Iraqis in Minnesota

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Increasing the cultural competence of health care providers serving diverse populations

In order to provide equitable and effective health care, clinicians need to be able to function effectively within the context of the cultural beliefs, behaviors, and needs of consumers and their communities. According to the 2002 Institute of Medicine report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, racial and ethnic minorities tend to receive lower quality health care than non-minorities even when access to insurance and income is accounted for. Failing to support and foster culturally competent health care for racial and ethnic minorities can increase costs for individuals and society through increased hospitalizations and complications.

Iraqis have been immigrating to the US at the rate of several thousand per year since the 1990 Gulf War. As of 2007, 102,000 Iraqi immigrants resided in the US, constituting less than one percent of the total foreign born population. With a renewed commitment by the US to resettle Iraqi refugees since the most recent Iraqi war, nearly 20,000 refugees have been approved for immigration in the last two years. Michigan, California, and Illinois have the largest Iraqi populations.

According to the 2000 census, Iraqis in Minnesota numbered only 500, but that number has grown, and is expected to continue to grow. In Minnesota, most Iraqis live in Fridley, Coon Rapids, and Brooklyn Park, with nearly 500 Kurdish refugees from Iraq living in Fargo, North Dakota. The United Nations reports more than four million Iraqis have been exiled because of war, including those who cooperated with the US military or businesses and minority Christians who have been targeted by anti-American extremists for kidnapping and death. Most Iraqi refugees have been unable to find work in the countries to which they escaped and have sought refuge in the US.

The following cultural patterns may represent many Iraqi immigrants, but do not represent all people in a community.

Social Structure

Iraqi immigrants may be either Sunni or Shiite Muslims. Sunni Muslims tend to represent the urban political elite, the military, and the merchant classes. They may be more educated than Shiite Muslims—especially women—and have professional careers.

The majority of Iraq’s population of 24 million are Shiite Muslims, a population with strict religious practices, food prohibitions, and treatment of women. Shiite households are private and segregated according to gender. Allegiance to the family and tribe takes precedence, with fear of bringing shame to the extended family an ongoing concern. Shiite women traditionally dress in black with a full hijab or purdah covering the body and face. In the Iraqi culture, marriage is considered sacred and serves as a bond between families. In Iraq, arranged marriages at 12 and 13 are not uncommon, with preference given to first cousin marriages. When a woman marries, she lives with her husband’s family. Although husbands control the finances, women exert influence over children and take care of the elderly.

Arabic is the universal language of Iraq with greater than 15 dialects spoken, presenting difficulties for US immigrants and health care providers seeking translators.

Religion

The core beliefs of Muslims are based on the religion of Islam, rooted in the Islamic holy book, the Qur’an, and the teachings of the Prophet Muhammad. In contrast to Shiite Muslims, Sunni Muslims represent a less restrictive group, with religious differences based on belief in the rightful successor to Muhammad.

Diet

Both Shiite and Sunni Muslims adhere to halal laws regarding food. Meat must be slaughtered by another Muslim, a process that involves asking God for forgiveness for taking the life of the animal. In the US, Iraqis prefer to buy meat fresh from a farm or from a trusted halal market. Sheep, goat, chicken, beef, or fish are often minced and cooked with onion and garlic. Islam forbids consumption of pork and alcohol. Staple foods include barley, rice, and wheat for bread.

Meals may include soup, salad, eggs, and beans, with a yogurt drink, apricot juice, sweet coffee or tea. Desserts may include almonds, dates, pancakes, and cinnamon pudding. Traditional Muslims do not use ice in drinks or drink cold beverages in the morning. Hot and cold foods are not eaten simultaneously. Since 1990 most Iraqis living in Iraq have been restricted to monthly rations of chicken, flour, sugar, and yeast, limiting their intake of nutrients and vitamins.

Two major Muslim feasts are Eid al-Fitr, celebrated at the end of Ramadan, and Eid al-Adha, celebrated during an annual pilgrimage to Islam’s holiest site, Mecca, in Saudi Arabia. During Ramadan, Muslims fast from sunup to sundown, eating their main meals before dawn and at sunset. Health care providers are advised that medication schedules may need to be adjusted during Ramadan.

Medical Care

Language, cross-cultural communication, unique cultural barriers, and variations in health beliefs can impact clinical outcomes and patient satisfaction. Establishing a relationship with the Iraqi patient and family before care begins and being receptive to family suggestions are essential to building respect and providing effective care. Most Iraqis are very religious and pray at dawn, noon, mid-afternoon, sunset, and in the evening. It is important to be respectful of their religious beliefs.

In the Arab world, smiling and sustained direct eye contact conveys trust, although women avoid eye contact with men. Iraqi patients may nod and smile, but still may not understand medical information. Ask patients to repeat back instructions. Iraqis tend to prefer a gradual, prolonged disclosure of information, rather than a brief explanation of diagnosis and prognosis. Health care providers are advised to explain how they would treat a member of their own family. Although the presence of family during visits is important, family members, especially children, should not to be used as interpreters. Use trained medical interpreters.

If possible, provide a same sex provider and interpreter for intimate exams and sensitive issues. Iraqi women are reluctant to see clinicians who do not speak their language or are not of Arab descent because they fear they may lack sensitivity to their unique cultural and religious needs. Women must be fully clothed when in the presence of a man and may not want to be touched by a man—not even a handshake.

In addition to adopting western medical practices, Iraqis often use home remedies and read the Qur’an for guidance. They believe in staying warm, being well-fed, resting well, and avoiding hot/cold and dry/moist shifts, such as wind and drafts. Good health is perceived as a gift from God, having strength, feeling good, and the absence of pain; however, being overweight also is associated with health and strength.

Health issues specific to Iraqi immigrants include nutritional deficits, typhus, cholera, tuberculosis, and especially post traumatic stress. Many Iraqi refugees are torture victims and have lost family members. They have unique treatment needs. Often the mental and emotional torture they received was so severe they are still struggling to cope with it after many years.

Although Iraqi immigrants respect western medicine, providers, and health education, preventive health is not a priority. They may resist diet change, exercise, regular screenings, and follow-ups.

Death and Dying

In the Arab world, death is feared and never discussed. Rather, Iraqis expect care to be discussed within the context of hope for life. The family may not allow the do-not-resucitate practice, autopsy, or organ donation. At death, the family summons an Imam, an Islamic spiritual guide. The body is wrapped in layers of white cotton and taken to a mosque for final prayers, followed by immediate burial.