People of Arab Heritage

Abstract

Arabs trace their ancestry and traditions to the nomadic desert tribes of the Arabian Peninsula. They share a common language, Arabic. Most are united by Islam, the world’s largest religion that originated in seventh-century Arabia. Despite these common bonds, great diversity exists among Arabs related to religious preference and other variant characteristics of culture discussed in Chap. 1. Many Arab Americans disappear in national studies because they are counted as white in census data. The September 11, 2001, al Qaeda terrorist attack on the US has increased the number and intensity of negative comments about Arabs. Health-care providers need to understand that few Arab Americans support terrorist attacks and that it is inappropriate to pigeonhole people by their cultural background.

8.1 Overview and Heritage

Arabs trace their ancestry and traditions to the nomadic desert tribes of the Arabian Peninsula. They share a common language, Arabic. Most are united by Islam, the world’s largest religion that originated in seventh-century Arabia. Despite these common bonds, great diversity exists among Arabs related to religious preference and other variant characteristics of culture discussed in Chap. 1. Many Arab Americans disappear in national studies because they are counted as white in census data. The September 11, 2001, al Qaeda terrorist attack on the US has increased the number and intensity of negative comments about Arabs. Health-care providers need to understand that few Arab Americans support terrorist attacks and that it is inappropriate to pigeonhole people by their cultural background.

First-wave Arab immigrants, primarily Christians, came to the US between 1887 and 1913 seeking economic opportunity. Most were male, illiterate, and unskilled mountain or rural immigrants who valued assimilation. Most post-1965 immigrants are Muslims. Arabism and Islam are intrinsically interwoven with some elements of Christianity so that Arabs, whether Christian or Muslim, share some basic traditions and beliefs. Consequently, knowledge of their religion is critical to understanding the Arab American patient’s cultural frame of reference. Second-wave immigrants entered the US after World War II. Most are refugees from nations beset by war and political instability. This group includes a large number of professionals and individuals seeking educational degrees who have subsequently remained in the US. Most are Muslims and favor professional occupations.

8.1.1 Communications

• Arabic is the official language of the Arab world. Modern or classical Arabic is a universal form of Arabic used for all writing and formal situations ranging from radio newscasts to lectures.

• Although English is a common second language, language and communication can pose formidable problems in health-care settings. Speak clearly and slowly, giving time for interpretation. Obtain an interpreter if necessary.

• Communication is highly contextual, where unspoken expectations are more important than the actual spoken words. Conversants stand close together, maintain steady eye contact, and touch (only between members of the same sex) the other’s hand or shoulder.

• Speech is loud and expressive and is characterized by repetition and gesturing, particularly when involved in serious discussions. Observers witnessing impassioned communication may incorrectly assume that Arabs are argumentative, confrontational, or aggressive.

• Privacy is valued, and many resist disclosure of personal information to strangers, especially when it relates to familial disease conditions. Among friends and relatives, Arabs express feelings freely.

• Good manners are important in evaluating a person’s character. If the health-care situation is not an emergency, inquire first about overall well-being and exchange pleasantries. Etiquette requires shaking hands (among men only if traditional) on arrival and departure. Devout Muslim men do not shake hands with women. When a man meets an Arab woman, he should wait for the woman to extend her hand.

• Individuals are protected from bad news as long as possible. Inform patients of bad news as gently as possible.

• Table 8.1 describes techniques for communicating with Arab Americans.

• Punctuality is not taken seriously except in cases of business or professional meetings. Explain the importance of punctuality in the American health-care system. Maintain flexibility with appointments when possible.

• Titles are important and are used in combination with the person’s first name (e.g., Mr. Khalil or Dr. Ali). Some may prefer to be addressed as mother (Um) or father (Abu) of the eldest son (e.g., Abu Khalil, “father of Khalil”).

• Address Arab patients formally until told to do otherwise.

Table 8.1 Guidelines for communicating with Arab Americans

8.1.2 Family Roles and Organization

• Muslim families have a strong patrilineal tradition. Women are subordinate to men, and young people are subordinate to older people. In public, a wife’s interactions with her husband are formal and respectful. However, behind the scenes she typically wields tremendous influence, particularly in matters pertaining to the home and children.

• Older male figures assume the role of decision maker. Women attain power and status in advancing years, particularly when they have adult children.

• Among the traditional, gender roles are clearly defined and regarded as a complementary division of labor. Men are breadwinners, protectors, and decision makers. Women are responsible for the care and education of children and for the maintenance of a successful marriage by tending to their husbands’ needs.

• Although women in more urbanized Arab countries often have professional careers, with some women advocating for women’s liberation, the family and marriage remain primary commitments for most. The authority structure and division of labor within Arab families are often misinterpreted, fueling common stereotypes of the overtly dominant male and the passive and oppressed woman. Do not be judgmental with family decision making and roles.

• Family reputation is important; children are expected to behave in an honorable manner and not bring shame to the family. Children are dearly loved, indulged, and included in all family activities. A child’s character and successes (or failures) in life are attributed to upbringing and parental influence.

• Childrearing patterns also include great respect for parents and elders. Children are raised not to question elders and to be obedient to older brothers and sisters. Discipline may include physical punishment and shaming.

• The father is the disciplinarian, whereas the mother is an ally and mediator, an unfailing source of love and kindness. Children are made to feel ashamed because others have seen them misbehave rather than to experience guilt arising from self-criticism and inward regret. Explain child abuse laws in the US.

• Adolescents are pressed to succeed academically. Academic failure, sexual activity, illicit drug use, and juvenile delinquency bring shame to the family. For girls in particular, chastity and decency are required.

• Women value modesty, especially devout Muslims, for whom modesty is expressed with their attire. Many Muslim women view the hijab, “covering the body except for one’s face and hands,” as offering them protection in situations in which the sexes mix. It is a recognized symbol of Muslim identity and good moral character. Ironically, many people associate the hijab with oppression rather than protection.

• Family members usually live nearby, sometimes intermarry (first cousins), and expect a great deal from one another regardless of practicality or ability to help.

• Loyalty to one’s family takes precedence over personal needs. Cultural conflicts between American values and Arab values may cause significant conflicts for families.

• Sons are held responsible for supporting elderly parents. Elderly parents are almost always cared for within the home, typically until death. In the absence of the father, brothers are responsible for unmarried sisters.

• Although the Islamic right to marry up to four wives is sometimes exercised, particularly if the first wife is chronically ill or infertile, most marriages are monogamous and for life.

• Homosexuality is highly stigmatized. In some Arab countries, it is considered a crime, and participants may be killed. Fearing family disgrace and ostracism, gays and lesbians remain closeted. Do not reveal sexual orientation to the family. Refer gay and lesbian patients to local gay/lesbian support groups.

8.1.3 Workforce Issues

• Discrimination such as intimidation, being treated suspiciously, and negative comments about their religious practices has been reported as a major source of stress among Arab Americans.

• Muslim Arabs who wish to attend Friday prayer services and observe religious holidays frequently encounter job-related conflicts. Make attempts at honoring Friday prayer services.

• In the Arab world, position is often attained through one’s family and connections. Explain nepotism policies in the US.

• Conversants stand close together and maintain steady eye contact. Do not take offense if Arab employees stand closer to you than that to which you are accustomed or maintain steady eye contact. Remember these characteristics are culture bound.

• Speech is loud and expressive and is characterized by repetition and gesturing, particularly when involved in serious discussions. Impassioned communication may incorrectly be assumed that Arabs are argumentative, confrontational, or aggressive.

• Criticism is often taken personally as an affront to dignity and family honor. In Arab offices, supervisors and managers are expected to praise their employees to assure them that their work is noticed and appreciated. Whereas such direct praise may be somewhat embarrassing for European Americans, Arabs expect and want praise when they feel they have earned it. Give honest praise for the work of Arab employees.

8.1.4 Biocultural Ecology

• Most Arabs have dark or olive-colored skin, but some have blonde or auburn hair, blue eyes, and fair complexions. To assess pallor, cyanosis, and jaundice in dark-skinned people, examine the oral mucosa and conjunctiva.

• Infectious diseases such as tuberculosis, malaria, trachoma, typhus, hepatitis, typhoid fever, dysentery, and parasitic infestations are common with newer immigrants. Schistosomiasis (or bilharziasis) infects about one-fifth of Egyptians and has been called Egypt’s primary health problem.

• Glucose-6-phosphate dehydrogenase deficiency, sickle cell anemia, and the thalassemias are extremely common in the eastern Mediterranean.

• High consanguinity rates (roughly 30% of marriages in Iraq, Jordan, Kuwait, and Saudi Arabia) occur between first cousins and contribute to the prevalence of genetically determined disorders in Arab countries. Individuals are at increased risk to inherit familial Mediterranean fever, a disorder characterized by recurrent episodes of fever, peritonitis, or pleurisies, either alone or in some combination.

• Some individuals have difficulty metabolizing debrisoquine, antiarrhythmics, antidepressants, beta blockers, neuroleptics, and opioid agents.

• Closely assess the effectiveness of narcotics such as codeine and morphine.

• Table 8.2 lists commonly occurring health conditions for Arab in three categories: lifestyle, environment, and genetics.

Table 8.2 Health conditions common to Arabs

8.1.5 High-Risk Health Behaviors

• Nonuse of seat belts and helmets are major issues. Encourage use of seat belts and helmets, explaining state laws.

• Despite Islamic beliefs discouraging tobacco use, smoking remains deeply ingrained in the Arab culture: offering cigarettes is a sign of hospitality. Partner with schools for anti-smoking campaigns at a young age.

• Women may be at high risk for domestic violence, especially new immigrants, because of the high rates of stress, poverty, poor spiritual and social support, and isolation from family members. Explain American abuse laws.

• Sedentary lifestyle and high fat intake among Arab Americans place them at higher risk for cardiovascular diseases. Provide factual information on the benefits of physical activity and the benefits of a low-fat diet.

• The rates of breast cancer screening, mammography, and cervical Pap smears are low because of modesty. Obtain female health-care providers for patients for whom modesty is a concern.

8.1.6 Nutrition

• Although cooking and national dishes vary from country to country and seasonings from family to family, Arabic cooking shares many general characteristics. Spices and herbs include cinnamon, allspice, cloves, ginger, cumin, mint, parsley, bay leaves, garlic, and onions.

• Skewer cooking and slow simmering are typical modes of preparation. All countries have rice and wheat dishes, stuffed vegetables, nut-filled pastries, and fritters soaked in syrup. Dishes are garnished with raisins, pine nuts, pistachios, and almonds. Favorite fruits and vegetables include dates, figs, apricots, guava, mango, melon, papaya, bananas, citrus, carrots, tomatoes, cucumbers, parsley, mint, spinach, and grape leaves. Bread accompanies every meal and is viewed as a gift from God. Lamb and chicken are the most popular meats.

• Consumption of blood is forbidden; Muslims are required to cook meats and poultry until well done. Some Muslims refuse to eat meat that is not halal (slaughtered in an Islamic manner).

• Obtain halal meat from Arabic grocery stores, through Islamic centers or mosques, or from one of the online distributors of frozen halal meals.

• Muslims are prohibited from eating pork and pork products. Muslims are equally concerned about the ingredients and origins of mouthwashes, toothpastes, and medicines (e.g., alcohol-based syrups and elixirs) and capsules (gelatin coating) derived from pigs. However, if no substitutes are available, Muslims are permitted to use these preparations.

• Grains and legumes are often substituted for meats; fresh fruit and juices are especially popular, and olive oil is widely used.

• Food is eaten with the right hand because it is regarded as clean. When it is necessary to feed an Arab patient, use the right hand, regardless of the dominant hand.

• Eating and drinking at the same time is viewed as unhealthy. Serve beverages after the meal is eaten.

• During Ramadan, the Muslim month of fasting, abstinence from eating, drinking (including water), smoking, and marital intercourse during daylight hours is required. See Table 8.3 for Ramadan dates through 2025.

• Although the sick are not required to fast, many pious Muslims insist on fasting while hospitalized. Adjust meal times and medications, including medications given by non-oral routes. Provide appointment times after sunset during Ramadan for individuals requiring injections (for example, allergy shots).

• Eating properly, consuming nutritious foods, and fasting are believed to cure disease. For some, illness is related to excessive eating, eating before a previously eaten meal is digested, eating nutritionally deficient food, mixing opposing types of foods (hot/cold, dry/moist), and consuming elaborately prepared foods. Gastrointestinal complaints are the most frequent reason for seeking care.

• Lactose intolerance is common. Eating yogurt and cheese, rather than drinking milk, may reduce symptoms in sensitive people.

Table 8.3 Ramadan calendar 2019–2025

8.1.7 Pregnancy and Childbearing Practices

• Fertility practices are influenced by traditional Bedouin values, which support tribal dominance and beliefs that “God decides family size.” Procreation is regarded as the purpose of marriage; high fertility rates are favored.

• Sterility in a woman can lead to rejection and divorce. Approved methods for treating infertility are limited to artificial insemination using the husband’s sperm and in vitro fertilization involving the fertilization of the wife’s ovum by the husband’s sperm.

• Many reversible forms of birth control are undesirable but not forbidden. They should be used when there is a threat to the mother’s life, too frequent childbearing, risk of transmitting a genetic disease, or financial hardship.

• Irreversible forms of birth control such as vasectomy and tubal ligation are “absolutely unlawful” as is abortion, except when the mother’s health is compromised by a pregnancy-induced disease or her life is threatened.

• Unwanted pregnancies are dealt with by hoping for a miscarriage “by an act of God” or by covertly arranging for an abortion.

• The pregnant woman is indulged and her cravings satisfied, lest she develop a birthmark in the shape of the particular food she craves. Girls are carried high; boys are carried low.

• Although pregnant women are excused from fasting during Ramadan, some Muslim women may still fast.

• Labor and delivery are women’s affairs. During labor, women openly express pain through facial expressions, verbalizations, and body movements. Nurses and medical staff may mistakenly diagnose Arab women as needing medical intervention and pain medications inappropriately.

• Care for the infant includes wrapping the stomach at birth, or as soon as possible thereafter, to prevent cold or wind from entering the baby’s body.

• The call to prayer is recited in the Muslim newborn’s ear.

• Male offspring are preferred. Male circumcision is almost a universal practice, and for Muslims it is a religious requirement.

• Mothers may be reluctant to bathe postpartum because of beliefs that air gets into the mother and causes illness.

• Many believe washing the breasts “thins the milk.” Breast-feeding is often delayed until the second or third day after birth because of beliefs that the mother requires rest, that nursing at birth causes “colic” pain for the mother, and that “colostrum makes the baby dumb.” Explain the importance of the immune properties of colostrum. Dispel myths.

• Postpartum foods, such as lentil soup, are offered to increase milk production, and tea is encouraged to flush and cleanse the body.

8.1.8 Death Rituals

• Death is accepted as God’s will. Muslim death rituals include turning the patient’s bed (or at a minimum the patient’s head) to face the holy city of Mecca and reading from the Qur’an, particularly verses stressing hope and acceptance.

• After death, the deceased is washed three times by a Muslim of the same sex. The body is then wrapped, preferably in white material, and buried as soon as possible in a brick or cement-lined grave with the head facing Mecca.

• Prayers for the deceased are recited at home, at the mosque, or at the cemetery.

• Among the very traditional, women do not ordinarily attend the burial unless the deceased is a close relative or husband. Instead, they gather at the deceased’s home and read the Qur’an.

• Death rituals for Arab Christians are similar to Christian practices in the rest of the world. Extended mourning periods may be practiced if the deceased is a young man, woman, or child. Although weeping is allowed, beating the cheeks or tearing garments is prohibited.

• For women, wearing black is considered appropriate for the entire period of mourning.

• Cremation is not practiced.

• Families do not generally approve of autopsy because of respect for the dead and feelings that the body should not be mutilated. However, Islam does allow forensic autopsies and autopsies for the sake of medical research and instruction.

• Organ donation and transplantation as well as administration of blood and blood products are acceptable.

8.1.9 Spirituality

• Most Arabs are Muslims. Islam is the official religion of most Arab countries, and in Islam there is no separation of church and state; a certain amount of religious participation is obligatory.

• Islam has no priesthood. Islamic scholars or religious sheikhs, the most learned individuals in an Islamic community, assume the role of imam, or “leader of the prayer.” The imam acts as a spiritual counselor.

• The major tenets of Islam are shown in Table 8.4.

• Many Muslims believe in combining spiritual medicine, performing daily prayers, and reading or listening to the Qur’an with conventional medical treatment. Assist the patient and family in making accommodations for prayer.

• Prominent Christian groups include the Copts in Egypt, the Chaldeans in Iraq (now largely refugees), and the Maronites. Contacting the local imam may be a helpful strategy for Muslims struggling with health-care decisions.

• School and work schedules revolve around Islamic holidays and weekly prayer. Because Muslims gather for communal prayer on Friday afternoons, the work week runs from Saturday through Thursday. Schedule appointments so that they can be completed before prayer time on Friday afternoon.

• The devout patient may request that his or her chair or bed be turned to face Mecca and that a basin of water be provided for ritual washing or ablution before praying. Women who do not wear the hijab may wear one when praying or reciting the Qur’an. Provide hand-washing facilities along with other accommodations as needed.

• Providing for cleanliness is particularly important because the Muslim’s prayer is not acceptable unless the body, clothing, and place of prayer are clean.

• Sometimes illness is considered punishment for one’s sins. Others emphasize that sickness should not be viewed as punishment but rather as a trial or an ordeal that brings about expiation of sins, which may strengthen character.

Table 8.4 The five major pillars, or duties, of Islam

8.1.10 Health-Care Practices

• Good health is considered the ability to fulfill one’s roles.

• Diseases and illnesses are attributed to an inadequate diet, shifts of hot and cold, exposure of one’s stomach during sleep, emotional or spiritual distress, and envy or the “evil eye.”

• Practices such as informed consent, self-care, advance directives, risk management, and preventive care are valued.

• Women are often reluctant to seek care because of cultural emphasis placed on modesty. Many fear that a diagnosed illness such as cancer or a psychiatric condition may bring shame and may influence their marriageability.

• Family members indulge the individual and assume the ill person’s responsibilities. Although the patient may seem dependent and the family overly protective by European American standards, family members’ vigilance and “demanding behavior” should be interpreted as a measure of concern.

• Communicating a grave diagnosis is often viewed as cruel and tactless because it deprives patients of hope. Break the news of a grave diagnosis gradually and with assistance from the family spokesperson.

• Most expect physicians, because of their expertise, to select treatments. The patient’s role is to cooperate. The authority of physicians is seldom challenged or questioned. When treatment is successful, the physician’s skill is recognized; adverse outcomes are attributed to God’s will.

• Because many medications requiring a prescription in the US are available over the counter in Arab countries, Arabs are accustomed to seeking medical advice from pharmacists.

• Witchcraft and magic, concerns about the powers of jealous people, the evil eye, and certain supernatural agents, such as the devil and jinn, are part of their religion.

• Those who envy the wealth, success, or beauty of others are believed to cause adversity by a gaze, which brings misfortune to the victim.

• Beautiful women, healthy-looking babies, and the rich are believed to be particularly susceptible to the evil eye. Thus, expressions of congratulations may be interpreted as envy.

• Protection from the evil eye is afforded by wearing amulets, such as blue beads, or figures involving the number five; reciting the Qur’an; or invoking the name of Allah.

• Do not remove amulets from the patient or from the bedside.

• Mental or emotional illnesses may be attributed to possession by evil jinn.

• Islamic medicine is based on the theory of four humors and the spiritual and physical remedies prescribed by the Prophet. Because illness is viewed as an imbalance between the humors—black bile, blood, phlegm, and yellow bile—and the primary attributes of dryness, heat, cold, and moisture, therapy involves treating with the disease’s opposite: thus, a hot disease requires a cold remedy.

• Although methods such as cupping, cautery, and phlebotomy may be used, treatment with special prayers or simple foods such as dates, honey, salt, and olive oil is preferred.

• Preoperative instructions are thought to cause needless anxiety, hypochondriasis, and complications. Determine the need for preoperative teaching on an individual basis.

• Most regard pain as unpleasant and something to be controlled, anticipating immediate postoperative relief.

• Although expressive, emotional, and vocal responses to pain are usually reserved for the immediate family, under circumstances such as childbirth and illnesses accompanied by spasms, Arabs express pain freely.

• The tendency of Arabs to be more expressive with their family and more restrained in the presence of health-care providers may lead to conflicting perceptions regarding the adequacy of pain relief. Whereas the nurse may assess pain relief as adequate, family members may demand that their relative receive additional analgesia. Complete a thorough assessment for anticipating pain medication requirements.

• Mental illness is a major social stigma. Psychiatric symptoms may be denied or attributed to “bad nerves” or evil spirits.

• When individuals suffering from mental distress seek medical care, they are likely to present with a variety of vague complaints, such as abdominal pain, lassitude, anorexia, and shortness of breath. Patients often expect and may insist on somatic treatment, at least “vitamins and tonics.”

• When mental illness is accepted as a diagnosis, treatment with medications, rather than counseling, is preferred. Hospitalization is resisted because such placement may be viewed as abandonment.

• Because of social stigma, people with disabilities are often kept from public view.

• Medical treatments that require surgery, removal of causative agents, or eradication by intravenous treatments are valued more than therapies aimed at health promotion or disease prevention.

8.1.11 Health-Care Providers

• Many individuals find interacting with a health-care provider of the opposite sex quite embarrassing and stressful.

• Discomfort may be expressed by refusal to discuss personal information and by a reluctance to disrobe for physical assessments and hygiene. Women may refuse to be seen by male health-care providers. Provide a same-sex caregiver whenever possible, especially with intimate care.

• Knowledge held by a doctor is thought to convey authority and power.

• Most patients who lack English communication skills prefer an Arabic-speaking physician. Provide an interpreter, preferably the same sex as the patient, when needed.

8.2 Reflective Exercises

• 1. Few in-patient facilities have the ability for halal food preparation. What might you do to obtain halal food for those who require it?

• 2. How would you administer routine medications during Ramadan?

• 3. What is responsible for such a high rate of genetic diseases among Arabs?

• 4. What is the difference between being Arab and Muslim?

• 5. What are the five major pillars of Islam?

• 6. How would you assess for pallor, cyanosis, and jaundice among dark/skinned olive complexioned patients?

• 7. An Arab patient indicates that he does not have sufficient pain to need medication. His wife demands that the nurse give him a pain shot because he is in severe pain. How would you handle this situation?

• 8. What are approved methods for treating fertility among Arabs?

• 9. What groups are excused from fasting during Ramadan?

• 10. How might you break a grave diagnosis to an Arab patient or the family?