zaharlick's cross-sectional study of long-term refugees in Ohio found that ethnic or lowland Lao who had access to physicians before migration eschewed traditional treatments in favor of
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Western medical care in the United States.7 Such contrasts in study findings support the argument that cultural and historical factors play a significant role in how people choose among healing options in a new country and may influence the interaction between health care professionals and refugee patients. Mien are but one of many Southeast Asian refugee groups who share similar practices, although most beliefs and practices are culture specific."1 Health practitioners and planners, therefore, need to be sensitive to the specific cultural issues of each ethnic group they serve and not make sweeping generalizations. REFERENCES 1. Barrett-Connor E: Latent and chronic infections imported from Southeast Asia. JAMA 1978; 239:1901-1906 2. Borchardt KA, Ortega H, Mahood JD, et al: Intestinal parasites in Southeast Asian refugees. West J Med 1981; 135:93-96 3. Muecke MA: Caring for Southeast Asian refugee patients in the USA. Am J Public Health 1983; 73:431-438 4. Muecke MA: In search of healers-Southeast Asian refugees in the American health care system, In Cross-cultural Medicine. West J Med 1983; 139:31-36 [835-
8401 5. Thao X: Southeast Asian refugees of Rhode Island: The Hmong perception of illness. Rhode Island Med J 1984; 67:323-330 6. Strand PJ, Jones W Jr: Health service utilization by Indochinese refugees. Med Care 1983; 21:1089-1098 7. Brainard J, Zaharlick A: Changing health beliefs and behaviors of resettled Laotian refugees: Ethnic variation in adaptation. Soc Sci Med 1989; 29:845-852 8. Buchwald D, Panwala S, Hooton TM: Use of traditional health practices by Southeast Asian refugees in a primary care clinic. West J Med 1992; 156:507-511 9. Lemoine J: Yao Ceremonial Paintings. Bangkok, Thailand, White Lotus, 1982 10. Habarad JK: Spirit and the Social Order: The Responsiveness of Lao Iu Mien History, Religion, and Social Organization-Dissertation. Berkeley, University of California, 1987 11. Cohon JD Jr: Southeast Asian refugees and school health personnel. J Sch Health 1983; 53:151-158 12. Habarad J: Refugees and the structure of opportunity: Transitional adjustments to aid among US resettled Lao Iu Mien, 1980-1985, In Morgan SM, Colson E (Eds): People in Upheaval. New York, NY, Center for Migration Studies, 1987 13. Habarad J: Five villages: Culture and resources among Lao Iu Mien. Kroeber Anthropol Soc Papers 1986; 65-66:83-100 14. National Health Interview Survey-Advance Data #129. Hyattsville, Md, National Center for Health Services Research, 1987 15. DeLay PR, Faust S: Depression in Southeast Asian refugees. Am Fam Pract 1987; 36:179-184 16. Faust S, Drickey R: Working with interpreters. J Fam Pract 1986; 22:131,134138 17. Yeatman GW, Dang VV: Cao Gio (coin rubbing): Vietnamese attitudes toward health care. JAMA 1980; 244:2748-2749 18. Kleinman A, Gale JL: Patients treated by physicians and faith healers: A comparative outcome study in Taiwan. Cult Med Psychiatry 1982; 6:405423
