Zhou and his Medicine
Sitting in the tiny Chinese restaurant where Zhou works in New York City is like taking a trip to China for the afternoon. Old men sit behind big bowls of noodles and communal plates of pork and whole fish. Everyone smokes non-stop and drinks and laughs with their friends, clicking their chopsticks together as they go.
Zhou is constantly on the go, busing tables, delivering food, cooking, tallying bills, and speaking to his mother on the phone. He is managing the chaos.
Zhou moved from Fujian Province, China, to America four years ago at the age of 22. He is not typically shy or nervous, but when he’s in the presence of American doctors, his nerves take over.
For many Chinese immigrants, the American health care system has become the battleground for clashes of cultural understanding between China and America.
Two years ago, Zhou was diagnosed with Type 2 diabetes, the kind associated with diet and lifestyle that was formerly called adult-onset diabetes, but that can now be developed at any age due to higher rates of obesity among children. He has failed to manage the disease the way doctors advised, for a variety of reasons common to many immigrants in New York City.
Type 2 diabetes is a worldwide epidemic, with the number of diagnosed people expected to rise from 171 million in 2000 to 366 million in 2030. But particularly worrying is the steep upward trend of Type 2 diabetes in Southeast and East Asia, especially China, where urbanization and changes in diet and exercise due to economic prosperity have led to more sedentary lifestyles.
According to the World Health Organization (WHO), the prevalence of diabetes in China in 1997 was three times higher than it was 10 years earlier. WHO predicts that developing countries will be seriously affected by diabetes more so than developed nations in the 21st century. Recent test results from a study reported in the New England Journal of Medicine suggest that more than 92 million Chinese adults had diabetes in 2010, with nearly 150 million more showing early symptoms. China is now the diabetes capital of the world.
The epidemic has affected not only those living in Asian countries, but also those emigrating from Asian countries to America and other developed countries. Health care has been a particular problem for Chinese immigrants in New York, especially in the case of diabetes because treatment requires constant monitoring and maintenance, which is particularly difficult for patients to do themselves in a foreign environment. Training immigrant patients to monitor their blood sugar levels and their medicine intake is extremely complicated and knowledge often does not get passed from doctors to patients. Immigrant communities are difficult to reach because of language and geographic isolation, so those with diabetes may go for years living with a disease they never heard of before.
Before Zhou was diagnosed two and a half years ago, he was looking for a doctor to address his chronic cough, unaware that he had any serious illness. But because he speaks very little English and is always working, he had difficulty finding one.
“I went to see a private doctor because everyone said that would be better than a public one. But it was very awkward, I had no way of knowing what was happening and I don’t think the doctor liked me,” Zhou says. He tried to write his symptoms in basic English so the doctor would understand, but he sensed frustration from the doctor and quickly left.
“I didn’t know how to act,” Zhou says. “I was just me and the doctor. Even if he spoke Chinese, what am I supposed to say? He doesn’t know my life. Doctors in China knew my life – at the very least they could guess what it was like.”
According to Ji Tang, a China-born doctor in New York City, many Chinese immigrant patients are uncomfortable with the doctor-patient relationship in America. Chinese patients do not like being alone in a room with the doctor because they are used to how things are done in China.
“In China, you go to the hospital, you get a number, and you wait in line. Then, while you’re talking to the doctor, the next patient is right behind you listening. There is no privacy. My mother prefers it that way. She would never go to see a doctor one-on-one here in the United States,” Tang says.
In China, physicians are expected to make a decision and give instructions – often they will be harsh, but patients tend to prefer this. Chen, a pregnant woman in Beijing, says going to the doctor in China is scary, but she prefers it to the American system.
“People go to the doctor with this feeling: Zhanzhanjingjing,” she says, using a phrase that translates as: scared out of one’s wits and trembling with fear. “You look for your relative to take you, or else the doctor will treat you like a piece of pig meat!”
But when Chen took her diabetic mother to a hospital in Beijing, she was surprised that the doctor inquired about her mother’s personal life and lifestyle habits.
“For every other problem, we barely speak to the doctor. But diabetes is very personal, because everything we do affects the condition. I would much rather tell a Chinese doctor what I am doing day-to-day than a Western doctor,” says Chen.
It was another two months before Zhou could take another day off work to visit a physician. This time a friend recommended Gouverneur Healthcare Services, a public hospital on the Lower East Side of Manhattan, just a few blocks from Chinatown.
Zhou checked in on the fourth floor with a nurse who spelled his name perfectly and guided him to a chair in one of the waiting rooms. He remembers feeling comfortable when he met his doctor at Gouverneur for the first time – the doctor was Chinese and spoke Zhou’s mother tongue, a dialect of Chinese called Fujianese.
Gouverneur is one of two hospitals in New York City specifically devoted to helping East Asian immigrants access health care services. (The other is the Charles B. Wang Community Health Center.) Doctors at Gouverneur are organized into small groups, and each group has four or five doctors who work together in three examination rooms that branch off from a common waiting area.
Photos and names of the doctors are prominently displayed on the wall at the entrance to each group waiting room, and posters in Mandarin, Spanish, and English fill the walls. In the corridor between group waiting rooms hang large frames with photos of current and recent patients giving tips to other patients. Posters urge patients to take their medicine on time, or take care of themselves when pregnant – reminders that health is not only the doctors’ responsibility, but the patients’ as well.
Zhou’s eyes roll inside his head when he remembers the doctor first telling him he had diabetes.
“He was surprised, I think, because I’m so skinny!” he says.
Zhou is thin as a rail, has dark eyes that stand out from his pale skin, and you can clearly see his prominent cheekbones. He has small tufts of black hair on his mostly bald head, and when he smiles black teeth outnumber the white ones. He never suspected he had a serious health issue commonly associated with obesity.
But according to Dr. William Bateman, Gouverneur’s director, the diagnosis makes sense. Chinese people in both America and China are more susceptible to type 2 diabetes, despite the relatively low prevalence of obesity in East Asia. This is because East Asians, and specifically Chinese people, typically become diabetic at a lower mean body mass index (BMI) than people from other cultures.
One hypothesis, called the Neel hypothesis, explains that East Asians have lower BMI’s because populations that have gone through multiple generations of starvation develop a thrifty gene that allows fat to be stored more readily, because that is how their ancestors survived during famine.
A second hypothesis is that humans were mostly plant eaters, but Europeans began eating meat early on and grew to tolerate this diet. When Chinese people migrate to America or to large, Westernized cities in eastern China, they begin to consume a large amount of meat, but their bodies are still built to handle the lifestyle of their grandparents.
Understanding new diseases is extremely challenging, especially for a poor immigrant in a new, modern environment. Diabetes was never a problem in Zhou’s family, and he wasn’t familiar with the medicines it required and their importance. Even more distressing was trying to figure out how he would incorporate a medicine-taking process into his busy lifestyle in New York. He simply does not have the time to take his medicine, exercise regularly or visit the doctor for the recommended check-ups.
“I can’t take the time off work. Plus, he gave me the medicine, it’s no problem,” Zhou says, waving his hand aside.
But according to Wang Yue, a researcher at Gouverneur, most Chinese immigrant patients do not have time to take medication regularly because they do not fully understand why the medicine is important and are so busy during the day that they do not remember. Yue says diabetic patients usually have their medicine once or twice a day instead of the prescribed three, and sometimes a patient will skip the day’s doses altogether, as Zhou often does. Yue also says that many patients who have already been diagnosed with diabetes do not come to Gouverneur for their regular appointments, even when they understand they should.
“I think the problem is that they know they have diabetes, but because of time and money they can’t afford to comply,” she says.
“Chinese are in a different socioeconomic class in their own country than in America. They find themselves in a lower class when they come here,” says Ji Tang, a colleague of Yue’s. Zhou, for example, graduated from a Chinese college with a degree in history, but has only been able to find restaurant work in America.
Bateman believes it is vital that doctors who treat Chinese immigrants understand immigrant lifestyles in New York City as well as traditional Chinese lifestyles. A study by Dr. Linda Ann Tom from the John A. Burns School of Medicine in Hawaii found that doctors and nurses need to understand that the Chinese population is heterogeneous in language and socioeconomic status, in both China and America. Chinese immigrants in American face economic and social barriers that force university graduates to work in restaurants and car shops seven days a week, 18 hours a day, to make a living.
Patients like Zhou might take their conditions more seriously if they knew that not taking medicine now might make it impossible for them to work at all in the future. But diabetes is unobtrusive to begin with.
According to the results of a focus group study at Gouverneur, many patients only get worried if their feet begin to hurt. By this time, the patient’s sugar levels have been out of control long enough that the small blood vessels are clogged, circulation to the feet is reduced, the feet go numb and often have to be amputated.
“So patients’ whole orientation is: This is important when my feet are hurt, but by then it’s too late,” says Bateman.
Yue believes that when diabetic patients do take medicine, it is as a passive observer taking medicine only because someone told them to.
When I asked Zhou what medicines he takes for diabetes, he could not remember the names or what they were for. He knew the disease had something to do with insulin, and said he no longer eats candy.
While Zhou may have practical reasons for not taking his medicine given his schedule, deeply rooted cultural and psychological reasons exist as well. Many Chinese hold a long-standing belief that Western medicine is best for curing acute problems, while traditional Chinese medicine is best for curing long-term illnesses. Many Chinese patients find it difficult to truly care about taking their medicine and making it a priority because they believe that if their symptoms are not acute, Western medicine will not help in the long term.
When asked to explain this belief, Zhou said, “There is no agreed-upon traditional Chinese medicine cure for diabetes, because this is a Western disease. But if there was, I would trust that more because Chinese medicine works for years and years.” Zhou’s reasoning is: Why miss a day of work to get a check-up or pick up more medicine when, simply put, Western medicine does not have the power to really cure long-term illnesses?
“We need to educate these patients to decide that when they are not feeling any symptoms, they still need to measure their sugar and see the doctor,” says Bateman. “It’s about shifting how we think about the practice of medicine in America.” Bateman believes that doctors need to inform Chinese patients of the merits of Western medicine and encourage them to adopt Western medicine to improve their own health. Educating patients can help them initiate taking medicine themselves. “Doctors need to move away from focusing solely on improving a patient’s condition. We need to instead say, ‘You have to do better as someone with this problem, and I will help you get the skills.’”
But Bateman admits that changing the behavior of patients is far more difficult than administering medicine.
“Behavior is guided by knowledge, skills, and attitudes,” says Bateman. “That’s what dictates what all of us do. But the most important one is the attitude.” If you can convince someone that something is important, then the knowledge and skills come. But that is easier said than done.
Ironically, while most patients came to America looking for higher salaries and better lifestyles, doctors are trying to revert diabetic patients’ behavior back to traditional lifestyles when they were poorer and eating more natural foods back in China.
“Diabetes is the disease of prosperity,” says Bateman.
According to the results of extensive research conducted at the China-Japan Friendship Hospital in Beijing, Chinese people should try to “retain certain features of their traditional lifestyle” to prevent the increase of diabetes. Chinese immigrants come to America to find a more prosperous life, but low social and economic status and their own genetic makeup leave them ill equipped for the jump to a life in America. The American definition of prosperity may not coexist with health after all, especially for Chinese immigrants.