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Religion Matters in Immigrant Health Care

This Internet site offers practical information and resources for health care professionals serving immigrant religious groups. A parallel Internet site for patients from these groups is being considered.

This Internet site is part of a project funded by the Donors Forum of Chicago through its Fund for Immigrants and Refugees. The project is housed in the McNamara Center for the Social Study of Religion, Loyola University Chicago, in cooperation with the Neiswanger Institute for Bioethics and Health Policy at the Stritch School of Medicine, Loyola University Medical Center. The project has developed two other practical approaches to enhancing culturally competent health care for immigrant religious groups.

• In-service programs for health care professionals

• Advice regarding Buddhist and Hindu patient care

In developing this Internet site, project staff Paul Numrich, Ph.D., Elisa Gordon, Ph.D., M.P.H., and Rebecca Burwell conducted a systematic review of cultural competence resources and met with advisory committees of local Buddhist and Hindu health care professionals and leaders.  Five topics emerged as crucial in caring for Buddhist and Hindu patients: the patient/caregiver relationship; diet; drugs and palliation; alternative medicine; and dying, death, and final religious rites.  Other topics and other religious groups may be added in the future. Recommendations for health care professionals appear in italicized text throughout this Internet site.  

Immigration, Religion, and Health Care

Buddhists

Hindus

Immigration, Religion, and Health Care

Recent immigration is changing the ethnic face of America.  Since the passage of the 1965 immigration act, US immigration has become more Latin American and Asian and less European than ever before.

Census Bureau projections show continued population diversification for the next half century. 

Locally, the Asian population, now totaling nearly 400,000, increased more than 50 percent overall between the 1990 and 2000 censuses, with some areas experiencing significantly higher increases.

Government population estimates do not track religious identities, yet we know that recent immigration has diversified America’s religious landscape as well.  As Harvard University professor Diana L. Eck describes in the book A New Religious America, the United States has become the world’s most religiously diverse nation, a fact particularly noticeable in America’s urban centers.  Self-estimates from their respective communities claim as many as 150,000 Buddhists and 80,000 Hindus in the Chicago area.  More than 30 local Buddhist congregations now serve members originally from several Asia nations; more than 20 local Hindu congregations serve members from all regions of India.

Due to immigration provisions favoring skilled occupations, many health care professionals in the US today are Buddhist and Hindu immigrants from Asia. Thai Physicians Assoc. of America  American Assoc. of Physicians of Indian Origin

The medical literature documents the importance of religious factors in health care generally.  The editors of the recent Handbook of Religion and Health explain that the United States is witnessing “the emergence of a new way of practicing medicine that considers the body, mind, and spirit.”  As scholar David K. Yoo observes in the book New Spiritual Homes: Religion and Asian Americans, religious identity is an integral force in the Asian-American experience.  The relatively few studies that devote adequate attention to the topic suggest that religion offers potentially positive resources for health care among immigrant populations, especially with traumatized refugee groups (Canda and Phaobtong 1992).  Facing a health crisis distresses everyone, but doing so as an immigrant in an unfamiliar land can be doubly distressing—for immigrants, “transplantation” involves “uprooting,” and “travel” may entail “travail.”  Religious identity often provides communal cohesion and support, and can play an important role in patient decision making and coping strategies.

It is crucial that health care providers attempt to sort out the religious identities and preferences of patients.  It makes a great difference, for instance, that an Asian-American patient is a Buddhist or that an Asian-Indian patient is a Hindu; provision of care in these cases will differ from co-ethnics who happen to be Christian, Muslim, Sikh, Jain, or some other religious identity. Religion matters to Buddhist and Hindu patients in ways that directly affect their health care.

Multicultural awareness programs and cultural competence initiatives are addressing the implications of increasing patient diversity in the United States.  The importance of religious identity is sometimes overlooked in these efforts for a variety of reasons, including reticence to pry into such a “personal matter.”  As one person in hospital admitting explained, she felt that the religious identity of patients is “none of our business.”  Yet religion matters greatly for many new immigrant groups since it binds them together as a community and offers strength and support to individuals and families in their daily lives and during times of need, including health care crises.  Moreover, many alternative healing beliefs and practices with religious underpinnings now affect access to, compliance with, and quality of health care in the US.   Precisely because religious identity is such an important personal and communal matter, it is all the more important for the health care system to be attentive to it in caring for immigrant patients.

Sources in Immigration, Religion, and Health Care:

Canda E, Phaobtong T.  Buddhism as a support system for Southeast Asian refugees.  Social Work 1992;37(1): 61-67.

Eck DL. A New Religious America: How a "Christian Country" Has Become the World's Most Religiously Diverse Nation. San Francisco: Harper, 2001.

Koenig HG, McCullough ME, Larson DB.  Handbook of Religion and Health.  New York: Oxford University Press, 2001.

Loue S, ed.  Handbook of Immigrant Health. New York: Plenum Press, 1998.

Numrich PD.  Healthcare and the new immigration.  The Park Ridge Center Bulletin 2000 (September/October):3+.

Paral R. Suburban Immigrant Communities: Assessments of Key Characteristics and Needs.Chicago: Fund for Immigrants and Refugees, 2000. http://www.donorsforum.org/forms_pdf/suburban_sm.pdf    

Understanding Asian American Chicago: A Research Report Series. Chicago: Institute for Metropolitan Affairs, Roosevelt University, 2000. http://www.roosevelt.edu/ima/pdfs/civic.pdf

Yoo DK, ed. New Spiritual Homes: Religion and Asian Americans. Honolulu: University of Hawaii Press, 1999.

Buddhists
The majority of Buddhists in the United States are recent immigrants from several Asian countries. They follow a variety of Buddhist traditions, all ultimately stemming from the historical founder of Buddhism, Gautama Buddha, who lived in northern India about 2,500 years ago.  Immigrant Buddhists also follow many cultural beliefs and practices shared by other Asian groups; however, here we focus on the Buddhist beliefs and practices that health care professionals in the US might encounter in treating an immigrant Buddhist patient.   At various points in the following discussion, the impact of Asian culture and cultural differences among Buddhists is addressed.

Certain Buddhist beliefs and practices differ from the major religions of the West such as Christianity and Judaism.  For instance, Buddhists believe that a person goes through many lifetimes, the circumstances of which are governed by the law of karma, or the moral value of the person’s deeds.  Buddhism does not contain the belief that an almighty and unchanging God created the universe and fashioned human beings in the divine image.  Buddhism does recognize the existence of numerous deities and spiritual beings, some of which can aid human beings in their life circumstances.  Buddhist ritual practices differ from the worship experience in most Western religions, and involve their own characteristic sacred images, aromas, and religious specialists.  One of Buddhism’s basic teachings is called the Four Noble Truths: 1) that life is suffering or inherently unsatisfying, 2) that life’s suffering and dissatisfaction derive from our own desires, 3) that we can attain liberation from life’s suffering, and 4) that there is a moral and spiritual path that leads to such liberation.

Immigrant Buddhists live throughout the metropolitan Chicago region, with concentrations on the north side of the city of Chicago and in the northern suburbs.  The largest local Buddhist ethnic groups are Cambodians, Chinese, Japanese, Koreans, Laotians, Thais, and Vietnamese.  Smaller Buddhist groups include Burmese, Sri Lankans, and Tibetans.  Socioeconomic status varies widely among these populations, ranging from highly skilled and educated professionals to refugees who fled traumatizing circumstances in their home countries.  Some of these populations also include significant numbers of people who follow religions other than Buddhism.  For instance, the local Korean population includes many Protestant Christians, while the local Chinese population also includes many Protestant Christians as well as those who combine Buddhist practices with native Chinese religious traditions.

Following is a list of local organizations providing information and resources about Buddhist immigrants:

• Buddhist Council of the Midwest. Umbrella association representing many local Buddhist temples and centers.

• Thai Nurses Association of Illinois, 6545 N. Kilpatrick, Lincolnwood, IL 60646, 847-677-8960.  Represents local Thai nurses.

Patient/Caregiver Relationship
Some Buddhist patients might ask a Buddhist monk or other religious leader to intervene on their behalf in health care decisions.  Due to Asian cultural influences and values around personal interactions and reserved demeanor, Buddhist patients may display a contemplative attitude towards their illness or might feel modest when being examined by doctors and nurses.  Gender is also an important aspect to consider; many Asian Buddhist women will prefer examination by a same-sex doctor or nurse.

The patient’s consciousness or state of mind should determine when to reveal his or her diagnosis.  The Buddhist precept against telling falsehoods is consistent with the notion of truth-telling in Western medical ethics.  Patients often know what is right or wrong with their own bodies.  Disclosure of information and diagnosis is legally required and ethical.  It is ethical also to disclose information about prognosis.   Doctors cannot predict with certainty when a patient will die; thus, it is important for the doctor to be honest, but also to allow the patient to live one day at a time.  Buddhist patients will recognize a basic Buddhist understanding here—that only the present is real, the past being gone and the future not guaranteed.  Physicians should inform patients that they are entitled to know health care professionals’ best, sincere estimates of prognosis, recognizing the uncertainty surrounding the prognosis.   Also, health care professionals should ask patients if they are interested in obtaining this information.  Patients can express their autonomy by declining further information.

Access to care can be an issue for elderly Buddhist patients, who might not seek medical attention if they do not have the resources.  In addition, elderly Buddhist patients might not comply with doctor’s orders, given certain ideas about karma (literally “deeds” or “actions,” the belief that the circumstances and quality of a person’s present life are shaped by their previous actions, including during former lifetimes).  They also might prefer to die at home.  Although family members, such as adult children, can be called upon for assistance, out of respect they probably would not tell an elderly person what to do.  Thus, family decision making structures must be honored in the patient/caregiver relationship.

Diet
Although some Buddhists are vegetarians, vegetarianism is not a religious requirement for all Buddhists.  It depends upon one’s particular tradition and status within Buddhism.  For example, Tibetan nuns are vegetarians, but Tibetan laypeople typically are not.  In general, Buddhist monks and nuns, who depend on the generosity of others for their food, cannot eat something that has been killed for them.  Buddhist monks are prohibited from eating meals after noon; after that time can consume only non-chewable foods, such as soup.  For other Buddhist patients, cultural background might be most important in understanding diet.  For example, a Chinese Buddhist may be influenced by traditional Chinese medicine and choose to practice certain dietary prescriptions that differ from traditional Thai beliefs about food and medicine.  Cambodian patients tend to prefer rice and fish dishes; this might be more influential than Buddhist beliefs about diet.  Thus, health care professionals should inquire about a Buddhist patient’s food preferences.

Drugs and Palliation
Buddhist concepts of suffering might influence a patient’s decision about pain palliation.   “Life is suffering” is the first of Buddhism’s Four Noble Truths.  This belief in the inevitability of suffering might lead patients to refuse drug treatment.   Likewise, patients might interpret pain as the effect of past karma and be willing to live with that pain in the hope of improving their chances in the next life.  Moreover, according to Buddhist teaching, suffering may eventually be overcome if the right spiritual path is chosen.

Some Buddhist patients choose to alleviate pain with meditation practices that can range from formal sitting postures to general efforts at concentrating the mind during routine tasks.   Meditating patients might request that family or friends refrain from visiting.  They might also decline drugs so that their minds will remain clear.  Physicians should investigate the viability of pain drugs that cause minimal mind altering side effects.

Alternative Medicine
Like many other ethnic groups, immigrant Buddhists in the U.S. utilize traditional alternative healing methods (Sullivan 1989; Pachter 1994).  Buddhists from Cambodia or China might engage in slightly different healing techniques due to differences in their respective cultures.  However, some commonalities among Buddhists can be enumerated here which may be compatible with Western medicine.

Many traditional healing systems have to do with maintaining harmony and balance within one’s body.  This is attempted through changing one’s diet, engaging in meditation, using massage therapies, wearing amulets, and/or anointing oneself with special oils or lotions.  Some of these remedies have carried over into mainstream society, such as the use of Tiger Balm to alleviate pain associated with headaches.  Many traditional healing techniques focus on warding off spirits or outside forces that might cause illness; hence, patients may wish to continue wearing protective amulets while receiving Western medical care.  In addition, steam baths of traditional herbs might be utilized or teas made with medicinal herbs ingested.  Finally, “cupping” might be used, which involves placing a heated glass on the skin to form a suction to draw out the bad force from an ill person’s body (Sandler and Haynes 1978).  Western medical professionals must keep this in mind if they see red, circular marks on a Buddhist patient’s body.  Medical cupping does not constitute abuse or neglect.  As with any kind of alternative medical practice, a presumption of incompatibility with Western biomedicine should not be made.

Dying, Death, and Final Religious Rites
Religious beliefs about the afterlife often affect health care decisions.  Buddhism teaches that people live through many lifetimes, being reborn into new life circumstances according to their karma.  Some Buddhist patients might display a reluctance to seek medical attention due to an acceptance of pain, suffering, and death as part of their karma.  However, Buddhist medical professionals point out that karma can be good or bad, and thus explaining to a Buddhist patient that suffering is not inevitable, or that karma can be positive, may change a patient’s attitude toward medical treatment.

For Buddhists, death is generally seen as a passage into the next life.  As a Buddhist patient nears death, he or she might submit to their suffering in order to avoid bringing that suffering with them into the next life.  Some Buddhist patients might want to have images of the Buddha or various spiritual beings in the room in order to facilitate feelings of well being or to alleviate suffering.  Also, patients might want to hear audio-taped chants or prayers conducted by Buddhist monks.  Family members might even call in Buddhist monks to chant by the patient’s bedside.  These individuals wear distinctive religious robes and shave their heads, and their chanting might sound out of place in a hospital, but we recommend accommodation of these important religious practices whenever possible.

Although incense and candles cannot be burned in hospital rooms, a Buddhist patient might use a light bulb to generate light for meditation or chanting.  Also, a Buddhist patient near the time of death usually wants to have a clear mind in order to make a smooth transition to the next life.  In this case, a patient might request that quiet be maintained as much as possible in the hospital room, or might request that family and friends refrain from visiting in order to find a peaceful state in which to pass from this life to the next life.

Finally, although many Buddhist countries do not have a strong tradition within their health care systems about organ or tissue transplantation, more and more Buddhists are becoming open to these procedures.  Buddhist ethics requires compassion for one’s fellow human beings; donating organs or tissues can be seen as having compassion for or assisting another person.  However, some Buddhists do not wish any tampering with a recently deceased person’s body due to the belief that a form of consciousness lingers near a person’s body for a period of time after death.  Tampering with the body might be perceived as preventing a peaceful transition to the next life.

Sources:

Report 13 of the Council on Scientific Affairs (A-97)

Ethnomed.org  Cultural competence information about several ethnic groups; inadequate treatment of religious factors.

Baylor University/Asian-American Health  Information about care of Asian patients; minimal religious content.

Baylor University/Religion and Refugees This site contains religious content, though not extensive.

Numrich PD.  The Buddhist Tradition: Religious Beliefs and Healthcare Decisions.  Chicago: The Park Ridge Center, 2001.

Pachter LM. Culture and clinical care: Folk illness beliefs and behaviors and their implications for health care delivery. JAMA 1994;271(9):690-694. NCBI, PubMed national Library of Medicine

Purnell LD, Paulanka BJ. Transcultural Healthcare: A Culturally Competent Approach. Philadelphia:F.A. Davis Company, 1998.

Rundle AK, Carvalho M, Robinson M, eds.Honoring Patient Preferences: A Guide to Complying with Multicultural Patient Requirements. San Francisco: Jossey-Bass Company, 1999.

Sandler AP, Haynes V.  Nonaccidental trauma and medical folk belief: a case of cupping.  Pediatrics 1978;61(6):921-922.

Sullivan LE, ed. Healing and Restoring: Health and Medicine in the World’s Religious Traditions. New York: Macmillan, 1989.

Hindus
Most Hindus in the United States are recent immigrants from India.  The majority of India’s population today follows religious traditions that can be generally labeled “Hinduism,” which is more like a family of religions than a single denomination.  Hinduism is perhaps the oldest of the major world religions.  It has no historical founder and no central authority or governing body.

Despite the great internal variety of Hinduism, most Hindus share certain beliefs and practices in common that differ from the major religions of the West such as Christianity and Judaism.  For instance, Hindus believe in reincarnation, that is, that a person goes through many lifetimes, the circumstances of which are governed by the law of karma, or the moral value of the person’s deeds.  Also, Hindus worship a variety of deities, although they often explain them as various manifestations of a single, all-encompassing divine reality.  Hindu ritual practices differ from the worship experience in most Western religions as well, and involve their own characteristic sacred images, aromas, and religious specialists.

Following is a list of local organizations providing information and resources about Hindus and other immigrants from India:

Apna Ghar, 4753 N. Broadway, Suite 518, Chicago, IL  60640, 773-334-0173.  Domestic violence shelter, its name meaning “Our Home.”

Hamdard Center for Health and Human Services, 355 N. Wood Dale Road, Wood Dale, IL 60191, 630-860-9122.  Serves South Asian and Middle Eastern immigrants. 

Indo-American Center, 6328 N. California Avenue, Chicago, IL 60659, 773-973-4444.  Provides services to Asian Indian immigrants.

Patient/Caregiver Relationship
Religion often shapes the decision making structure of a family or community.  Usually, if Hindu patients are well enough, they will make health care decisions for themselves.  They might call upon family or a respected elder family friend for counsel; they might even put this person in contact with a doctor.  However, the individualistic nature of the Hindu religion is compatible with Western notions of individual rights and autonomy.

Diet
Hindu patients may have special dietary requirements. Many Hindus are vegetarians; however, this must not be confused with non-Hindu vegetarianism that tends to have fewer rules for food production and consumption.

Sources:
Desai PN. Health and Medicine in the Hindu Tradition.  New York: Crossroad, 1989.
Ethnomed.org Cultural competence information about several ethnic groups; inadequate treatment of religious factors.
Baylor University/Asian Health Information about care of Asian patients; minimal religious content.
Lad V. Ayurveda: The Science of Life.  Wilmot, WI: Lotus Press, 1984.
Purnell L, Paulanka BJ. Transcultural Healthcare: A Culturally Competent Approach. Philadelphia: F.A. Davis Company, 1998.
Rundle AK, Carvalho M, Robinson M, eds. Honoring Patient Preferences: A Guide to Complying with Multicultural Patient Requirements.  San Francisco: Jossey-Bass Company, 1999.
Sharma A. The Hindu Tradition: Religious Beliefs and Healthcare Decisions. Chicago: The Park Ridge Center, forthcoming.

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