Salma Abdul was born and grew up in Bangladesh. Her children left for the US to study, then settled in the country as permanent residents. When her husband died, she found herself alone. Her children, unable to leave their lives in the US, but worried about her aging alone, asked her to come and join them in America. When Abdul arrived in the USA at 69 years of age, she had to find her feet in a brand new country and culture. Her adopted country was technologically more advanced and spoke a language she didn’t understand. Its culture was completely different from hers. Its systems were complex and, because she couldn’t speak fluent English, harder to navigate.
With the numbers of immigrant elderly surging in cities like NYC, cultural competency on the part of service providers like hospitals becomes ever more important.
“I feel tension in my mind,”: Being ill and unable to communicate
Abdul’s real troubles began when she became ill with kidney disease and had to visit a city hospital on her own. Her children were pre-occupied with work and demands from their young families, and couldn’t spare the time. The hospital had few interpreters. Intake staff at the hospital couldn’t speak Bengali and instead made her access the Translation Hotline and tell the disembodied voice at the other of the phone her symptoms. Doctors ignored what she was struggling to say in her broken English, or dismissed her after a cursory examination.
Discrimination as a barrier to care
According to a study in the Journal of General Internal Medicine, researchers analyzed data from 6,017 Americans older than 50 who took part in a Health and Retirement Study and found that one out of five of these adults experience discrimination in healthcare settings, and one in 17 experiences it frequently. “Ageism in healthcare is very common and experienced by many older adults,” says lead author Stephanie Rogers, MD, MPAS, MPH, a clinical geriatric fellow at University of California San Francisco. There have also been several studies that prove that immigrants in particular report more discrimination in healthcare settings (Derose et al., 2009).
In Abdul’s case, she “found it difficult to understand the instructions the doctors gave her or the questions he asked her,” said Afroditi Panna, India Home’s Case Manager. Abdul’s daughter also spoke to Panna. Abdul’s daughter felt her mother, was being ignored and treatment options were left unexplained, perhaps because she was older immigrant woman of color who spoke hardly any English. The doctors and nurses would explain things to her when she accompanied her mother, Abdul’s daughter reported, however, when her mother went alone, they would be unresponsive and “not nice”.
“That’s when we decided to start accompanying Salma to the hospital because, as with so many of our immigrant elders, she didn’t know what questions to ask her doctor, how to fill forms, or even where to go, or how to get to different specialists,” Panna said.
Case managers and cultural Interpreters
In her experience with Care Management, Panna said, older adults need help with much more than just paperwork. Sometimes, she and her team are called upon to become interlocutors between cultures.
For instance, when a doctor asks a Bangladeshi senior, how she feels emotionally or mentally she’ll invariably answer, “amar onek tension ,” or “I have a lot of tension in my mind.” In Bengali culture, the English word tension is often used as a catch all term for anxiety or depression or worry, and other distressing mental issues. Most American doctors don’t understand this culturally specific term, unless someone with cultural competence (like an accompanying case worker) can explain what the elder means.
Salma Abdul’s case highlights an important point that often gets lost in the scramble to deliver aging services: with the numbers of immigrant elderly surging in cities like NYC, cultural competency on the part of service providers becomes ever more important.
The fact that her team speaks Bengali and understands South Asian ways has made a huge difference in her clients lives, says Afroditi Panna, the Case Manager at India Home.
How to deliver Culturally Responsive Care
At India Home, where we have culturally competent and multi-lingual staff like Panna, working with our South Asian elder population, we have found that the culture from which our elders come affects all aspects of their behavior. For example, it affects whether they seek help, the kind of help they seek, the symptoms and concerns they bring to their doctor or their family’s attention. Here are some of the guidelines that our case workers and managers follow in order to become more cuturally responsive:
Maintaining the tradition of respecting elders: A focus on engaging clients in a manner that is consistent with their cultural values and adapting communication to be consistent with the client’s traditions. For example, in Asian and South Asian culture this would entail addressing our elders with a honorific and never by their name. It would also mean case workers listen respectfully (and patiently) so that the elder feels understood and establishes rapport before rushing into the business at hand. It would mean being respectful of cultural norms around touch, personal space and so on.
Involving the Family: Most of our immigrant elders live with their families and are dependent on them. Individualistic Western methods where the patient is solely responsible for their own welfare may need to be modified for aging South Asian elders. Other family members may have to be made familiar with the treatment process and involved actively in their care. To take Abdul’s case as representative: our case workers engaged with her family members and took the time to talk to them and explain her treatment.
Framing issues in culturally relevant ways: For example, music and art therapy is used in Western practice to reduce tension and stress, but some South Asians older adults may have restrictions based on their religious beliefs on the kind of music or they are allowed to listen to or the art they may practice. A culturally competent case worker may have to advise the Western doctor to come up with alternate methods to help her client to cope.
Facilitating collaboration: Many older adults have learned important ways of coping with life’s stress and have developed impressive resilience that is informed not only by their experiences but also by specific cultural beliefs and values. Our case workers learn a lot by showing cultural humility and listening and learning from our clients. These are some of the ways in which India Home’s case management department is developing client-agency interactions. It’s an evolving art Ms. Panna says and her team learns something new every day. But for her, she says:
“cultural competent case management means that for every one of our 75 active cases, our clients feel that we understand their concerns, and that we are treating them with respect. We want them to feel that we hear them.”
Join India Home and the Diverse Elders Coalition for a Twitter chat about cultural competence in aging services on Wednesday, March 21st at 3pm EST. Follow the hashtag #CultCompMatters to join in.
New York University’s Center for the Study of Asian American Health (CSAAH) held a community health forum at our Desi Senior Center on Tuesday, September 26th. The forum celebrated the advances in the health of our seniors thanks to our partnership with CSAAH. MD Taher is the Project Coordinator for NYU’s Department of Population Health and a Community Health Worker with CSAAH. He has, for the past several months, helped to coordinate impactful health projects at the Desi Senior Center in Jamaica. “We wanted to share our results with the community, celebrate their health,” he said. Also being celebrated was our successful partnership with New York University’s Center for the Study of Asian American Health (CSAAH), which is the leading institute in the US set up to study Asian American health. Our collaboration with the institute has helped facilitate and advance several health projects.
We wanted to tell the community what our findings were, and thank the seniors from India Home, MD Taher, Project Coordinator, NYU Department of Population Health, said.
These projects fill a necessary void in care because as MD Taher said: “There are serious health concerns in the community.” One in four Bangladeshis have diabetes. One in five suffer from hypertension.
One of these projects, titled Keep On Track / Reach Far trained 26 volunteers at India Home to monitor blood pressure as part of a Community Health Assessment. Over 80 seniors from Desi Senior Center participated in the project.
Other projects too have had a direct impact on the health of our seniors. One helped to disseminate nutrition information with culturally and linguistically adapted brochures in Bengali and Hindi. “They came many, many times to the center to teach our seniors about nutrition. They gave them a cup and a spoon, taught them how to measure their food portions, ” Nargis Ahmed, the Site Director for Desi Senior Center said. Nargis worked closely with the NYU team to get seniors to try these new nutrition strategies.
The team from CSAAH shared the finding from various projects with the seniors at India Home’s Desi Senior Center.
Another important innovation has been CSAAH’s partnership with five area pharmacies to create linguistically adapted health materials in Hindi and Bengali, the languages spoken by our seniors. CSAAH also launched a nutrition strategy by working with area restaurants like Star Kabab in Jamaica to replace ingredients in common dishes so as to make them healthier. For example, switching white rice with brown in kitchurie ( a Bengali rice and lentil dish) increased its nutrition content. CSAAH has also partnered with local mosques to serve healthier foods for the iftar meal that breaks the Ramadan fast.
Other CSAAH projects like the DREAM (Diabetes Research, Education, and Action for Minorities) project, a five-year community based participatory research study, have also had success in improving attitudes toward health in the Bangladeshi community. The DREAM project aims to develop, implement, and test a Community Health Worker (CHW) Program designed to improve diabetes control and diabetes-related health complications in the Bangladeshi community in New York City. As a result of this effort at diabetes management, over 400 patients who participated across the city lost weight, became more active physically, managed their medications better and saw their doctors regularly.
The community health forum was held in the spirit of transparency and partnership and sought to update the seniors who participated in the projects and create ongoing dialogue. “We wanted to tell the community what our findings were,” MD Taher said. “And thank them.” The forum was well attended by community leaders, partners, local businesses, policy makers, and media partners.
Dr. Nadia Islam, PhD, the Deputy Director and co-investigator of the Center for the Study of Asian American Health presents findings on the DREAM Project.
The response from the community of seniors has been excellent. Even with all the barriers like work, taking care of grandchildren and busy lives, participants have been able to maintain the lifestyle changes they made as a result of the projects. India Home is happy to have done its part in improving the lives of our seniors. In the face of the rapidly growing older adult population of Bengali seniors in New York City, India Home’s vision is to continue to be a leading resource to our seniors and agencies and institutions that are working to respond to their changing and emerging needs. “Our seniors were very happy that they learned new things and I plan to continue to remind them,” Nargis Ahmed said.
India Home’s Executive Director, Dr. Vasundhara Kalasapudi, along with Dr. Swapna Dontinneni, Dr. Pratik Jain and Ms.Vani Tirumal presented a study on Attitudes to American Health Care among Elderly South Asians at the 34th Annual AAPI Convention.
AAPI or the Association of Indian Physicians, is the largest non-profit ethnic medical organization in the United States. It stands for over 60,000 practicing doctors and 20,000 students and residents of Indian origin. Every year doctors and healthcare professionals come together for an annual convention in a major American city. They meet to talk about medical advances, health policy, participate in presentations and exhibits that highlight the newest advances in caring for patients, and medical technology. This year, India Home’s Executive Director, Dr. Vasundhara Kalasapudi, MD, attended the convention in New York city in her capacity as a practicing geriatric psychologist. Dr. Vasundhara Kalasapudi, Dr. Swapna Dontinneni, MD, Dr. Pratik Jain, MD and Vani Tirumala made a presentation about Attitudes to American Health Care among Elderly South Asians using their research conducted with participants from India Home’s Sunnyside Center and Services Now for Adult Persons Center. Most of the doctors leading the 2010 study were from Brown University.
Some of the key findings were that elderly South Asians relied on non-allopathic forms of medicine such as homeopathy, Ayurveda and herbal home remedies as a first line of defense. When they used allopathic medicine it was a second choice, and very few believed that it was important to have a primary care physician.
The Poster for the study
Barriers to healthcare
Interestingly, the study* also found the barriers to healthcare were the burden of paperwork, discrimination, communication (lack of English access) and affordability. With this study, the doctors made an important contribution to the growing body of knowledge about South Asian seniors and their attitudes toward American health care.
* Please enlarge image of poster for references
Shireen Mansoor was born in 1949 in Bogra village in, what was then, undivided Pakistan. Sheikh Mujibur Rahman, the founding leader of Bangladesh and its first President, was a cousin. Perhaps that’ is why the revolutionary spirit burned bright in her. From a young age she broke with tradition, went to college and became one of the few women in the country with a medical degree. Hardly 22 years old at the time of the Bangladesh War of Independence, Dr. Mansoor secretly smuggled herself into Assam’s refugee camps to help her country and the Bangladesh Revolutionary Party. This is her story in her own words.
Eight years old and in boarding school
I was born in Bogra. My father was a business man in Dhaka and my mother lived with him away in the city. We were 9 sisters and my grandfather, a retired lawyer, was taking care of us. He said to my father, “No matter what the sex of the children they need an education. Let them stay here..Bogra is a quiet place.”
I was bored at home and so my grandfather asked my father to put me in the POD Girls School. It was a dorm school (boarding). He said, “There’ll be a library, she will have companions.” I was eight years old when i joined the 5th grade.
All the other girls were bigger than me and one of them came and asked me, “You are so little what are you doing here.”
When my father was about to leave I said, ” I said let me sleep in your lap. When I’m asleep you can put me to bed and you can go.”
My dad used to send money to the post office and the school clerk would handle my finances. Sometimes he’d say, the teachers haven’t been paid so can I give them some money and I’d say please go ahead. When they got paid, he’d return the money.
I would buy breakfast for my school friends. I would tell the peon, “Today I want four parathas with bundiya and rasogulla.” He’d say, “Why four?” I wanted to give my friends breakfast because my breakfast came from outside and they didn’t like the school breakfast.
One of 10 female medical students in 1968
Shireen was a champion in Medical School sports
I went to college and I got admission into medical school. I was selected on merit. The medical school was set up by the World Health Organization and it was in the Rajshahi district, close to India. It was a wonderful school, newly built. Very big campus. There was the medical school, hospital, hostels for teachers and students, playgrounds. It was beautiful.
We were 100 students in the medical school. Out of the 90 students from home country, I was one of 10 female students. One time we had to do anatomy and thanks god I was one of the first to get to do it. I got to dissect the abdomen. It is a big part of the body and has a lot of organs intestine, spleen and so on. The Grey’s Anatomy was our book – it was so heavy we had to carry it on our shoulder. I had a study partner; she didn’t know good English and I always helped her to study. So she was always carrying my books, like my secretary. She was very good. I love her.
Called to help in the Bangladesh War of Independence
In 1971 the college informed the international students that there was going to be political unrest and asked them to go home. They told us that the ambulance would drop every girl from the hospital at home. So they dropped me home. My parents were worried about the unrest. Then on the 27th of March the war started and the army started marching from Dhaka to all the districts. My parents decided it wasn’t safe to stay in the city, so we moved to the village. On the 28th of March, we went to the village. I was a third year student.
Working in the delivery room in the OBGyn ward in Libya
One afternoon I was standing on my balcony. I saw a young boy was coming through the gates. When he came closer I realized he was my cousin. He was dressed like a soldier. He brought a letter from my uncle, asking me to go with him to the refugee camp in Assam, India set up by the officers of the Revolutionary Party. There were a lot of women refugees with gynecological problems, urinary tract infection and so on. The Red Cross was helping but there were no female doctors.My father said, “Yes, definitely this is your time to go and help.
“My mother started crying. “If she goes to the war front no one will marry her. No one will take her in marriage. People will talk.”
But my father said, “She definitely needs to go because she’s needed there.”
Hiding in the forest from Pakistani fighter jets
This happened at about 2:00 o’clock in the afternoon and I had to leave at 6:00 because they had hired a big boat with a motor. There were 100 people on the boat, including my relatives and some political persons. It had two floors like a steamer. They gave me a lot of honor. I had a corner on the boat with a curtain. In the daytime they moved very fast down the Brahmaputra river and at night they would hide. The Pakistani fighter planes were flying overhead all the time. It took three days; it’s a long distance from Bangladesh to Assam.
One time the boat was anchored and the Pakistani planes were overhead, they were looking to drop bombs. So all the political people on the boat said everyone get off the boat slowly and crawl into the forest. They asked us to scatter, to not go in groups. So my cousin and me got off the boat. It was a very terrible feeling. But on the other hand I did it for my country. My cousin held my hand and we crawl crawl crawl and we waited for two three hours in the forest. Then the plane went away and we went back to the boat and continued. This is one memory that stays with me even today.
Working in the refugee camps
With a co-worker in the OB-Gyn
The refugee camps were filled with refugees who had run away from Bangladesh to survive. There were building like a school or a police station, there were offices for the red cross. The camp officials were very happy to see me and they took me to meet the women. The women had problems with the language so they couldn’t tell anyone what was going on. There were like half a million refugees there. Many women were from good families. There was no water for washing. There was bread in plastic bags, but it wasn’t enough. Many were going hungry. There was canned milk, canned vegetables from abroad. They washed in the river. So I worked there and that’s how it went until December 16. Then knew the country was independent! Oh happy days.
Land covered in bones
When I went back home and had to go back to medical school. There were dead bodies on both sides of the road, collected there in huge numbers. It was nine months after they had been killed and all the flesh had disappeared.
The ambulance came to take us back and on the way there–oh my god –I saw the land was covered in bones.
Marriage and becoming an OB-Gyn in Libya
Husband and wife on holiday in Switzerland
I did an internship after graduation then I came back to Dhaka and started working in the OBGyn ward. My mother was crushing her head that I should get married. Then at the age of 26 I got married and moved to Libya. My husband was an eye specialist. Libya was beautiful, like a Mediterranean, European country. It had been developed along the curve of the Mediterranean ocean. The weather was not too hot, not too cold. I worked there with Italian, German and Indian doctors. I worked in Libya for 16 years, my children were born there and were going to British schools. Finally I resigned and followed my husband to Switzerland, then New York in 1994.
Husband’s stroke and hard times
In America it was hard. I had to study, I had foreign student status. I was older, my children were in school. It was very difficult to get residency. I finally started working with a Pakistani doctor who had 4-5 offices. She realized I had done everything possible to work here. I was working with her and she got me immigration, good salary and I survived. My children were still studying when my husband had a stroke and became bedridden. I started supporting the house. Just like my parents took care of me, I took care of my family. What to do? You do it for the children. I worked with the Pakistani doctor for ten years. I stopped working in 2014. It was not easy but I survived.
Proud of her children
I have two daughters and a son. My daughter is a doctor, she’s waiting for her residency. Second one was doing a Ph.D. at Columbia and then she got three scholarships to UPenn, so she moved there. My son got scholarships from Cornell.
Her feelings for India Home’s Desi Senior Center
It keeps us busy and in flow with the world. There’s wonderful feedback here for body and mind.
I had come to the mosque upstairs for prayer and then someone asked me to come to Desi Senior Center because she said, “They have physical exercise.” I came for the physical exercise because I have to take care of myself keep myself fit. When she saw me Nargis (Nargis Ahmed, the Program Coordinator) said, ” Oh my God! Dr. Mansoor, I was your patient!” Here I’m learning about senior citizens health issues, how to take vitamins, fight osteoporosis. I gave some health lectures here on how to protect from the cold, how to take vitamins. It’s a wonderful place for senior citizens. If they are sitting at home, they sleep. It is better that they stay active here. We get one hour exercise everyday and we communicate with each other.