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
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
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
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
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
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
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
"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
"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
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>.▪