After arriving in Dearborn, Mich., from Iraq three years ago, Namah Hamoudi faced a "doctor dilemma." Although she speaks English well, doesn't wear a hijab (Islamic head scarf), and considers herself a thoroughly modern Muslim woman, she had trouble when it came to choosing a doctor.

"I need to feel at ease with my doctor," she told Psychiatric News. "I am more comfortable going to a female doctor who is also an Arab, like myself."

Hamoudi could have been speaking for tens of thousands of Middle Eastern women in the United States. While language is the main hurdle for many of them, more important are the unique cultural and religious barriers they run into when seeking health care that suits their special needs.

Middle Eastern women are reluctant to go to health care providers who do not speak their language or are not of Arab descent because they say there is a lack of sensitivity to their needs. "Arabic culture and practices within the Islamic religion make it awkward for us and difficult for an American doctor," Hamoudi said.

"Modesty demands that Muslim women to be fully clothed when in the presence of another man," she explained. "We do not want to be touched by a man—not even a handshake."

Understandably, this leads to problems for hospitals in finding enough female physicians. Add the need for an interpreter for many immigrants who do not speak English and a translator to decode medical documents in Arabic, if the documents exist at all, and it's easy to imagine how complicated things could get—not to mention the chances for misunderstandings and hurt feelings. Worst of all, patients could end up with a wrong diagnosis.

Fortunately, southeastern Michigan is at the forefront in addressing the health concerns of the roughly 300,000 Arab Americans who live in the Detroit area (see box at right). Both the Arab Community Center for Economic and Social Services (ACCESS) in Dearborn and the University of Michigan Health System (UMHS) in Ann Arbor have developed culturally competent, patient-centered services and programs for Middle-Eastern women.

Hamoudi said she chose ACCESS because they would treat her without insurance, and all her friends recommended it.

About 15,000 Middle-Eastern patients visit the Ann Arbor hospital each year, according to a survey conducted by Maya Hammoud, M.D., director of the Middle Eastern Women's Health Program there. She said that issues of cross-cultural communication and variations in health beliefs are real and not only influence patient satisfaction, but can also impact clinical outcomes.

Last year the ACCESS Community Health and Research Center treated more than 25,000 Middle-Eastern women and provided more than 12,600 patients with counseling and psychiatric services. ACCESS also has a wide variety of social, legal, employment, and vocational services, in addition to its health care programs for children, teens, and adults. Almost all the 150 staff members speak Arabic, and all health care pamphlets and medical forms are in Arabic. Three of its 15 full-time staff physicians are psychiatrists.

Since ACCESS established its first medical, public health, mental health, and family counseling services 17 years ago, it has been so successful that the National Arab American Medical Association is using it as a model for its members in Chicago, Cleveland, and New Jersey, according to Ghaleb Hatem, M.D., president of the organization, which is based in Birmingham, Mich.

Hammoud said more attention has been given to the Middle-Eastern population since the September 11 attacks. But few studies have been conducted on any aspect of the Middle-Eastern population in the United States.

Of special interest at ACCESS is its rehabilitation program for survivors of torture and a program for family counseling for refugees. The Victims of Torture Center was established four years ago through a government grant.

One of the psychiatrists at the center who treats torture victims is Pravin Soni, M.D., a Hindu who comes from a long line of English-speaking Indian physicians.

Soni graduated from the M.P. Shah Medical School in Jamnagar, part of the Punjab state in West India, and grew up around Muslims. Almost every year he visits his brothers in Kuwait and Dubai. Because he is not completely fluent in Arabic, he uses an interpreter, but says that in terms of getting the job done, this is not as important as having a background in Muslim culture and customs.

He works 2.5 days a week and sees about 500 patients each year. His coworkers are six Arabic-speaking therapists who do preliminary screening: three have Ph.D.s in psychology, two have M.A.s, and one has an M.S.W. degree." They usually pick up the psychopathologies, and we discuss the case before I see the patient," he told Psychiatric News.

He stressed the need to be very respectful and sensitive to the social and religious beliefs of his patients, as most are very religious.

Most patients come in with family members in attendance—the women always with their husbands.

Most of his patients are Iraqi and Yemeni refugees, and the majority suffer from posttraumatic stress disorder (PTSD) as well as depressive disorders. A small number have schizophrenia or bipolar disorder.

"A typical patient is a young man who is very withdrawn and not functioning well at all. He comes in and sits in corner of the room and doesn't speak. He appears to be totally uninterested in life. He doesn't read and doesn't even watch TV because programs with violence disturb him and reactivate memories of his war experiences.

"Very slowly you can draw the patient out by asking him whether he was ever in jail or prison. You often find he was imprisoned because he was suspected of plotting against the Iraqi regime.

"The going is slow," Soni explained, "but after a time they break down and begin to tell their story. Most of them cry as they recall what happened to them in prison. They relate their traumatic experiences—being given electrical shocks or being suspended upside down and having their head forced into a barrel of cold water. In between torture sessions most endured terrible beatings."

Many patients say that the physical torture they endured, though it threatened their survival, did not leave a permanent mark on their lives, he noted. The memory of the pain often healed along with the body. But the mental and emotional torture they received was so severe they are still struggling to cope with it even after many years.

"I was surprised myself when I learned of what many refugees had gone through," Soni said.

To break their spirit and force them to confess to false charges, they were often subjected to mock trials at which they were sentenced to death. As a prelude to their punishment, some were forced to watch the execution of their parents and children. Afterwards, on the threat of death, they were forced to defile their dead family members by walking on the corpses.

"All of these horrible images reactivated memories and flashbacks that led them to having nightmares and developing extreme anxiety," he said.

Despite their need for help, many torture victims never enter the treatment program because they suffer from extreme paranoia. They are afraid to associate with other refugees because they suspect the presence of spies. Some are so damaged it is almost impossible for them to socialize with anyone ever again, even with their own family, or to tell anyone what happened to them.

It is not unusual for asylum seekers to be held in detention for months or even years while awaiting an official ruling on their asylum claims, according to a study conducted at Bellevue Hospital in New York. During detention their symptoms of anxiety and depression get worse as their detention period increases.

"We usually start with medications from the SSRI group and antianxiety agents to help them relax and enable them to sleep," Soni said. Patients are started at very low doses to minimize side effects. For patients hearing voices continuously, Soni said he prescribes an antipsychotic medication, which he finds is often very effective for these patients.

"They start to sleep well, and the frequency of hearing voices goes down once they are given" the medication, he said.

Patients undergo psychotherapy with Arabic-speaking therapists at least once a month, then visit a psychiatrist to have their medications adjusted.

"So far the majority of outpatients seem to be doing well," he said. "The main problem is that most are poorly educated and relatively unsophisticated. They also have an acculturation problem because they are trying to adapt to their new life and surroundings. Some have great difficulty adapting because they keep trying to hold on to an earlier way of life."

To help them adjust to their new life, ACCESS provides English classes. But few refugees are sufficiently motivated to adopt a completely different lifestyle and learn to speak English, Soni pointed out.

Information about the ACCESS program is posted online at<www.accesscommunity.org>.▪