Ginseng and Aspirin: Health Care Alternatives for Aging Chinese in New York 9781501721717

Table of contents :
Contents
List of Tables
Preface
Introduction
Part I. Elderly Chinese Immigrants in Flushing
1. Setting the Stage
2. Chinese Americans in the United States - A Population of Diversity
3. The Research Site
4. Fieldwork in Flushing
Part II. Health Care Concepts and Resources
5. Aging, Migration, and Health
6. Traditional Chinese Medicine
7. Health Care in Modern China and Taiwan
8. Health Care Resources in Flushing
Part III. Aging and Health among the Chinese Elderly
9. Concepts of Aging
10. Big and Small Problems
11. Self-Care and Home Remedies
12. Health Care Decisions
13. Using the U.S. Health Care System
14. Conclusion
References
Index

Citation preview

Ginseng and Aspirin

The Anthropology of Contemporary Issues A SERIES EDITED BY

ROGER SANJEK

A full list of titles in the series appears at the end of this book.

Ginseng and Aspirin HEALTH CARE ALTERNATIVES FOR AGING CHINESE IN NEW YORK

Zibin Guo

Cornell University Press Ithaca and London

Copyright© 2000 by Cornell University All rights reserved. Except for brief quotations in a review, this book, or parts thereof, must not be reproduced in any form without permission in writing from the publisher. For information, address Cornell University Press, Sage House, 512 East State Street, Ithaca, New York 14850 First published 2000 by Cornell University Press First printing, Cornell Paperbacks, 2000 Printed in the United States of America Library of Congress Cataloging-in-Publication Data Guo, Zibin, 1961Ginseng and aspirin : health care alternatives for aging Chinese in New York I Zibin Guo. p. em.- (The anthropology of contemporary issues) Includes bibliographical references and index. ISBN 0-8014-3757-1 (cloth)- ISBN 0-8014-8651-3 (pbk.) 1. Minority aged-Health and hygiene-Social aspects-New York (State)-New York. 2. Minority aged-Medical care-Social aspects-New York (State)-New York. 3. Chinese Americans-Medical care--Social aspects-New York (State)New York. 4. Transcultural medical care-New York (State)-New York. I. Title. II. Series. RA448.5.C45 G86 2000 362.1'08995'10747l--dc21 00-024457 Cornell University Press strives to use environmentally responsible suppliers and materials to the fullest extent possible in the publishing of its books. Such materials include vegetable-based, low-VOC inks and acid-free papers that are recycled, totally chlorine-free, or partly composed of nonwood fibers. Books that bear the logo of the FSC (Forest Stewardship Council) use paper taken from forests that have been inspected and certified as meeting the highest standards for environmental and social responsibility. For further information, visit our website at www.cornellpress.cornell.edu. Cloth. printing Paperback printing

10 9 8 7 6 5 4 3 2 10 9 8 7 6 5 4 3 2

1 l

To my parents

Contents

List of Tables ix Preface xi Introduction 1

Elderly Chinese Immigrants in Flushing

PART 1.

1.

2. 3. 4.

Setting the Stage 7 Chinese Americans in the United StatesA Population of Diversity 15 The Research Site 24 Fieldwork in Flushing 33

PART II.

5. 6. 7. 8.

Health Care Concepts and Resources

Aging, Migration, and Health 45 Traditional Chinese Medicine 54 Health Care in Modern China and Taiwan Health Care Resources in Flushing 71

59

[vii]

Contents PART III.

9. 10.

ll. 12. 13. 14.

Aging and Health among the Chinese Elderly

Concepts of Aging 87 Big and Small Problems 95 Self-Care and Home Remedies 113 Health Care Decisions 125 Using the U.S. Health Care System 137 Conclusion 151

References 157 Index 165

[viii]

Tables

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23.

Population change in Flushing 26 Characteristics of surveyed population 29 Characteristics of structured interview participants 39 Classification of natural phenomena according to the Five Elements 56 Examples of Chinese medicine providers 79 Chinese Western-style health providers 80 Common health problems and symptoms 98 Problems related to mental health 99 Problems related to hot-cold imbalance 103 Musculoskeletal problems 104 Cardiovascular diseases 104 Illnesses and symptoms identified as small problems 107 Illnesses identified as big problems 108 Illnesses and symptoms identified as intermediate problems Self-care beliefs ll4 Twenty-five most common home remedies ll6 Thirteen most common herbal remedies ll7 Food items and their specific treatment for health problems Pian fang 120 Health problems to be treated by Western doctors 126 Problems to be treated by traditional Chinese doctors 127 Problems to be treated at home 129 Insurance coverage 135 [ix]

llO

120

Preface Heaven, Earth, and I are living together, and all things and I form an inseparable unity. CIIUANG ZI

For a long time after I returned from field research in Flushing, I often found myself reflecting on the stories told to me by elderly Chinese friends. Quite often I would remember how Mother Zhang shared her secret recipes for dealing with her diabetes and kidney problems; the emotionless face of Mother Chen, who tried to run away three times from a nursing facility to rejoin her only daughter and who eventually ended up in a wheelchair, diagnosed with dementia; the worried face of Mr. Lin, who in the opinion of his doctor had mental problems because he was reluctant to have surgery; the concerned face of Mother Huang, who was suffering from many chronic problems, yet only worried of being a burden to her adult children; and the many happy faces of those elderly who danced and sang in the Chinese senior center. Sharing these stories is not the main purpose of this book. Drawing from ethnographic accounts of how Chinese elderly make sense of their illness experiences and deal with their health problems in an unfamiliar social and cultural environment, I aim to show how abstract culture and cultural belief~ are manifested through problem solving. From the example of Flushing, where an integrated medical market I subsystem has been created to meet the health care needs of its ethnically diverse population, we can also see how immigrants modifY their culture to adapt to a new cultural and social environment. [xi]

Preface This book would not be possible without the support and contributions of many. First of all, I would hke to salute the individuals and Chinese community organizations of Flushing for facilitating my field research. I especially thank all the elderly Chinese who participated in this study for their willingness to share their stories and knowledge. What I learned from them has been not only the impetus for the completion of this book but an important inspiration for my personal growth. I cannot thank Dr. Pertti Pelto enough. He introduced me to the field of medical anthropology ten years ago and guided me through my field research and the completion of this book. I have been constantly inspired and enlightened by his wisdom and his distinctive vision. The significance of his inspiration, I am certain, \Vill continue throughout my career. Dr. Gretel Pelto also has been instrumental to my understanding of anthropology. I also wish to acknowledge the respect and admiration I have for them both personally. I am especially indebted to Dr. Roger Sanjek, whose careful and insightful comments and editing have contributed to the quahty of this book I would also like to thank Ms. Dunja Pelto, who tirelessly edited the first draft. Many thanks also go to my colleagues in the Department of Social Medicine at Harvard Medical School for helping me to shape and develop my understanding of culture and medicine. Many more persons deserve my gratitude. I regret that there is not enough space to thank them all here. But I would hke to acknowledge a few: Dr. Gropper Rena, Crane Cesario, Dr. Pamela Erickson, Dr. Thomas Blank, Dr. Allison Bingham, Karen Schifferdecker, Dr. Marry Gannotti, Dr. James Forsythe, Shirley Wright, Alex Zhou, and Dan and Renu Bostwick. I also owe a special debt of gratitude to the Asian American Health Forum I National Center for Health Statistics, the University of Connecticut Research Foundation, and the National Institute on Aging. Without their generous financial support this book would not have been possible. My largest debt is to my mother, father, brother, and wife. Their love, patience, and understanding have been, and always will be, the source of my courage. ZIBIN Guo Bedford, Massachusetts

[xii]

Ginseng and Aspirin

Introduction

Health care systems reflect the ideological traditions and the social and economic structures of their cultural environment. In researching health care behaviors in different populations, it is important to recognize that a health system constantly changes to meet the needs of society. The structure of the health system will overall reflect the political ideology and economic structure of the culture. On a micro level, people use their cultural knowledge of health practices to make health care choices; the diverse belief systems of health care practitioners also begin to make changes in the overall community health picture. Over time, a community health care system will begin to resemble the community it serves, although these incremental changes may not come in the form of "policy decisions" for the larger health community. This convergence is partly due to the response of the system to the specific needs of its population; it is also due to the diverse experiences and beliefs among the health care practitioners themselves. People bring their perceptions of health and the appropriate way to respond to health concerns into their communities, and frequently the health services which take hold will be those that most resemble the communities' views of "appropriate" health care. The daily news reports on medical research breakthroughs and setbacks have created a climate of dissatisfaction and uneasiness about Western medicine. The increasing interest in so-called alternative therapies such as Chinese traditional medicine is often described as a "challenge to Western medicine," implying a conflict in health ideology that may not in fact exist; on a micro level, individuals often use a combination of health choices, Western and "alternative" concurrently. My research focuses on how elderly Chinese [1]

Introduction

immigrants living in Flushing, a neighborhood in Queens, New York City, make choices about which type of health system to use in different health situations. The growing interest in alternatives to Western medicine is not just a result of dissatisfaction with the American health care and delivery systems; it may be more the result of the diversity of health beliefs within the American population. It is important for health care workers to be aware that the vvide varieties of health beliefs within an immigrant community create a multifaceted view of the established Western health care services within that community. The dynamics of change vvithin a particular health care system is the focus of my research in Flushing's community of elderly Chinese immigrants. In this book I present various attitudes toward health, illness, and aging that these people expressed during my two years of fieldwork among them. I describe in some detail their diverse cultural backgrounds, their shared cultural knowledge of health, and some of the sociopolitical issues that have shaped their views of medicine. This research demonstrates, through the example of one community with its complex population, how a health system changes depending on the way people view and use it. In Chapter 1, I present three case studies: three individual stories of health care experiences within Flushing. I use these studies to introduce the community and to give the reader a sense of the perhaps unfamiliar roles and attitudes that patients and health care providers may take on. It is important to remember that any individual health care situation may only vaguely resemble a "textbook'' view of the wider American health care scene. Chapter 2 briefly describes some of the main points about the history of Chinese immigration to the United States; it illustrates the diversity within the Chinese-American population due to variations in immigration patterns, diverse economic adaptations, and different degrees of acculturation. Chapter 3 provides a brief history of Flushing and a chronology of the migration of Chinese into the area. Chapter 4 describes the methodology of my research in Flushing: how I made my contacts within the community, conducted my interviews, and designed my surveys. In Part II, Chapter 5 discusses medical research findings on the health consequences of migration and resettlement in populations, the role culture plays in defining health and illness, and the way different populations develop shared systems to approach health problems. [2]

Introduction

Chapter 6 briefly describes the origins and philosophy of traditional Chinese medicine. Chapter 7 focuses on the political and social realities that have led to a gradual integration of Western and traditional Chinese medicine in China and Taiwan in the past century. This examination will provide background for the analysis and understanding of health beliefs and health care behaviors of the population studied in Flushing. Chapter 8 details the variety of health care resources in Flushing: allopathic health care providers (hospitals, private practitioners of Western medicine); non-allopathic health care providers (mostly Chinese traditional medicine); and other health care resources (health stores and Chinese markets, bookstores, etc.). In Part III, Chapter 9 describes the attitudes about health and aging expressed by the Chinese elderly people in this study. Chapter 10 examines the way elderly Chinese in Flushing make sense of health problems and how they choose among various health care methods, including Western health care. Chapter 11 discusses the "self-care" methods that elderly Chinese Americans use to maintain health and to treat various health ailments. Chapter 12 describes beliefs about Western medications and Chinese medical remedies as they are understood within this community. Chapter 13 examines perceptions of the American health care system and the difficulties that elderly Chinese Americans have in understanding how best to utilize the system. Chapter 14 provides a summary of this part and elaborates on some of the problems described in the previous chapters regarding health care within the Flushing area. Here I speculate on how this information can be relevant to other American health communities, and I discuss the potential for further integration of the two medical traditions. In order to protect the privacy of the individuals who participated in my research, all names including the names of some organizations have been changed in the text.

[3]

PART I.

Elderly Chinese Immigrants in Flushing

[I] Setting the Stage

The cold, powered by the wind, drove the rush-hour pedestrian traffic even faster than usual. It also made me hungry. At an intersection near the center of Flushing I saw a food stand. I had noticed this stand when I arrived in Flushing a few months before. There was nothing unique about it among the dozen or so one can find. A Chinese food stand always attracts a lot of people. "Try some hot-from-the-oven dumplings-" I decided to make a friend of the owner. "My bao-zi is very good," he said as I bought two meat-stuffed dumplings. He introduced himself as Mr. Si-fan Ding. Mr. Ding looked to be in his sixties, was of medium height and weight, and apparently enjoyed what he was doing. He became very friendly after we found that we came from neighboring provinces in China. I told him that I was a student researching attitudes toward healtl1 care among elderly Chinese immigrants. "Then you probably speak English well. Can you correct my pronunciation?" He told me he had been teaching himself English. I complimented him on his accent and on the dumplings. "I cannot do anything else here," he said, "it's just to make a living." His face became serious when I asked what he had been doing before he came to the United States. After a moment's silence he said, "I was an administrator in the education system back home. No, I am not a professional dumpling maker." I noticed his change in mood and switched to other topics. More people came to buy his dumplings. As I was watching him busily talking to his customers I remembered a statement made by one of my re[7)

Elderly Chinese Immigrants in Flushing

search informants who had been a high-ranking officer in Taiwan before he immigrated here. 'When you walk around Flushing, you will see many elderly people. They do not seem extraordinary. They look like typical old people. But if you stop them and ask what they did before, you will be surprised. Many of them were fang yun ren wu (the man of the time). Now, they are nobody." I understood his point. These people did not expect that their lives would take such a tum when they moved into their last years. Like Mr. Ding, for example. How does he feel about this change in career? Mr. Ding laughed frequently as we talked, and especially loudly when he told me he was surprised that he could be so accomplished at making dumplings. I had another appointment so I thanked him and crossed the street. When I glanced back, I saw he was still busy talking to his customers. A month later I joined the rush-hour crowd passing where his stand had been, but he had disappeared. I learned from Mother Zhang at the senior center that he had become ill. He was surprised when I telephoned him-I was just someone he had met on the street. "I could not keep my stand any more because of my health problems. An ulcer. It has been getting steadily worse. There is no way, no way." He sounded depressed. When I asked if I could visit he sounded glad at first; then he became hesitant. "I would love to talk to you, but please do not laugh when you come here. Our apartment is very small and a mess." Mr. and Mrs. Ding greeted me warmly, as if I was an old friend from China. Mrs. Ding seemed much younger than her husband. In China she had been a teacher in a middle school. She had the character of many women from Southern China: sweet, hospitable, and very skilled in hosting guests. Mr. Ding made more apologies to me for the "mess" in their home. Mrs. Ding didn't say anything but smiled with an embarrassed expression and cleared off a small table next to their bed. Their home is a one-room studio in a medium-sized older house. One curtain divides the room into two. The whole apartment is full of things, but all is very well organized. The room is so tiny that they have to put chairs and other things on top of each other to make room. Modem paintings, piCtures, and postcards are neatly arranged on the walls, and they give this small and crowded home a lively and friendly feeling. Later I learned that Mr. Ding is an artist. Four years ago they immigrated to this country under his brother's sponsorship. At sixty-one years of age, he has found he has no place in this "land [8]

Setting the Stage

of opportunity." "We had to do something to save some money for our children's arrival." So they decided to get a license and set up a food stand at the comer of Main Street and 41st Street in Flushing. Every day Mrs. Ding prepared the dumplings at home and Mr. Ding sold them on the street. Mr. Ding's face had aged since I last saw him. He looked as if he had been thinking a lot. To treat his ulcer he had been relying on home remedies and other medications sent from China by his relatives, but he said he could not stand in the streets anymore. "Standing in the middle of the streets in the winter is a hard thing." However, they still sell dumplings. They make the dumplings at home and sell them to several local Chinese sewing factories during the lunch hour. "We have to do this, because we need the money to pay the rent at least." Their apartment costs over five hundred dollars a month. "We never expected this. If people back home knew it, they would laugh their teeth off," Mrs. Ding smiled with bitterness. "We can make a few hundred a month selling dumplings. We also get two hundred dollars in food stamps each month." Mr. Ding looked embarrassed when he said that. "It is just for surviving, there is no other better way," he said, shaking his head. 'We are suffering here, I want to go back to enjoying life. Hail" Mrs. Ding sighed deeply. Mr. and Mrs. Ding came to the United States in order to bring over their adult children, who have families of their own. According to current immigration law, one of the parents must first receive U.S. citizenship. "But what are they going to do here?" Mrs. Ding asked me. "Why don't you tell them the truth?" I said. "They would not believe us, we have told them many times. You know what they said? They said: 'If so, why do so many people go to America but so few come back?' " At the end of the visit, I learned that a doctor had told Mr. Ding recently that he needs to see a psychiatrist for his depression and for stress. His health condition has continued to deteriorate.

The Dragon Ginseng Herb Company The main entrance to Dragon Ginseng Herb Company is a glass door protected by a homemade iron door. When I rang the bell, two men and a woman seated inside looked up. The door was opened electronically. [9]

Elderly Chinese Immigrants in Flushing

Large herb cabinets took up most of two walls in the waiting room. Glass counters stood in front of them, in which various Chinese herbal drugs and other products, such as a "Tai-chi ball" and a "health belt," were neatly displayed. Several Chinese calligraphies including a painting of a Chinese fortune God hung on the walls. The woman asked how she could be of assistance; I said I was there to gather information for a research project. One of the men turned back to whatever he was doing at his desk The otl1er man was quite friendly. "Sit down, please." I sat down next to a little table by the door and he offered me a cup of tea. A big tea maker stood against the wall, with a sign above it-"Ginseng tea." The room was filled with the smell of moxa. I noticed smoke drifting out through a door behind the counter. After I toldhim I was from Nanjing, the man smiled and said, "I am from Hongzhou" (a city not far from Nanjing). He is Dr. Rong. Dr. Rong said he had been a successful bone doctor in Hangzhou, trained in both Chinese and Western medicine. He came to Flushing a year ago. I was able to interview Dr. Rong while he was treating a male patient in his mid-twenties who had a serious back problem. Dr. Rong said that after coming to him four times for treatment the young men's back had improved significantly. The young man walked out of the treatment room, set his phone and car keys on the bench, and started to talk to Dr. Rong. Dr. Rong asked him to place his feet together while standing there. He did, and he did not seem to have any problem at all. "You see," Dr. Rong turned to me and smiled. "He is getting better now." I had a brief conversation with the young man before he left. He spoke very fluent English, although I did not get the impression he was Americanborn. He told me that he had hurt his back about a year ago and had seen many doctors, inclucling two chiropractors. But the pain continued to aggravate him. "I could hardly walk straight," he said. He decided to see a doctor of Chinese medicine after his regular American doctor told him that the only solution for him would be an operation. "I am too young to have a back operation," he told me. "I am lucky to have found Dr. Rong and did not have to take the other doctor's advice." ''What is the big difference between practicing Chinese medicine in China and here?" I asked Dr. Rong after his patient left. "One of the big problems here is that the American government prohibits us from importing and using the remedies made from animals. In Chinese [10]

Setting the Stage

medicine, some remedies, such as animal bones, insects, and poisonous snakes, are useful in treating many serious diseases. You cannot use them here. They do not understand Chinese medicine. They want to protect the animals' rights here, so what can you do?" Dr. Rong said this with a bit of emotion. "So, these animal remedies are important?" I asked. "Of course!" Dr. Rong replied without hesitation. "Herbs are good for many problems, but they are not for everything." "I heard that sometimes people come here with their own prescriptions. Where do they get them?" "Oh, they copy them from books." Dr. Rong found I was still looking at him, so he explained further. "Some people, especially the elderly who came here not too long ago, thought it would cost them a lot to get a prescription from a doctor, so they copied the prescriptions from books." "Can you give me an approximate percentage of the patients you see who are elderly?" "Many, many," Dr. Rong replied. 'T d say more than half." "Why do they come to see you?" 'There are many reasons." Dr. Rong seemed to get emotional again. "The main reason is the difficulty of understanding. Most Chinese elderly do not speak English, so they cannot communicate with American doctors. But the communication problem is not always a language one. I'll give you an example: An elderly patient told me that she visited a Western doctor and complained that she had a problem with ringing in her head. In Chinese medicine this is a recognized type of problem. But, you know what the Western doctor told her? He said, 'Come on, there is no such thing. You have a ringing in your ear.' The old lady told that doctor repeatedly that it was not ear ringing but head ringing. But he never believed her." ''Why does the head make a ringing noise?" I asked. "In Chinese medicine we believe that when some of the blood vessels in your head begin to have sclerosis, you will feel 'ringings' in your head. But Western medicine does not have this symptom described for sclerosis. It is very difficult to find a common language between Chinese patients and Western doctors." The second reason patients came to him, Dr. Rong explained, is that he is cheaper. ''We only charge between $30 and $40." "Anything else?" I asked. Dr. Rong thought for a second and then said: "Qing qie gan" (closeness). This term means the feeling of being in a place like home. [11]

Elderly Chinese Immigrants in Flushing

A Very Nice Man Dr. Hui is a practitioner of Western medicine. His office is located in a sixstory apartment building. Like many other apartment buildings in Flushing, this building is built close to the sidewalk, with an arched, culvert-like fac;ade of dark-colored glass. Above the arched door a large sign in English reads: Medical Building. The resident directory indicates there is nothing but medical offices in the whole building. There were about seven people in the waiting room when I walked into Dr. Hui's office. I sat down and looked around. It is a pleasant, clean room, a typical doctor's office. The only thing that this waiting room lacked was a plant. On my left were two elderly white American ladies. On my right, an older Chinese woman sat quietly. I decided to start a conversation with the two American ladies. "Are you sisters?" I thought this was probably a good way to begin. "Yes, we are." They told me that Dr. Hui is a wonderful doctor. "\Ve were introduced by our previous doctor. He is also Chinese. He was a doll. We met him when he had just started. He was so patient, so nice to us. I didn't feel as if I was talking to a doctor when I was with him. He spoke just like he was talking to someone of his own family. We cried when he left this area. He told us, 'Do not worry, I will refer you to a good doctor.' That is why we came here." These two ladies lived not far from this office. They had been seeing Dr. Hui for a couple of years now. "Why didn't you see a Western doctor?" I asked. "Dr. Hui treats us so well. He will give out his drugs for free to help you out if you do not have the money. How could we leave this kind of doctor?" They sounded like they might once have thought about switching doctors but did not, for "he is too good to leave.'' Many people told me that Dr. Hui was a good doctor. "But he is a very ambitious person," one informant said. "He is not a true doctor, he is a politician. He spends less of his time on his medical practice than on other social activities. He gives political speeches at the senior center.'' It sounded like Dr. Hui was a social activist in this community. "I heard he is a pretty good cardiologist." I said to this informant, to see what response she would give. "I would not go to see him if I had a heart problem," she replied. This surprised me indeed. Dr. Hui does not practice Western medicine alone. He also uses acupuncture to treat his patients. He uses Chinese medicine for many things. [12]

Setting the Stage

With mixed impressions, I went over to his office for the interview. He had asked me to come to his office at 6 P.M., but we did not talk until close to 7:30. "It is late for you. You must be very tired now, I do not mind coming back again." I offered. "No, that is okay since we are not going to talk too long, right?" Immediately, I sensed that he was a skilled person socially. I asked him to give me a healtb picture of his clientele. "High blood pressure, heart disease, arthritis, stomach and intestinal diseases, then diabetes, hepatitis, and various cancers are the most prevalent health problems among elderly Chinese in this community. For example, many people love pork, especially the fatty part. And tbey like to cook their foods with various strong-tasting ingredients. Some of them will cause high blood pressure if consumed frequently." According to Dr. Hui, other factors such as lack of exercise, stress, and problems within the family also increased tbe likelihood of high blood pressure and other health problems. "Is it true that the Chinese, especially elderly Chinese, would not come to see a doctor unless they had no choice at all?" I asked. He agreed. "Money sometimes plays a role in tbis, but it is not tbe only factor." He indicated that his American patients have completely different patterns of spending money on doctors than the Chinese. "Americans think tbat money should not be a concern when it comes to health. They think it is a must expense. The Chinese tbink of this issue a little differently; it is an extra. The Medicare system is really doing a good job on this issue. So most elderly patients who come to see me are those who have Medicare benefits. Without any insurance, nobody would come here unless it was an emergency. Many people have said tbat the new immigrants, especially tbose from Mainland China, are very careful about their expenditures for health care. Many people think money is the essential factor. So they think that people from Mainland China are usually poorer. How true is tbis? "It may be a factor, but I don't think it is a determining one. People from Mainland China do think tbat medical expenses are very high in the United States, but it does not mean tbat they do not have the money to pay for it. Being able to pay for it and not wanting to spend the money on it are different things. People from Mainland China are used to tbe socialist medical care system. Most of them had not spent their own money on tbeir health care for many years; and when tbey did, the amount they had to pay was nothing compared to U.S. medical expenses." I asked, 'What do you think of Chinese medicine?" [13]

Elderly Chinese Immigrants in Flushing

Dr. Hui replied that one problem is the lack of scientific method. "Chinese medicine has various theories of herbs and other remedies in relation to treating different diseases. Recently, Western scientists have discovered through experiments that a material extracted from squirrels can kill cancer cells. Well, many people say: 'It is Chinese medicine.' You know the difference? The difference is that they are scientific and we are not."

[14)

[2] Chinese Americans in the United StatesA Population of Diversity

Chinese Americans have become the largest subgroup of Asians in the United States. In 1990 they numbered 1,645,472, which was 0.7 percent of the U.S. population. The Chinese population includes old settlers who came here early in this century; second-, third-, fourth-, and fifth-generation Chinese Americans; new immigrants; runaway sailors; students; and Southeast Asian refugees of Chinese ancestors. There is also a small flow of Chinese relocating from Caribbean and Latin American countries. Chinese Americans are indeed a heterogeneous population.

Nineteenth- and Early Twentieth-Century Arrivals

San Francisco, California, 1848: "The American brig Eagle arrived here from Canton, China on the 2nd of February, 1848, with two Chinamen and a Chinawoman, who were looked upon as curiosities by some of the growing town of San Francisco, who had never seen people of that nationality before" (Knoll1982:9). Although individual Chinese were reported in Pennsylvania as early as 1785, significant migration from China began with the California gold rush of 1849 (Daniels 1988:9). During that period, hundreds of Chinese men, most of them farmers from Guangdong Province, left for California to make their fortunes. Most had planned originally to return to China some day. When the first group of these sojourners arrived at the West Coast of the United States to respond to the need for laborers in mining and railroad construction, "they were indeed welcomed, even praised, and were considered almost indispensable by white Americans" (Chen 1992:1.3). This, [15]

Elderly Chinese Immigrants in Flushing

of course, was in part because the Chinese laborers were willing to take the worst jobs and accept the lowest wages. A contributor to Scribner~s Monthly wrote, "If for no other purpose than the breaking up of the incipient steps toward labor combinations and 'Trade Unions' ... the advent of Chinese labor should be hailed with warm welcome ... because they could be the final solution to the labor problem in America" (Norton 1871). Despite the near-slave labor conditions, the Chinese still often managed to send some of their earnings back to their home villages. Because of the need for Chinese laborers on the West Coast and the potential for economic gains for the Chinese, many of these immigrants decided to settle dovvn. As a result, the first Chinatown was formed, in San Francisco. Conflicts soon developed between Chinese workers and other European immigrants. During the 1870s, when California was experiencing an economic depression, the Chinese workers who had once been praised by white Americans were now attacked and became the rationale for hatred. 'White workers attacked them because they accepted the wages forced on them" (Chen 1992:4). Legislators soon joined the anti-Chinese movement, including many of those who had earlier praised Chinese contributions to American society. In 1876, the Democratic Party staged a special anti-Chinese rally that attracted a crowd of twenty-five thousand people (Chen 1980:136). In calling for Chinese exclusion, the San Francisco Alta warned, "Every reason that exists against the toleration of free Blacks in Illinois may be argued against the Chinese that are here" (Takaki 1989:101). As a result of these anti-Chinese movements and riots in West Coast cities, many Chinese were killed and others were forced to move out of their communities. One result of this turbulent situation was Chinese migration to the east and other parts of the United States. In 1879, after the Henry Grimm play The Chinese Must Go was staged in San Francisco, the call for legislative measures against Chinese immigrants and immigration reached its highest point. In the same year, President Rutherford Hayes called Chinese immigration "the present invasion," stating that it was "pernicious and should be discouraged. Our experience in dealing with weaker races-the Negroes and Indians ... -is not encouraging .... I would consider with favor any suitable measures to discourage the Chinese from coming to our shores" (Miller 1969:190). On May 6, 1882, President Chester A. Arthur signed the first of a series of Chinese exclusion acts into law. [16]

Chinese Americans in the United States

In 1888 the Chinese Exclusion Act was broadened to include "all persons of the Chinese race," and no Chinese was permitted to enter the United States, except Chinese officials, teachers, students, and merchants (Takaki 1989:111). In 1924 Congress passed new legislation, which forbade "the United States citizens of Chinese ancestry to bring in alien Chinese wives" (Daniels 1988:98). As the result of these Chinese Exclusion Acts, Chinese immigration to the United States was halted, and for more than sixty years the ChineseAmerican population declined. In 1880 the census showed a total of 105,465 Chinese living in the United States; by 1940 the number dropped to 77,504. Because the 1924 legislation made it impossible for Chinese immigrants to bring their wives into the United States, a "bachelor society" was created.

The New Waves of Chinese Immigration Because of the participation of Chinese-American soldiers in World War II, in 1943 the United States Congress lifted the Chinese Exclusion Act, which had been used to restrict Chinese immigration to the United States, and issued the War Brides Act. However, the next significant legislative change that relaxed Chinese immigration restrictions did not come until 1965, when Congress finally scrapped the old national origins legislation and passed a new law allowing more Chinese and their family members to immigrate to the United States. This new Immigration Act repealed the old quota of 105 Chinese per year and allowed up to 20,000 per year to immigrate (Chen 1992:6). Since then, thousands of Chinese from Taiwan, Hong Kong, and other parts of the world have come to the United States to join members of their families, work, and receive higher education. Some of the new arrivals were political refugees. Especially since the middle 1970s, as a result of the normalization of diplomatic relations between the United States and the People's Republic of China in 1979, the population of Chinese immigrants to the United States has increased rapidly, from 117,140 in 1950 to 1,645,472 in 1990. Also over the last two decades, many Chinese have been migrating to the United States from Hong Kong to join their American family members as the 1997 deadline for Hong Kong to revert to Mainland China's control was approaching. [17]

Elderly Chinese Immigrants in Flushing

The new wave of Chinese immigration has brought new features to the intracultural diversification of the Chinese-American population. The earlier migrants had been primarily young people from rural areas of southern China. Almost all were manual laborers such as miners and railroad construction workers; some were imported to southern plantations to replace slaves after slavery was abolished. Later, as a result of anti-Chinese movements, they "were forced into undesirable, noncompetitive jobs, particularly in personal services" (Chen 1992:8), including Chinese restaurants, grocery stores, gift shops, and laundries, among others. Among the newer waves of Chinese immigrants, there are large numbers of individuals who come from more modem Chinese urban settings, including Hong Kong and Mainland China. Their competitive educational backgrounds and entrepreneurial skills prepared them for more professional occupations in the United States. A striking change in the occupational distribution of the Chinese-American population occurred between 1870 and 1970. In 1870, 41 percent of Chinese Americans were engaged in personal services, 37 percent were engaged in mining, 8 percent were engaged in manufacturing, and 8 percent in agriculture. In 1970 the same four categories of occupation showed employment levels of only 7 percent in personal services, 0.2 percent in mining, 17 percent in manufacturing, and 1 percent in agriculture. In 1970 the three leading occupations were wholesale and retail trade (35 percent), professional services (21 percent), and manufacturing (17 percent) (King and Locke 1988). Many of these Chinese Americans have not only achieved considerable economic success but also formed an elite class and are actively participating in the development of politics, culture, education, science technology, medicine, and business in the United States (Huang 1989; Mei 1989).

Patterns of Settlement "Most Americans have the impression that the Chinese in the United States live in Chinatowns, isolated from the broader community" (Chen 1992:3). Because of cultural differences, language barriers, persecutions, and economic and political isolation, the earlier groups of Chinese formed their own enclaves in various cities. Especially after the series of anti-Chinese American movements, Chinese Americans became more isolated from the cultures outside their communities, and they developed greater eco[18]

Chinese Americans in the United States

nomic and social self-sufficiency. Hierarchical social structures developed which regulated and controlled the daily activities of Chinatowns and their residents. For example, the district associations (tongs), clan associations, and Chinese fraternal associations provided jobs and loans, settled disputes between members, and "protect[ed] Chinatown against American racism" (Kinkead 1991:56). The CCBA (Consolidated Chinese Benevolent Association) head functioned as the "mayor" of the Chinatown community, exerting influence in life from politics to education. To many Chinese, especially the second and third generations, and for most of the newcomers, the CCBA was considered a "retrograde organization, because its leaders advise[ d) Chinese to preserve their culture, and not assimilate" (Kinkead 1991:63). By the 1960s, however, the rival Chinese-American Planning Council in New York City and other similar social service groups offered more sophisticated services, such as job training, legal advice, health care, day care, and translation services. Before 1970 these organizations were under the control of the CCBA. Many Chinese in the newer waves of immigration of the 1980s and 1990s did not live in the existing Chinatowns. Instead, most of the new arrivals from Taiwan, Mainland China, and to a lesser extent Southeast Asia have developed new Chinese-American settlement patterns and subcommunities. In Chinatown No More, Hsiang-shui Chen shows that the new Chinese immigrants in Queens do not live in isolated Chinese communities and instead are scattered and mixed among other ethnic groups. According to Chen, the differences in culture, education, economic expectations, and language among these newcomers are major factors in their choice of more dispersed living (Chen 1992). Chinatowns were established by the earlier Chinese immigrants who came from rural areas of southern China with cultural traditions harking back to the nineteenth century. A large part of the culture found in traditional Chinatowns reflects the social structure of nineteenth century Mainland Chinese cities (Crissman 1967). Because of the experiences endured in various anti-Chinese movements, the spirit of Chinatown remains that of self-sufficiency and isolation. However, the post-1965 immigrants are indi'riduals from modern Chinese urban settings. Many have been educated in the United States or have come from higher classes of Chinese society. Chen notes that the new immigrants have varied educational backgrounds. After the 1960s many college students came from Taiwan and Hong Kong for advanced studies in the United States and remained here. The well-publicized "brain drain" phenomenon, the exit of highly skilled persons, marked immi[19]

Elderly Chinese Immigrants in Flushing

gration from Taiwan at this time. Not until1979 did the Taiwanese government permit its people to apply for tourist passports, and people who could afford to could now leave; many changed their tourist visa status and stayed in the United States (Chen 1992:6). The "brain drain" also applies to immigrants from Mainland China. Since the middle 1970s, many scholars and students have come to the United States and remained in the country. Even among those who came more recently from Mainland China to join family members, there is a large number of highly skilled individuals. These individuals of all ages come expecting to use their professional skills to make a living. Unlike the earlier immigrants who mostly came from the rural area of Guangdong Province and who represent a homogeneous ethnic group, the new immigrants also came from different parts of China, and speak Mandarin, Taiwanese, and other dialects in addition to Cantonese. These differences make it difficult for the new immigrants to settle in the already crowded, Cantonesedominated Chinatowns.

Elderly Chinese Americans In this study, the designation "early immigrants" refers to three groups of elderly Chinese who immigrated to the United States before 1965. First, sons and "paper sons" are mostly the second-generation descendants of old Chinese immigrants. Because of the prohibition against bringing wives or children into the United States, most young Chinese immigrants formed a "bachelor society." However, American law permitted those who were born in the United States to come and go as they pleased and to bring back children fathered abroad. The 1906 San Francisco earthquake brought luck to many first-generation Chinese immigrants because the immigration building, which housed their immigration records, burned down. Following that, many Chinese obtained forged certificates declaring they were born in this country and claiming they had children outside the United States. In this way, hundreds of Chinese children came to the United States under their alleged fathers' sponsorship, and were known as "paper sons." Second, in 1945 the United States lifted the legislation restricting Chinese women from entering the United States and passed the War Brides Act. Thousands of wives and hundreds of babies and children subsequently arrived from villages of southern China and Hong Kong. [20]

Chinese Americans in the United States

The common characteristic of these first two subgroups is that most came from peasant families, had little education, and worked in restaurants, groceries, laundries, and other unskilled jobs in or near Chinatowns. They tried to retain their cultural traditions, and many elderly still speak only their native tongue. Because of their life experiences and living arrangements, they often do not trust the "white society." They have learned to resist being "Westernized." The early immigrants of a third subgroup came to the United States for education or other specific missions and were not able to return to their homeland because of World War II and the Chinese Revolution. Some came with their families; others married people of similar backgrounds after completing their education. Most were highly educated from wealthy urban families, and tlwy were more Westernized in their lifestyle and outlook A large number lived and worked outside the confines of Chinatown at universities and research centers or as engineers, accountants, architects, doctors, and other professionals. Compared with the early immigrants who mainly arrived as young adults, the new immigrants who have come since the middle 1970s include a large proportion who are elderly. According to Chen (1992:7), of the total number of Chinese immigrants each year, 30 percent are over fifty. Most of these individuals have reached retirement before they arrive in the United States. A majority of the Taiwanese immigrants are not originally from Taiwan. They are Mandarin-speaking Mainland Chinese who went to Taiwan when Jiang Je Shi (Chiang Kai-shek) and the defeated Guomindang leaders and their more affluent and influential followers fled from the Communist takeover. Although the Guomindang people or Mainlanders, as they are called in Taiwan, assumed political and social dominance there, they were a minority population and were resented by the native Taiwanese. Consequently, many Mainlanders were never completely comfortable in Taiwan. In addition to the animosity of the local population, there was for a long time the threat of an invasion from the mainland. The United States, of course, sought to protect Taiwan from invasion as part of the "containment of Communism." In the middle of the 1970s, as better relations developed between the United States and the People's Republic of China, and especially after these two nations officially normalized their relations in 1979, many Mainlanders began to leave Taiwan and find their way to the United States. A second movement of Mainlander immigration from Taiwan to the United States began in the late 1980s as the independence movement among native Taiwanese grew. [21]

Elderly Chinese Immigrants in Flushing

Unlike the early immigrants who have aged in the United States, most of these recent elderly arrivals came to the States after they had reached retirement age. Some of them came to the United States as business investors; others came to join adult children who had received education and remained in the United States; and still others arrived under the sponsorship of other relatives who had settled in the United States in previous decades. Due to political tension and ideological conflict between the United States and the People's Republic of China, only small numbers of immigrants came to America from the People's Republic of China before the 1980s. The thawing of the cold war tensions, and especially the resumption of diplomatic and trade relations between the United States and the People's Republic of China, resulted in the relaxation of immigration restrictions. This allowed considerable numbers of Mainland Chinese to come to America, particularly to join younger relatives. These immigrants come from various social, cultural, political, and educational backgrounds; among them are farmers, factory workers, teachers, engineers, professors, doctors, artists, and musicians. Their motivations to immigrate to the United States were diverse. A few decided to leave everything behind to join aged parents who left Mainland China before the Communist takeover. Some came to join children or other family members. Many came to open channels for education and work opportunities in the United States for their children. In terms of health, the elderly among the new Chinese migration differ in a number of respects from Chinese elderly who immigrated to this country in the nineteenth and early twentieth centuries. l. Their cultural beliefs concerning health, illness, and curing reflect an ex-

tensive modem history of the integration of traditional Chinese health beliefs and practices with knowledge and use of Western medicine. 2. They come from situations in which the health care system has, on the whole, been fairly successful in meeting their health care needs. 3. They have a complex knowledge of illnesses and remedies, as well as elaborate modes of home treatment; they have, in fact, a far more substantial inventory of home remedies than almost any ethnic group in North America. 4. This population includes considerable numbers of persons skilled in traditional medical practices as well as persons trained in the practice of Western medicine, including many trained in both Western and Chinese traditional medical treatment. [22]

Chinese Americans in the United States

The history and the development of Chinese immigration to the United States demonstrates that a great diversity in language, culture, and socioeconomic levels has resulted from the various immigration patterns in different decades, different economic adaptations, and varying degrees of acculturation. The intracultural variations in the elderly population are especially important in relation to health care. The differences in education, occupation, language, and financial resources-and, particularly, the diverse experiences of gro'.'.ing old in different social, political, and historical contexts-affect all aspects of health care beliefs and patterns of utilization of services.

[23]

[3] The Research Site

Flushing is situated in the northeast section of Queens in New York City. In 1636 the Native American Matinecock sold it to the Dutch. English settlers came later and developed the area for farming and then agricultural nurseries. By 1840 the nursery industry reached its highest peak and dominated much of the twelve-square-mile area (Chen 1992). The nineteenth and early twentieth centuries brought waves of German, Irish, Jewish, and Italian immigrants. Over time, downtown Flushing became a retailing and transportation hub, serving the predominantly lowermiddle-class neighborhoods, which had spread out from its center (Wysocki 1991). Starting in the 1960s and early 1970s, however, it experienced a significant period of economic decline, and many of the earlier residents, predominately white, middle-class Americans, began to move out. During the 1970s central Flushing became an economically depressed area. Since then, however, the arrival of a large number of Asians has transformed the area physically, culturally, and economically (Smith 1995). The history of Asian immigrants in Flushing may be traced back to 1946, when the United Nations office briefly operated in Flushing. Later, small numbers of Asians moved to Flushing after the World Fair in 1964-65, which was held at nearby Flushing Meadows-Corona Park (Smith 1995). However, not until the end of 1970s did large number of Chinese, particularly from Taiwan, begin to move to Flushing. Chinese restaurants, grocery stores, and other businesses were established. Immigrants from South Korea and the Indian subcontinent also moved into the area. Unlike earlier Asian immigrants, many of these new arrivals were from the middle class, and some arrived with considerable financial assets. The arrival of these new set[24]

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tlers changed Flushing dramatically, awakening what one local bank executive called a "sleeping dog."' By 1990 the community was a rapidly developing center of commercial activity, with a large number of immigrants from Taiwan, Mainland China, Korea, India, and other countries. Flushing now teems with renewed energy and enterprise, especially in the center, where on a typical weekday 100,000 people use the IRT subway, 76,000 use the twenty-three bus lines, and 75,000 vehicles pass through the downtown area. Entire streets of shops have signs in Chinese and Korean. Teller machines are programmed ·with Chinese and Korean instructions. Recently AT&T established a new communication center in downtown Flushing targeted at the Chinese, Korean, and Indian populations. The Asian boom also inspired real estate development. Most older buildings in central Flushing were three stories tall, but many ten- and twelve-story commercial and residential buildings are now located in the area. The continued growth of the middle-income Asian population has increased real estate values. In 1990 the Wall Street Journal reported that office rents soared above $30 a square foot, making them comparable to rates on Wall Street. Despite the high prices, the new Asian population has continued to grow resulting in more development. Daily, and especially on weekends, thousands of Asians as well as others from all over the New York area drive or ride the "Orient Express" (subway No. 7 connecting Manhattan to downtown Flushing). They come to shop, eat, or do business. Today it is an attractive commercial alternative to Manhattan's more densely populated Chinatown. As the Chinese population has been rapidly increasing, the development of Chinese economic enterprise has also been expanding dramatically. In 1991 the Wall Street Journal reported that there were nearly six hundred Chinese firms in Flushing (Wysocki 1991). In an interview witl1 a staff member of the Flushing Chinese Business Association in 1993, I learned that there were 1,300 Chinese businesses registered with this association as well as an additional 450 Chinese restaurants. These enterprises, which employ many local Chinese residents, include banks, real estate agencies, electronics stores, clothing stores, knitting factories, newspaper publishers, garn1ent factories, video rental shops, printing factories, computer shops, gift shops, jewelry stores, hardware stores, large modem grocery stores, liquor stores, film developing laboratories, construction companies, automobile dealerships and garages, driving schools, dance studios, accountant offices, attor1 Richard Gelman, president of National Bank of New York City, used the term "sleeping dog" to refer to old Flushing when talking to a reporter from the Wall Street ]oumal (Wysocki 1991).

[25]

Elderly Chinese Immigrants in Flushing

ney offices, physicians, dentists, herbal stores, tea stores, and pharmacies. There are also several Chinese-owned banks in Flushing, including Asia Bank, Chinese American Bank, Greater Eastern Bank, Hong Kong Bank, Golden City Bank, and Bank of China. Taiwanese immigrants are the dominant group in enterprises ranging from real estate to large-scale business establishments. The development of Chinese enterprise in Flushing has provided a magnet for the Chinese-American consumers who live nearby and in surrounding Queens and Long Island communities. One informant remarked, "When I first came to Flushing twenty years ago, there were only a few Chinese restaurants. Every time I wanted Chinese food or Chinese vegetables, I had to go to Chinatown. Now I almost don't have to cook anymore." According to U.S. census figures (City of New York 1991), the population of Flushing grew from 204,785 in 1980 to 221,763 in 1990. As the total increased by 8 percent during this 10-year period, the white population decreased by 17 percent, from 156,282 to 129,172. At the same time the Chinese population increased 204 percent, from 6,700 in 1980 to 20,352 in 1990, and the total Asian population was 47,264 (see Table 1). Many believe that these figures are inaccurate because the Asian population was undercounted. According to a New York Times report (April 12, 1990), the Asian population in Flushing may actually have been as high as 80,000 in 1990. Another report (January 14, 1992) estimated the total Asian population of Flushing at 140,000. Large-scale Chinese immigration to Flushing started in 1974. Due to the economic depression in New York City at that time, many companies in Flushing either closed their businesses or moved elsewhere. New arrivals, especially those from Taiwan with large sums of cash, rushed into Flushing Table 1. Population change in Flushing (total population by ethnicity) 1980

Ethnicity White Hispanic Black Chinese Asian Indian Korean Filipino Total

[26]

N 156,282 20,045 9,580 6,700 4,592 3,794 919 204,785

1990 %

76.3 9.8 4.7 3.3 2.2 1.9 0.4 100

N 129,172 33,299 9,352 20,352 7,200 17,803 1,909 221,763

%

58.2 15.0 4.2 9.2 3.2 8.0 0.9 100

The Research Site

to make investments. At the same time, a large number of Korean immigrants migrated to Flushing. Some overseas companies, particularly from Taiwan, Hong Kong, and Korea, began investing in Flushing "as an outlet for the vast foreign exchange surplus that has been amassed as a result of the phenomenal success in terms of economic development" (Smith 1995:72). 'Witl1in two years, things began to change, the economy started to recover" (Chen 1992). Many Chinese who had migrated to Manhattan and other parts of New York City, particularly those who speak Mandarin, now moved to Flushing. Mr. Yang, an early Chinese immigrant from Taiwan, said, I was living not far from Chinatown (in Manhattan) then, when I heard about Flushing. At that time I was working for an insurance company in Manhattan. After we heard [about] it we moved here immediately. At first, we were really glad we made the decision. vVe bought a house here, and also made some small investments in real estate. We liked the community since there are many people speaking "Guo Yu" [Mandarin]. It is not too much trouble at all to get to work, the No. 7 train only takes forty minutes to get into Manhattan. Especially at that time there were no high buildings and very few people [he laughed at this point] ... but, as you can see by yourself, now it is very different. People call it "the second Chinatown." But I still like it. A large number of young people came to the United States from both Mainland China and Taiwan to receive graduate education in the 1980s. Some of them, after completing their studies, found Flushing to be a good place to start their careers. During fieldwork I met many of these individuals, who were now operating various small businesses (computer shops, real estate agencies, music schools, consulting firms). At the Chinese-American Radio Station in Flushing, for example, almost half of the staff members were former university graduate students. Many who had jobs in other areas of New York City find living in Flushing comfortable because it is a middleclass community, and they can communicate with people in their own language and dine at home-style restaurants. Chinese in Flushing are a diverse population. The largest subgroup is made up of immigrants from Taiwan; the next largest, from Mainland China. Walking on the streets of Flushing, one can hear not only Taiwaneseaccented "Guo Yu" (Mandarin) but also the Beijing, Shanghai, Cantonese, and other dialects of Chinese. Unlike the social organizations of Chinatowns formed a hundred years ago and based on either kinship or district of origin, the members of Flushing [27]

Elderly Chinese Immigrants in Flushing

Chinese organizations are from diverse origins, speak distinct dialects, and have different economic and political backgrounds. In contrast to most associations found in Chinatowns, these voluntary associations not only monitor and coordinate the development and activities of the Chinese community, they also function as bridges between Chinese immigrants and their non-Chinese neighbors (Chen 1992:183). Board members (both men and women) in these associations, especially the business and political associations, are professionals who have obtained a high level of education. Although in principle each of these associations acts independently, they often collaborate on community activities. A majority of board members, especially in business and political associations, are immigrants from Taiwan. Religious establishments are among the fastest growing Chinese organizations in Flushing. There were six Buddhist temples and at least fifteen Chinese Christian churches. Chinese medical professionals are also often invited to give lectures. During my fieldwork I participated in several health education seminars and free physical examinations organized by these houses of worship, including seminars on how to prevent cancer, heart disease, and diabetes. Most of the speakers were Chinese physicians in the community.

Chinese Elderly in Flushing

In 1993 there were at least three thousand elderly Chinese in this community. The Chinese elderly population is heterogeneous, and its diversity is the result of variations in immigration patterns, economic adaptations, and degrees of acculturation among the subgroups. Immigrants from Taiwan make up the largest subgroup of Chinese elderly in Flushing; most of these individuals have immigrated during the 1980s and 1990s. The majority of the elderly Taiwanese immigrants had left Mainland China at the end of the 1940s after the civil war between the Communists and the Guomindang "nationalists." Because of political circumstances at that time, many individuals who were able to move from the mainland to Taiwan were associated with elite elements of the defeated Guomindang government. Most were military personnel, government officials, bureaucrats, businessmen, intellectuals, artists, and their family members, and were Mandarin-speaking. Recent Mainland Chinese immigrants are the second largest group of Chinese in Flushing. They can be divided into subgroups according to the [28]

The Research Site

pattern and the time of their immigration. Some Chinese elderly in Flushing came to the United States decades ago for education or other purposes, but due to World War II and the subsequent civil war in China were not able to return to their homeland. Other Mainland Chinese arrived during the late 1980s and 1990s to join their children who had come to the United States as students beginning in the 1970s and had settled in the Flushing area. Many were intellectuals and administrators who had suffered during various political campaigns in Mainland China during the 1950s and 1960s. Some had high educational backgrounds but had enjoyed little opportunity to advance socially and economically, often because of the stigma of having family members living in Taiwan or in the United States. Since the late 1970s most were able to enjoy a moderate degree of improved status in Mainland China as the political climate changed. By the 1990s, having a family member in either Taiwan or the United States had, ironically, become an advantage. Some elderly Chinese have joined children here; for others, the major motivation to immigrate has been to bring their children to the United States by first establishing residence here themselves.

Table 2. Characteristics of surveyed population (1993)

Male Female Age 60--69 70--79 80 and over Years in the United States 5 or less 5 to 10 10 to 15 Education Less than primary Primary Middle school High school College Occupation before retirement Professional Business Other

Total

Taiwan (N= 42)

Mainland (N = 41)

N

%

20 22

19 22

39 44

47 53

16 23 3

27 12 2

43 35 5

52 42 6

20 13 9

32 6 3

52 19 12

63 23 14

8 3 2 13 16

6 5 11 9 10

14 8 13 22 26

17 10 16 26 31

5 22 15

4 23 14

9 45 29

11 54 35

[29]

Elderly Chinese Immigrants in Flushing

Table 2 illustrates the characteristics of my sample of eighty-three Chinese elderly in Flushing. The results show that the majority of individuals (81 percent) immigrated to the United States between 1983 and 1993. Large numbers from both Mainland China and Taiwan have an advanced educational background. Thirty-one percent of the individuals were college graduates, 26 percent were high school graduates, and 16 percent were middle school graduates. Among those included, 65 percent reported that their previous occupation was either professional or business related. Seventy-eight percent of Mainland Chinese respondents reported that they immigrated to the United States during 1988-93, compared to 48 percent of Taiwanese respondents.

The Chinese Senior Center Unlike the situation in many Chinatowns, where large numbers of elderly Chinese have resided in the United States for decades, in Flushing the majority of elderly Chinese came to the United States after they had reached retirement age. These individuals were accustomed to living in a familiar social environment, and some had very active lifestyles before arriving here. Flushing is fast paced, and making money is of great concern to the younger Chinese, who are often so busy working that elderly family members are left without much attention. The Nan Shan Chinese Senior Center was established in Flushing in 1977 to meet the concerns of the elderly. When the center was first founded it had only a small membership. Because of a lack of funding and resources, the center operated in a small upstairs facility with limited hours. As the Chinese elderly population increased, providing proper care for the elderly became more than just a family issue. With the support of the community and government agencies, the center was able to relocate and receive more funding in 1987. As a result, the membership increased to six hundred. In 1992 the center relocated again, and the enrolled membership rose to twenty-eight hundred by the summer of 1993. Currently the center operates daily from 8:30 in the morning to 4:30 in the afternoon. With three full-time staff and twelve volunteers, the center provides a congregate lunch, and also organizes educational and recreational activities for 100 to 150 Chinese elderly each day. In addition to having set up a mahjongg room, the center offers activities such as Tai Chi and Qi [30]

The Research Site

Gong, 2 English language classes, sing-alongs, birthday parties, holiday celebrations, day trips, movies, and arts and crafts. Periodically the center invites professionals, including various kinds of Chinese and Western health providers, community leaders, and attorneys, to give lectures. The center also helps its members to obtain Medicare, Medicaid, 3 and other social benefits. Still, with limited staff and funds, the center often finds itself without sufficient resources to meet the needs of the rapidly growing Chinese elderly population. Other institutions in Flushing provide activities and programs for the Chinese elderly population. These include churches, non-Chinese senior centers, and various Chinese social and political associations. Only a small number of Chinese elderly participate in these programs, however. Although the enrollment in the Nan Shan Chinese Senior Center has reached 2,800, the majority of these members come only when they need assistance. The diverse ethnic population of Flushing has raised new issues and challenges for the community (Sanjek et al. 1991). Christopher J. Smith indicates in his demographic research that the major reasons for many Asians to immigrate to Flushing have been that Flushing presents opportunity, excitement, convenience, and an ideal entrance for success (Smith 1995). Obviously, these would hardly be reasons for the significant number of Chinese elderly in Flushing. Why are they here, and how do they feel about being here? There is no easy answer to these questions. Although many were happy to be able to join their children and other family members in Flushing, a large number of elderly are finding themselves disappointed, and some even sense they are trapped. Mr. Li, a former Guomindang officer of high rank who came to this country seven years ago after he lost his wife, told me during lunch, "I do not want to live here. Here is not my home, here is ' Tai Chi, which originated from Chinese martial arts, is a form of mind and body exercise with slow and gentle movements. It emphasizes the integration of mind with body movement and breathing. Recent clinical studies have shown that there are powerful therapeutic effects of Tai Chi practice, especially for the elderly individuals (Lan et a!. 1996; Wolf 1997; Wolfson et al. 1996). Qi Gong is also a form of traditional Chinese exercises. Based on the theories and principles of traditional Chinese medicine, Qi Gong exercise can activate, cultivate, and control the movement of one's intemal energy. ' Medicare is a federal health insurance program that covers medical care costs for individuals aged sixty-five and over, and disabled individuals regardless of age, through the social security system. Medicaid is a combined federal and state program that covers health care costs for persons with income and financial resources falling below stated eligibility levels.

[31]

Elderly Chinese Immigrants in Flushing

not my country. But where is my home? My home was in the mainland, but it was gone during the war. I cannot go back because I once was their enemy, and they were my enemy as well. Taiwan was the place I spent most of my life, but I am not Taiwanese, and they are against people like me now. So I had no choice but to end up here."

[32]

[4] Fieldwork in Flushing

My fieldwork in Flushing was conducted over fourteen months during 1992-93. The research was divided into four phases: direct observation and interaction; thirty-two key informant interviews and accompanying focused participant observation; twenty-five structured interviews; and a final questionnaire survey of eighty-three elderly Chinese.

Entering the Community Beginning in 1992 I made several dozen day trips to explore Flushing. I soon met various individuals considered to be insiders in Flushing's Chinese community. One who played an important role in helping me to get to know others was Mrs. S. A well-knmvn local Chinese-American politician who was running for a city office, Mrs. S is a middle-aged Chinese immigrant who came from Taiwan in the late 1970s. During the 1980s she became a strong advocate for Chinese Americans, and especially for the elderly population. When I met her Mrs. S was preparing her campaign for a New York City Council seat. She showed great enthusiasm and expressed warm support of my research ideas, and provided me vvith names of several individuals whom she thought might be helpful to me, including the director of the Chinese Senior Center in Flushing. "Be sure to mention my name when you call them," she said. I called the senior center director the very next day. After I introduced myself and described the purpose of my research, he agreed to my request to visit his center and said he would do whatever he could to facilitate my research. [33]

Elderly Chinese Immigrants in Flushing

I moved to Flushing in May 1992. With the permission and assistance of the Nan Shan Chinese Senior Center director, I began attending various activities and observed and talked with Chinese elderly at the center. Through these introductory interactions with numerous center participants and with Chinese and Western medicine practitioners, lawyers, and other professionals who gave presentations at the center, I was able to begin research and expand my network. Eventually, the senior center director often asked me to take part in activities when he was short of staff. Throughout this initial period I found that my fluency in Mandarin, the language spoken by most Mainland Chinese, and my familiarity with American health services and practices facilitated my observations in Chinese and Western health settings. Elderly persons who had been frustrated by previous encounters with health care providers were very willing to have me act as a facilitator or cultural broker for them. I had many opportunities to perform that role at local hospitals as well as at various Western and Chinese medical providers' facilities. Initial research observations and interviews also included identifying other community locations where Chinese elderly congregated. In addition to the Nan Shan Senior Center, places such as churches, Chinese Buddhist temples, coffee shops, and ballroom dancing studios were main sites for observation. 'When people are polite to you, do not expect too much from them yet," one of key informants once told me. A problem I frequently encountered in the first phase of my research was how to establish deeper relationships with the people whom I hoped to observe in their interactions with health care providers. In the first several months most people, especially Chinese elderly in the senior center, were unwilling to discuss or comment on questions that required detailed responses. Although they were very friendly, they would give ambiguous answers and then politely end the conversation when I asked specific questions about their experiences or their own opinions on things other than common conversation topics. I later found that these Chinese elderly were quite knowledgeable about and paid great attention to what was happening around them. My fieldnotes describe my first encounter with one of them: Mr. Fan, about seventy years old, always sat at the comer of the activity room in the senior center. He occasionally would crack a joke and make people who sat around him laugh, but most of the time he was quiet, sitting and watching what was taking place round him. He would always smile at me when I walked in the center, but nothing more. [34)

Fieldwork in Flushing

So, today I decided to pick a seat across the table from him. After I sat down, I said hello in Chinese and looked at him directly. "So, what are you doing here, since you obviously do not qualify for membership?" Mr. Fan asked with a smile. "Research on laoren (older people's) health? Interesting." After I explained what I was doing in Flushing, he made this comment: "You know you are doing a very good thing here. I have being watching you for a while, it seems everyone here likes you. Good young man." He never moved his eyes away from me while he was talking. At this point I thought to relax the conversation a little. 'Why are you here, you do not look like a senior either?" "You are a very smart boy, you have good eyes." He laughed, and looked around the people who sat next to him. "So, what have you found about our health?" He continued. 'Well, I do not know much about it yet, that is the reason I am here. I hope you can enlighten me," I replied with customary Chinese humility. "Me? No, no, no. I am too old to be useful to you young people. I am here just to waste my time. You are the future." What he said may sound a bit self-deprecating, but indeed such remarks often indicate modesty. I was reminded of the situation when I was a martial arts athlete. I often begged those elderly Chinese, who are said to have great skill, to teach me. At first they always said exactly the same thing: "I am too old to know anything," or "What I know is not useful to you." But as I continued to ask them, they would eventually teach me, and they turned out to be great martial artists indeed. "I am sure I will learn a great deal from what you consider useless," I said. He laughed again and looked at me as he had earlier. I felt that he was gauging what kind of person I am. ''\Veil, I have said too much. It is the first time we talked. We have to know each other." As the lunch was getting ready, Mr. Fan concluded our conversation. I felt there were always many eyes looking at me whenever I walked into the senior center. People were polite, yet there was an obvious distance between us. One day, when I was watching the Tai Chi class with some fifty elderly in the senior center, an idea came to my mind. During the break, I approached the instructor with whom I had occasional conversations. After we talked about Tai Chi, he said to me: "You must know Tai Chi well." I told him about my martial arts background. Without saying anything more, he turned to his group, and said: "Everyone, did you know that Xiao Guo (Young Guo) is a well trained Chinese martial artist? He will give us a demonstration." I [35]

Elderly Chinese Immigrants in Flushing

was unprepared, but appreciated the opportunity. After my demonstration, people gave me a warm applause and insisted that I give another one. When I finished, several people asked me to sit next to them. "Are you tired?" "You must be exhausted." "Come sit with us." "Look at him, sweating all over." As they were making comments, tea and towels were brought to me. Looking at many smiling and caring faces, I felt that a different atmosphere had emerged, one that came from a more personal acceptance of my presence at the center. Two days later, I was invited by an energetic old lady to their Wednesday Karaoke program at the center. Before an audience of sixty or so, I sang three songs. After that, people would often greet me and ask me to sit with them when I came to the center. Unlike the previous period when I had to try to make people talk to me, people would now initiate conversation. Styles of conversation were much more relaxed and moved from formal to chatting about daily family life. People told me why and how they had come to the United States, and how successful their children were in the United States. They also told me how lonely they were living alone in a strange land without the attention of these successful children. When we discussed health, they would vividly describe the methods they used to treat illnesses and maintain good health. At the same time they would also whisper to me with emotion about their unfortunate experiences in the process of seeking health care. When they discovered that I was also fluent in English and familiar with managing bureaucratic problems in the United States, many started to ask me for solutions to problems regarding their visa status or related legal problems. Many of them asked me to help them obtain Medicare, Medicaid, and SSI benefits, for example. I felt that people now began to see me as a friendly person who liked to chat with them rather than as a student here only to do research. After they heard that I had no family in the United States, many invited me to their homes for dinner. If I wore only a sweater on a cold day, they told me to wear more clothing to prevent catching a cold. Several times when I looked tired, they asked me how I was feeling and provided me with recipes for various home remedies. If I did not go to the senior center for several days, people would telephone me to see if I was all right. My ties with these elderly went beyond the purpose of research. I soon felt that I had become part of a big family. This acceptance of me by the Chinese elderly facilitated my interactions and interviews there and enhanced my research activities outside the center. Through their introductions and contacts, my social network in Flushing was considerably strengthened. [36]

Fieldwork in Flushing

A Chinese proverb says, "If one wants to know the taste of a pear, then one must take a bite of it." The establishment of close bonds with many Chinese elderly, as well as with the community in general, expedited the process of selecting the thirty-two Chinese Americans who became my key informants. They included fifteen elderly Chinese (seven males and eight females, six of them from Mainland China, eight from Taiwan, and one from Hong Kong), the senior center director, five Chinese healers, three Chinese M.D.'s, a pharmacist, two herbal store owners, the director of a Chinese radio station, a politician, and a priest. Lengthy, open-ended interviews were conducted at least three times with each of these informants. These interviews, especially those with the Chinese elderly, provided me with rich ernie (or insider) perspectives on health and health care beliefs, health care practices, and health problems as well as attitudes toward the health care system and health care services. Although most of these key informants were relaxed and friendly, some still felt uncomfortable when I asked if I could use a tape recorder, and a few even objected if I took notes during interviews. In these cases, immediately following the interviews I went to my car and quickly recorded what I remembered on a tape recorder. If I thought that I had missed some important phrases or comments, I would telephone them, or make notes to myself to ask them again in our next interview.

Interviewing Homebound Individuals

In the earliest phase of my fieldwork, I became concerned that I was not reaching individuals who were unable to leave their homes because of their health conditions. It was important to include homebound individuals in my study, as there appeared to be a large number of such individuals in the community. Consequently, during a conversation with the radio station director I inquired if it were possible for me to make an announcement about my research. He agreed and in fact suggested that he interview me on the air. Many Chinese elderly rely on this radio station to receive local and homecountry news because it broadcasts programs in Mandarin. Especially for those who are homebound, its educational and entertainment programs, broadcast twenty-four hours a day, are both a major connection to the outside world and a congenial way to pass the time. [37]

Elderly Chinese Immigrants in Flushing

In the first one-hour radio interview, the director and I discussed the nature and the purpose of my research in detail, as well as what other health researchers have to say about the situation of the Chinese-American elderly population. Following the interview, a thirty-second spot announcement was broadcast twice a day for one month. After a brief introduction to the purpose of my research, the announcement asked those who wanted to share their perspective to give me a call. Soon after the interview aired, the station received a number of telephone calls from the audience. A week later, the director called to invite me for a second live broadcast. "The reaction from our audience after the first interview was very good," he said. Three radio interviews in all were broadcast, and I received twenty-five calls from homebound individuals. I eventually interviewed twenty-three of them. These interviews exposed some reasons why many Chinese elderly are unable and unwilling to utilize the health care system available to them. Some, although "living within the system," are ineligible to receive health care services. They are a population that needs health care the most, but receives the least. Most of these homebound individuals lived alone and depended on their adult children to provide their basic means of living. Their children usually lived elsewhere and visited them once or twice a week. Because of the language barrier, poor health, unfamiliarity in dealing with the U.S. health care system, and financial difficulty, these individuals found themselves living without hope in this "dream land."

Other Contacts

Every Wednesday I went to a Baptist church to take part in its Read the Bible and View One's Life program with a group of thirty ChineseAmerican elderly. On Sunday mornings I went to a Chinese Buddhist Temple in Flushing to participate in its Sunday Prayer program with seventy Chinese Americans, including a large number of elderly individuals. In both places, people expressed their difficulties and the experience of hardship as elderly immigrants in the new country; they described their health problems and how they went about seeking health care. People shared their successful coping strategies with one another, often exchanging recipes for treating health problems and introducing their doctors to those who needed one. [38]

Fieldwor* in Flushing

I also frequently joined the Chinese elderly who spent time in local coffee shops, and on many mornings I exercised with others in the parks. Over two dozen interviews with key informants were conducted in coffee shops, restaurants, and parks. Participant observation also included taking elderly persons to hospitals, private physicians, and Chinese traditional healers' offices, and to the local Social Security Office to apply for benefits; I often served as a driver and a translator in these activities. Here I was able to observe the process of seeking health care as individuals encountered it, and I was able to observe the interaction between the elderly and official personnel in these various settings.

Structured Interviews

From my research activities I obtained much information about health problems, health care behefs, and the various behaviors of the elderly Chinese in Flushing who seek health care and health maintenance. This information was useful in constructing formal interview schedules for a sample of twenty-five Chinese-American elderly, all of whom were chosen from theresearch locations I have described (see Table 3). Table 3. Characteristics of structured interview participants

Gender Male Female Age 60-69 70-79 80 and over Years in the United States 5 or less 5 to lO 10 to 15 Education Primary school Middle school High school College Occupation before retirement White Collar Blue Collar

Taiwan

Mainland

Total

6 8

4 7

10 15

10 3 1

9 2

19 5 1

4 8 2

7 4

11 12 2

1 5 4 2

8 2 3

1 13 6 5

9 3

lO 3

19 6

[39]

Elderly Chinese Immigrants in Flushing

Each structured interview took about four hours, sometimes in two or more sessions. These interviews were conducted at various locations according to the convenience of each informant: some occurred in homes, others in the senior center, a coffee shop, a park, a dancing studio, or a restaurant. A few were completed while I was driving persons to or from health care facilities. Drawing on the data gathered from previous sources, I constructed lists of common health problems and of health care practitioners and facilities, both Chinese and Western. I also developed a list of traditional and modern medicines, remedies, preparations, and other materials. These lists were the basis for the structured interviews: sets of index cards-a card for each item on a list-were prepared for several methods of sorting by the twenty-five informants. During each interview, I first presented the cards bearing the names of home remedies and asked the participant to put those items they utilized on one side. When they were done, I asked them if they used other items that I had not included. As additional items were indicated, I added each remedy onto a new index card, and recorded all items selected on a prepared sheet. The next exercise was to present the set of index cards containing names of health problems and symptoms. Informants were asked to indicate which they had experienced during the past twelve months. At the end, I added any health problems or symptoms that the informant mentioned but which were not included in the set of cards. Again, all responses were recorded on a prepared sheet. The third exercise was to ask informants to sort the index cards of health problems and symptoms into piles according to their perceptions of the degree of severity and their level of concern for each problem. There are many ways of categorizing health problems. During the interviews, I tested identifying health problems by a scale of "not serious I serious I very serious." This manner of conceptualizing health problems was not well received by Chinese informants. Some felt any health problem or symptom might become serious in the future; others said that to label health problems and symptoms as serious or not was not the Chinese way, or at least it was not the way they understood these problems. Drawing upon information from participant observation among Flushing Chinese and the input from my informants, I devised a categorization of health problems and symptoms into "small problems, problems between small and big, and big problems." These terms were commonly used among [40]

Fieldwork in Flushing

Chinese elderly. Although the content of each of these terms may vary in usage from individual to individual, their intended meanings are usually easily perceived, even without application to a specific health problem. As a final exercise, a set of index cards with various health care methodsWestern medical doctors, Chinese traditional doctors (acupuncturist, herbalist, tui na 1 practitioner), and self-care practices-were presented. Informants were asked to indicate which of these health care resources were "most suitable or appropriate" for each problem or symptom. During all of the exercises, informants were frequently asked for the reasons why certain categorizations were made, and all their comments were recorded.

Questionnaire Survey

Finally, I wanted a larger sample of one hundred elderly Chinese immigrants-fifty from Taiwan and fifty from Mainland China-that would be as diverse as possible. Several locations in Flushing were used to produce this sample: the Chinese senior center, two non-Chinese senior centers in Flushing where many Chinese elderly participate in educational programs and use the lunch programs, ten Chinese churches, five Buddhist temples, twelve Chinese-owned sevving factories (my fieldwork revealed that a large number of Chinese women between the ages of sixty and sixty-five work in these establishments), coffee shops, and public parks where elderly exercise each morning. The sample also included homebound individuals contacted through my radio interviews. By utilizing these different locations, the sample represented the major variables in the Flushing Chinese elderly population. The questionnaire was constructed from data gathered in all previous research phases. It included questions on health and health care beliefs, on utilization of health care services from modern practitioners and alternative healers, and on social, demographic, and other background data. The questionnaire was tested in three trials with a small number of elderly informants, and then revised for its final version. After obtaining permission at each senior center, church, and temple, I distributed questionnaires during peak hours of activity. The staff at the centers supported this activity, and some of them also voluntarily provided an explanation of the purpose of the 1 Tui na is a Chinese healing method that involves the utilization of various hand manipulation techniques on the patient's body.

[41]

Elderly Chinese Immigrants in Flushing

survey and encouraged participation by center members. Some elderly participants also helped to explain survey questions to individuals who had weak eyesight, or helped fill out questionnaires for persons who could not read or write. For those who wished to answer the questionnaire at home, I provided stamped envelopes. During the month in which the questionnaire was administered, 120 of the 200 I distributed were collected. Of these, 108 were completed by fortyone Mainland Chinese immigrants, forty-two Taiwanese immigrants, and twenty-five others, mainly persons from Hong Kong. In this book I use only the responses from Mainland Chinese and Taiwanese immigrants.

[42]

PART II.

Health Care Concepts and Resources

[5] Aging, Migration, and Health

The health consequences of migration and resettlement have been widely studied. Research on this subject has suggested that migrant populations are vulnerable to various health problems, especially groups that move to \Vestern urban centers from non-Western settings (Antonovsky 1979; Hull1979; Janes 1990; Kulys 1990). The vulnerability of a migrating population is the result of a combination of factors, including the physiological and psychological stresses generated from the process of removal and resettlement and the problems and difficulties migrants confront in dealing with health problems and the health care culture in the new environment (Janes 1990; Krause and Baker 1992; Thoits 1983). In recent years the integration of anthropological and epidemiological approaches to understanding the health consequences of migration have provided some significant new perspectives. Lorna Moore and her associates proposed the human ecology model (Moore et al. 1987) in which factors related to health and health care in a migrating population were conceptualized at two levels-environmental and individual. Factors at the environmental level consist of the basic social and cultural structures, including the health culture, the health care system, and the political and economic strategies that exist in the host community. Factors at the individual level include a person's social and biological characteristics such as socioeconomic status, age, gender, and education, all of which determine an individual's adaptive capacity. The physical and mental well-being of a migrant population is determined by interaction between factors on both levels. When there are few differences in environmental variables between the host and immigrant [45]

Health Care Concepts and Resources

communities, and when individuals bring highly adaptive capacities, there is less difficulty in obtaining successful health outcomes. It is clear that although all age groups within a migrant population experience stresses and difficulties in physical and mental well-being (Kemp, Staples, and Lopez-Aqueres 1987; Mui 1996), elderly individuals are particularly vulnerable (Scudder and Colson 1982). In a recent study which examines the degree of acculturation in relation to health and psychological stress among a group of elderly Hispanics in the United States, Thanh V. Tran and colleagues (Tran et al. 1996) found that because of language barriers and low financial and education levels, elderly immigrants face multitudinous issues in facing "acculturation" and have few relevant social and psychological coping resources (see also Kulys 1990); they suffer more than younger persons from physical and mental problems and have more difficulties in maintaining overall well-being.

Modernization, Aging, and Health Elderly persons are often viewed by researchers as "disadvantaged" populations in situations of cultural change and migration. Donald Cowgill (1986), for instance, suggests that social change produces adverse effects upon the social position of the elderly, especially if change is rapid and involves social and economic transformations associated with "modernization." The modernization theory introduced by Cowgill (1974) is controversial as an explanatory model, but it highlights important cultural variables that affect the perception of the aged in contemporary societies. Specifically, it is relevant for understanding how social and cultural change affects elderly immigrants' health and well-being. In the United States, medicine has been much affected by rapidly a changing economy, science, and technology. This modernization of medicine in the United States has not only changed the way that health care is delivered, it also has affected how health problems are perceived. As a consequence, the social position of elderly individuals is more and more defined by their physiological characteristics. As Carroll Estes, Elizabeth Binney, and Thomas Cole have observed (Estes and Binney 1989; Cole 1992), the "biomedicalization of aging," or the recent power of the U.S. medical establishment to define and "treat" aging, has exerted the most powerful influence on the meaning of aging at all levels of American society. Moreover, medi[46]

Aging, Migration, and Health

cine as a social institution, a system of knowledge, and a practice, together with its definition of old age as disease, has become the dominant framework for the lives and problems of many old people in the United States (Lindenbaum and Lock 1993; Kaufman 1994). Considering other factors, including language barriers, financial constraints, and racist practices existing in the American health care system (Page and Thomas 1994), it is inevitable that elderly immigrants, especially those who came from non-Western societies, face enormous challenges and difficulties in dealing with a society in which interaction with the health care system is essential in everyday life.

Asian and Chinese-American Elderly The Asian elderly, including the Chinese, have often been portrayed as a silent and neglected segment of American society. Especially among earlier immigrants, strong 'Nishes to retain traditional life styles and distrust of outsiders because of unpleasant treatment in the past (e.g., anti-Chinese persecution) pushed them toward self-reliance. Previous studies have found that although the elderly of all ethnic groups were socially and economically disadvantaged in the United States, Asian and Chinese elderly suffered greater disadvantages than other groups (Wong 1984; Wu 1975). In a study conducted in San Francisco's Chinatown, Victor Nee and Brett de Bary Nee (1972) found that San Francisco's Chinatown had the highest suicide rate in the nation and that its residents suffered disproportionately from alcoholism and depression. Ten years after the Nees' study, much research continued to demonstrate that Chinese-American elders suffered from serious deterioration in mental well-being (Chen 1979; Chen 1980; Chenug et al. 1980; Cheung 1989; Deely et al. 1979; Yu 1984). As the elderly Asian population in the United States has expanded dramatically in recent years, and as the influence of cultural norms and traditional values diminish, problems related to health and health care have increased. Recent studies show that health, and mental health care in particular, rank high among the major concerns of Asian and Chinese elderly populations (Cheung 1987; Min 1995; Pang 1991; Ying 1990). Various factors contribute to this concern, including culturally constructed meanings and interpretations of specific symptoms which play a role in complicating the care-seeking process (Cheung 1987; Min 1995; Nilchaikovit, Hill, and Roland 1993; Pang 1991; Ying 1990). [47]

Health Care Concepts and Resources

Health and Illness in the Cultural Context There is a great deal of variation in people's concepts of health. The definition of health provided by the World Health Organization is frequently cited: a "state of complete physical, mental and social well being and not merely the absence of disease" (Spector 1996). This definition is broader than the one commonly found in the medical literature, which defines health as the absence of pathological symptoms (Mercer 1979). In general practice, the term "disease" has been used to describe this pathological state and is the focus of the biomedical model. Disease is defined as "malfunctioning of the chemical and physiologic systems of the body" (Fabrega 1978:21). In a discussion of disease in Western medicine, Gregg Lewis states: "Western biomedical views on the classification of disease are often invoked as the standard for universal use: with varying stress, it has been implied that they are objectively framed, free from cultural bias, scientifically based, and correct" (1993:99). By contrast, medical anthropologists suggest that "health" and "illness" are cultural defined concepts. Not only do people of various cultural groups define health differently according to their own culturally constructed norms and beliefs (Hantman and Harrison 1982; Koo 1987; Leininger 1985; Roberson 1982; Sultana 1991; Young 1991), but people also classify illness according to different criteria from those used in Western biomedicine (Lewis 1993). In his discussion of the meaning of illness in the context of culture, Arthur Kleinman (1980) states that illness refers to those human experiences which represent personal, interpersonal, and cultural reactions to symptoms or discomfort. The distinction between medically defined disease and culturally defined illness is not always clear or possible to make. The important fact is that no matter what the nature of disease and its causes, its expression involves a range of physical, psychological, social, and cultural responses. Illness consists not only of the sick person's attention to and perception of the manifestations of disease but also of his or her culturally guided search for treatment. "Illness behavior" is a concept that refers to "the ways in which given symptoms may be differently perceived, evaluated and acted (or not acted) upon by differen~ kinds of persons" (Mechanic 1962:189). Thus, the form of behavior in dealing with illness is strongly influenced by sociocultural expectations and perceptions concerning that illness. To a Western-trained health practitioner, a non-Western cultural perspective on health may seem unfamiliar; moreover, the lack of"common ground" [48]

Aging, Migration, and Health

in defining and perceiving health issues may not even be anticipated. For example, many non-Western cultures do not distinguish between physical, psychological, and spiritual problems, nor do they differentiate their symptoms according to specific organs. Rather, they approach illness as an affliction of the whole person, and as a generalized lack of well-being or an interference with daily activities (Ford 1973; Kleinman 1980; Snow 1974). Therefore, when members of these groups seek medical help, their symptoms are a mixture of somatic, psychological, spiritual, and social complaints. There are also cultural differences in responses to pain among different populations. These differences are attributed to cultural expectations and allowances for the expression of pain rather than to different biophysical characteristics. One famous study of Irish and Italian Americans presenting illness complaints found that Italians "overstate" their symptoms and complain about family and other problems, while the Irish "understate" their symptoms and restrict them to physical problems (Zola 1966). Another researcher found that Navajo respond to pain "stoically" by Western standards, have limited language to describe the experience of pain, and are apparently less concerned about it (Adair, Deuschle, and Barnett 1970). Clearly, the learned behaviors of different populations in identifYing and reacting to disease and physical discomfort play a role within the larger context of the patient's cultural environment. It is important for health care workers to be aware that differences in how people express their experience with illness, even the way one "feels" his or her symptoms, can affect the assessment of a patient's condition.

Healing Practices "Healing practices" have been classified in many different ways. Often, Western medicine, folk medicine, and popular medicine are classified as distinct from one another, with their differences implying separateness in use and a basic incompatibility. Western medicine is often described as professional, biological, scientific, cosmopolitan, modem, and standard. Folk medicine, on the other hand, is often seen as unorthodox, primitive, local or regional, informal, and traditional. Popular medicine refers to self-care by individuals and families, "the lay, non-professional, non-specialist, popular culture arena" (Kleinman 1980:50). In cross-cultural contexts, a distinction between folk medicine and popular medicine is not always clearly made. [49]

Health Care Concepts and Resources

Folk healing and treatment, which vary widely around the world, draw on cosmological explanations of illness, references to people's fate, symbolic healing, and therapeutic treatment. Folk medicine can include oral administration of herbs, application of various natural materials, massage, cupping, regulation of diet, and magical or spiritual cures. Researchers of folk medicine point out that although each ethnic group may have a unique pattern of healing practices, many in fact utilize multiple health resources concurrently or serially, including Western biomedicine. Individuals frequently will make their choices in seeking appropriate health care from a combination of folk, popular, and Western medical traditions. Earlier studies on healing practices of culturally diverse groups have been criticized for failing to consider folk healing practices such as shamanistic rituals, herbal treatment, and home self-care as part of the legitimate health care of their societies (Kleinman 1980; Leslie 1976). Medical anthropologists reject distinctions made between folk medicine as "magic and religion" versus modern medicine as a "rational and scientific practice," arguing that it is wrong to consider folk treatment to be irrational or nonscientific: "Folk healing practice is a coherent medical system and not a ragtag collection of isolated superstitions. If the underlying premises are accepted, it makes just as much sense to the believer as the principles of orthodox medicine do to the graduates of an accredited medical school" (Snow 1974:83). Many studies demonstrate that folk healing practices often successfully exist side by side with modern medicine (Clark 1970: Good 1987; Janzen 1974; Kunstadter 1975; Young and Garro 1982). Patients select from a variety of health care resources and utilize them concurrently or consecutively. The presence of diverse health beliefs, knowledge, and behaviors have demonstrated that it is important to study all available health care resources in order to understand the health care of a particular group of people.

Decision Making in Pluralistic Health Care Since the 1970s, medical anthropologists have been trying to understand the process of decision making by which individuals select healing practices from the various health care resources in pluralistic cultural settings. The different "phases" an individual goes through in deciding how to respond to illness give different priority and significance to such factors as health information availability, cost of treatment, the role of family members in deciding treatment, and other considerations. Five phases of decision making in [50]

Aging, Migration, and Health

seeking health care were outlined in one study of Spanish Americans in New Mexico: a self-care phase, a phase of consultation with the immediate family members, a community phase involving friends and neighbors, a folk specialist phase, and a professional phase (Weaver 1970). A similar four-phase model in defining and managing illness was described for Chinese Americans in San Francisco (Louie 1975). First, individuals determined what was wrong with them by picking up information from various scientific, religious, folk, cultural, and interpersonal sources. Then they identified or "linked" the information with their own bodily experience. Third, individuals tried self-care; if that was not effective, they consulted \vith others recommended by friends or relatives. The fourth stage was the actual engagement of particular healing practices as the individual entered treatment in order to be cured. All agree that decision making in relation to health care begins with a definition of illness. The decision that the individual is ill rests mostly with family members. Whether assistance will be needed depends upon several factors: the nature of illness, the individual's degree of impairment, his or her status in the family, and the family's financial and interpersonal resources. The selection of an appropriate healer depends on proximity, the healer's cost, and the probability that the healer \vill accept the patient. The decision to remain with a healer depends on acceptance by the family of the diagnosis and treatment, cost, and any restrictions the healer places on the family. Deciding when the patient is well is made either in conjunction with the healer or solely by the patient's family on the basis of observed improvement. In Kleinman's delineation of "explanatory models" (1980) the health care system is a cultural system that consists of an individual's beliefs about the causes of illness, knowledge about how to respond to specific episodes of sickness, and actions taken to effect a change, all influenced by macro-social and bio-environmental factors, including various social institutions. The degree of congruence between the culture of the clientele and that of the health care professional is an important factor in deciding to seek professional help: if the meaning an individual attaches to an illness is similar to the meaning a physician attaches, then he or she is more likely to seek care from that physician. On the other hand, when an individual's explanatory models differ from those of the physician, there is less likelihood of seeking care. The "meaning" of the illness is formed from a variable combination of cultural meanings, e.>.})eriences, and expectations. Kleinman identifies five issues in the organization of information about illness: etiology, onset of symp[51]

Health Care Concepts and Resources

toms, pathophysiology, course of sickness, and treatment. This information guides choices among available therapies and therapists and gives personal and social meaning to the experience of illness. The congruence of patients' and practitioners' explanatory models therefore influences the entire health care process.

The Systematic Nature of Health Care Beliefs and Practices

Pertti Pelto and Gretel Pelto, in their recent discussion regarding the nature of health care beliefs and practices, comment: "a central feature of anthropological theory that has strongly influenced anthropologists' conceptualization of the relationship between health beliefs and behavior is the idea of 'systemness.'" (1997:150). According to this view, individuals' beliefs in health and their health care practices are reflections of their interaction with the whole cultural system (Paul1955; Fabrega 1974; Young 1991). In elaborating his explanatory models, Kleinman writes: "Explanatory models are the notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process" (1980:105). In this theoretical framework, the health care system is regarded as a cultural system which consists of an individual's beliefs about the causes of illness, knowledge about how to respond to specific episodes of sickness, and the process of actions taken to effect a change. Macro-social and bio-environmental factors, including various social institutions and cultural norms, influence an individual's interpretation of illness symptoms and health care strategy.

Diversity within Cultures

John Roberts and Brian Sutton-Smith (1964) used the analogy of an "information economy" to illustrate how people share, store, and re-create information in the process of maintaining culture. They suggest that within a culture an individual's knowledge is only a sample of the larger pool of cultural knowledge, and "the agreement among individuals is a function of the extent to which they share similar information." Suppositions about the cultural uniformity of health and illness beliefs and cultural stereotypes are clearly inadequate. "The assumption of cultural homogeneity is an unwarranted stereotype which can produce misleading results, particularly when studying ethnicity and its relationship to patterns of behavior" (Hessler et al. [52]

Aging, Migration, and Health

1975:254). Studies in Boston's Chinatown found that not all Chinese Americans shared the same beliefs about health and health care seeking. People went to traditional medical practitioners for certain problems and to Westem medicine practitioners for others. This intraethnic diversity of health beliefs and health care behaviors among Chinese Americans was attributed to differences in age, gender, language, and cultural adaptation (Hessler et al. 1975).

[53]

[6] Traditional Chinese Medicine

The origin of Chinese medicine abounds in myths and legends. It is said that during the legendary Five Rulers period in Chinese history, three of the five founders of ancient Chinese civilization-Fu Hsi, Sheng Nung, and Huang Ti-created the basic medical system (Wang and Wu 1936). Although historical records are ambiguous and unclear about these legends, throughout Chinese history the three legendary characters "are always classed together, forming a medical trinity, and they are worshipped in all temples of merucine throughout the country" (Wang and Wu 1936:6). Fu Hsi (2953 B.C.), the first of the Five Rulers of the legendary period, is said to be the creator of picture symbols, rules of marriage, fishing, breeding domestic animals, cooking, and playing music. Beside inventing acupuncture, another major contribution he supposedly made to Chinese medicine was the theory of Pa Kua, or Eight Diagrams, on which were based the I Ching, or Book of Changes, and the principles of Chinese medical diagnosis (Wang and Wu 1936). The second of the three founders, Sheng N ung, is considered the most important according to the chronicles of Chinese medical history. Sheng Nung (2838-2698 B.c.) is also considered to be the father of agriculture, as he devoted most of his life to testing plants and herbs to examine their properties and determine which were beneficial for people's health (Wang and Wu 1936). In the classic Pen Zao, or Herbal, believed to be the first Chinese pharmacopoeia, he recorded 365 drugs that he had tested. Of these, 120 drugs were categorized as "superior," 120 as "medium," and 125 as "inferior." "The superior drugs are supposed to be non-poisonous, possessing rejuvenating properties and can be taken for long periods without harm. The [54]

Traditional Chinese Medicine

medium drugs are said to have tonic effects, their toxicity depending on the dosage. The inferior drugs are only employed for curing disease, being considered poisonous and should not be taken any length of time." (Wang and Wu 1936:7). Huang Ti, known also as the Yellow Emperor (2698-2598 B.C.), is said to have written the Huang Ti Nei Jing, or Classic of Internal Medicine. The Nei Jing was written in the form of a conversation between the Yellow Emperor and his court physician. The origins of diseases and cures for them are discussed in the Nei Jing, as are the roles of diet, hygiene, emotion, environment, and "nature" in maintaining health and preventing illness. The Nei Jing, which established Chinese medicine as the art of maintaining health, not curing disease, states: a wise man prevents diseases rather than treating them, and a good emperor prevents disorder rather than restoring order (Veith 1970). The three founders of Chinese medicine are only a few mythical characters in a much more complex history, and Chinese medicine is a product of many people's work Reliable historical records show that Chinese medicine began to be systematized in the middle of the Chou dynasty (1122-255 B.c.)(Wang and Wu 1936). This era is also called the Spring and Autumn period, a time in which the great Chinese philosophers and educators Confucius, Mo Zi, Lao Zi, and Zhuang Zi were prominent (Bary and Chan 1969). During this period, in which literature, art, religion, philosophy, and other sciences reached great heights, the scholarly study of medicine also intensified. Two philosophical doctrines that define the theory and causation of disease were formed: the Doctrine of the Two Principles-yin and yang-and the Doctrine of the Five Elements (Wang and Wu 1936:15). These doctrines reflect the Chinese view of the world. They seek to explain the causes and laws of motion and change in the natural world. According to Chinese thought, the constantly evolving material world as well as all matter resulted from the antagonistic movement of two great opposing material forces, yin and yang. Thus, "yin and yang are the Tao (creator) of heaven and earth, the principle and plan of all things, the parents of all change, the origin of birth and death, and the source of all mysteries" (Liu 1988:31). Yin-yang theory holds that everything, including the human body, is constructed and originates from two flowing energies that are opposed to each other but exist side by side, and even within each other, and regulate the ceaseless emergence, variation, and change in all things (Wang and Wu 1936). The theory posits that the "alternating of the variation in functional [55]

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conditions of the body is the result of the inte1play of these two forces" (Liu 1988:31). An equilibrium state-a healthy state according to this doctrinemanifests harmonious interaction between the two forces. When the equilibrium state is threatened, or when the normal relation between the two forces is disturbed, functional disorders will occur. Therefore, maintenance of a proper relationship or balance of the two forces within the body is essential for good health. The ways of obtaining this equilibrium "range from proper conduct [and] mental hygiene to dietary rules" (Croizier 1968:16). The Doctrine of Five Elements holds that the living human environment is constructed of five fundamental materials: wood, fire, earth, metal, and water. As a microcosm, each person therefore is also composed of these elements, which interact with each other to provide a dynamic balance (Liu 1988:48). Applied to the human body, this theory defines all human organs and tissue as analogous to the five elements. The quality of a person's health is determined by interactions among the organs and tissues and between these and the surrounding environment. The theory of the Five Elements "provides a model for the interaction among the organs of the body and for the transmission of disease when one of them fails to function properly" (Liu 1988:64). Table 4 illustrates how the five elements are conceptualized in Chinese medicine. The formation of the Yin-yang and Five Elements theories were major achievements in ancient Chinese thought. The synthetic approach of viewing all natural systems, including the human body, in terms of these two doctrines has shaped the epistemology and methodology of all subsequent Chi-

Table 4. Classification of natural phenomena according to the Five Elements Element

Wood

Colors Climatic factors Seasons Flavors 7Angorgans Fu organs Sense organs Tissues Emotion

Green Wind Spring Sour Liver Gallbladder Eye Tendon Anger

Fire Red Heat Summer Bitter Heart Small intestine Tongue Vessel Joy

Source: Adapted from Liu 1988:.50.

[56]

Earth

Metal

Yellow Dampness Late summer Sweet Spleen Stomach

White Dryness Autumn Pungent Lung Large intestine Nose Skin and hair Grief

Mouth Muscle Pensiveness

Water Black Cold Winter Salty Kidney Urinary bladder Ear Bone Fear

Traditional Chinese Medicine

nese science, including traditional medicine (Liu 1988:31). Over several thousand years, a conception of "integrity"-the basic concept in both yinyang and the Five Elements medical philosophy-has expanded into a multifaceted system of theory and practice. According to the Nei Jing, "A wise man prevents diseases rather than treating them, and prevents disorder rather than restoring order" (Veith 1970). This is the keystone of the entire system of Chinese traditional medicine. Over centuries, the concepts of prevention and the beliefs about illness causation and health maintenance have infiltrated the consciousness and daily life of the Chinese people. Proper diet and personal behavior, emotional balance, and exercise have been seen not only as ways to prevent illness but also as the most important methods of treating health problems (Liu and Wang 1991; Yu 1991; Zhang and He 1992; Zhou 1984). In China, "people think about their health as a balance of the person and the environment, the active and the receptive" (Liu 1988:1).

Medicine in Imperial China During the Tang and Sung dynasties (A.D. 618-1279), there was a flourishing development of Chinese medicine. "The practice of medicine became more intensive and specialized," and "research and publication exceeded that of all the previous dynasties put together" (Wang and Wu 1936:86). Practice became systematic and monographs were published on preventive medicine, internal medicine, pathology, obstetrics, gynecology, pediatrics, surgery, inoculation, geriatrics, pharmaceutical chemistry, forensic medicine, acupuncture, and the classification of medicines (Liu 1988:25; Wang 1936:89). In the Tang dynasty the Imperial Medical College was founded, its main function being to meet the health needs of the emperor. In the Sung dynasty, other medical colleges were established across the country to train men for the profession (Wang and Wu 1936:94). The subjects taught in these colleges covered a wide range, including "Diseases of Adults, Children's Diseases, Diseases Due to vVind, Obstetrics and Women's Diseases, Eye Diseases, Diseases of Mouth, Teeth, and Throat, Fractures and Wounds, Swellings and Sores, Acupuncture and Moxibustion, Charms and Incantations" (95). State-administrated medical examinations used to certify doctors, and other medical personnel were further systematized and standardized during this period (94). The examinations covered a broad range of subjects in both written and oral questions. Official posts and salary-levels [57]

Health Care Concepts and Resources

were determined by examination results. Although the practice of medicine by women has a long history in Chinese society, it was not until the Sung Dynasty that female doctors were given official recognition (97). However, the medical colleges established during the Tang, Sung, and subsequent dynasties trained only a small proportion of medical practitioners. The vast majority of Chinese traditional doctors were trained as apprentices according to the medical tradition of their master, and passed no formal examinations. There was an enormous difference between the scholarly physician trained at a medical college and the typical rural practitioner in terms of their socioeconomic status and method of medical practice.

Impact of Foreign Influence

From the first arrival of an Arab medical practitioner in A.D. 738 until the outbreak of the Opium War in 1840, Chinese health culture underwent a series of encounters with foreign medicine systems. Over several centuries, Chinese medicine was influenced by the Arabic, Persian, Indian, Tibetan, and Mongolian traditions, but its dominant position in Chinese society was not seriously challenged. After the Jennerian smallpox vaccination was introduced by a British East India Company surgeon in 180.5 (Hillier and Jewell 1983:3), however, a steady stream of medical missionaries and other emissaries of Western medicine began to gain a foothold within China. After the Opium War, the Qing dynasty was too weak to either maintain power or stop the invasion of foreign powers, and a series of '¥estern interests divided and colonized China. As these colonists established power in their territorial enclaves, medical personnel and facilities were brought into China. At the same time, however, because of the corruption and decline of the ruling dynasty, Chinese people started to question their own traditions, and to call for "self-strengthening" (Crespigny 1992:20). Under both external and internal pressures, the Qing court had no choice but to respond to demands for reform. Western books and technological materials were allowed to be translated into Chinese. Students were selected to go to Westem countries to study ·western sciences, including medicine (Lucas 1982:39). In 1880 the first Western medical school was established in Tianjin-a major city in northern China (41), and since then the Chinese medical system has undergone massive change.

[58]

[7] Health Care in Modem China and Taiwan

Over several thousand years, Chinese society built up a rich body of beliefs and practices concerning health, illness, and treatment. Beginning in the nineteenth century, when \Vestem nations began to stream into China, this traditional system confronted enormous challenges. These confrontations also contributed to a transformation of Chinese social and political structures. An examination of the political and social realities leading to the gradual integration of Westem and traditional Chinese medicine in China and Taiwan in the past century will give us a better understanding of the health-related beliefs and behaviors of the elderly Chinese in Flushing.

Chinese Health Care before 1949

In 1911 the Qing dynasty was overthrown and replaced by the Republic under the leadership of the Nationalists or Guomindang Party. The establishment of the Republic was followed by more than ten years of political struggles among warlords attempting to assert political control in different regions. In 1927, after the joint effort of the Guomindang and the Chinese Communists led to victory over the warlords, these two political parties separated in bloody conflict. The Japanese invasion and subsequent occupation in the early 1930s led to a war against Japan from 1937 to 1945, with catastrophic effects on China. Beginning in 1944 the catastrophe deepened into a five-year civil war between the Communists and the Guomindang. In 1949 the Communists defeated the Guomindang and established the People's Re[59]

Health Care Concepts and Resources

public of China on the mainland. The remnants of the Guomindang were forced into exile on Taiwan. Following the fall of the last imperial dynasty in 1911, nearly a half centmy of wars and unrest destroyed the social fabric of Chinese society and devastated the health of the Chinese people. Because of the wars and cormption within the government, millions of people, young and old, died from lack of food, shelter, or medical attention (Cheng 1944; Fan 1933; Hodgkin 1932; Hsu 1930; Hsu 1936; Tawney 1932). Following the fall of the last dynasty, China experienced dramatic political and social changes driven by a spirit of modernization (Bei 1982:4.57). This desire to learn from the \Vest was, in part, a reflection of Chinese people's fmstrations with the social reality they were facing. A once powerful nation reliant on Confucian tradition was becoming helpless, divided by "foreign barbarians" and their modern technologies. People questioned their traditions, and some began to believe it was these very traditions that had made China vulnerable to the West. After the Republican victory, the leadership of the new central government transformed the spirit of modernization into a national development plan. Under that plan a Western model of medical modernization was adopted to reform the Chinese health care system (Lucas 1982:59). Private medical schools and Western medical facilities, including many missionarysupported hospitals, were developed and expanded with the help of Western resources (Hillier and Jewell1983:42). Since the government's modernization policy focused on urban areas, however, most of these new health facilities were located in cities (54). The government realized that China was an agrarian society; 80 percent of the population lived in mral areas, and medical attention was much needed there. The Nationalist blueprint for developing a "modem" health care system in the rural areas, however, was never enforced, and its ambitious plan for medical modernization in cities was only partially implemented (58). Traditional medicine retained popularity at all levels, especially in mral areas where modem medicine was almost nonexistent. The government, however, had practically no interest in developing Chinese medicine. The major reason for this lack of interest was the belief of large numbers of reformers and government elites that Chinese traditional medicine was not "modem" and its practice needed to be curtailed (Croizier 1968:120-37). With support from these reformers and elites, the Guomindang government passed a bill in 1929 "to ban the traditional medicine in order to clear the way for developing modern medical work" (Wang 1983:71). [60]

Health Care in Modem China and Taiwan

Despite official disdain for the practice of Chinese medicine, over the next twenty years its practice prevailed, especially in the vast rural areas. According to Pei Wang, director of the central laboratory at the Academy of Traditional Chinese Medicine established after 1949, Chinese medicine survived for several reasons. First, many common people earnestly believed in traditional medicine. Secondly, the use of traditional Chinese medicine and medicinal herbs did yield rather satisfactory results in the treatment of diseases, including some diseases intractable by modem medicine. Traditional remedies could reduce symptoms and even produce remission. Moreover, Chinese medicinal herbs were readily available at low cost, were convenient and simple to use, and had very few side effects. Thirdly, traditional medicine had a unique theoretical system which can neither be replaced nor explained by modem science (Wang 1983:71).

Health Care under Communism

In 1949 the People's Republic of China was established. The new government faced a society in which enormous health problems had been aggravated by years of war and political unrest. Almost every type of nutritional and infectious disease was prevalent throughout the nation. A large population, especially in the rural areas, suffered from cholera, leprosy, meningitis, plague, relapsing fever, tuberculosis, typhoid fever, Japanese B encephalitis, smallpox, trachoma, hookworm, clonorchiasis filariasis, kalaazar, malaria (with some areas having infection rates of 50 percent), paragonimiasis, and schistosomiasis. Schistosomiasis alone was estimated to affect over 10 million persons (Worth 1975:478). Venereal disease was common with prevalence rates of 3 to 5 percent in cities and rates as high as 10 percent among the frontier peoples (Lampton 1974:2). Nutritional illnesses included caloric deficiencies, deficits in proteins, and vitamin deficiencies, and resulted in beriberi, osteomalacia, pellagra, and scurvy (Side! and Side! 1973:18). The cumulative effect of these problems impacted all parts of Chinese society. In 1949 infant mortality in the first year of life ranged up to 200 deaths per 1,000 live births; it is conjectured that 30 percent of children died before the age of five. The maternal mortality rate was about 2 percent (Wilenski 1977:7). The average life span was only thirty-five (People's Daily, December 3, 1990). [61]

Health Care Concepts and Resources

The high rates of disease were, in part, a reflection of the almost total absence of modem medical resources and trained manpower. "In 1949, the ratio of doctors to population was exceedingly low by any other standard than abysmal poverty'' (Bryant 1969:51). Hospital facilities were scarce, with the province of Anhwei having .006 hospital beds per 1,000 persons; Fujian, .05; and the populous province of Shantung, .06. Lack of trained Western doctors resulted in doctor-to-population ratios of between 1:25,000 and 1:50,000 (Lampton 1974:41, 4). Ralph Croizier describes the situation of 1949: "The 10,000 or so modem physicians were pitifully inadequate to cope with the medical needs of the country, especially its huge rural population. On the other hand, there was the large number of traditional doctors, perhaps as many as 500,000, and there was the experience of the Yen-an years in making do with native resources" (1968:157). Responding to these realities, at the first National Health Conference in 1950 the Ministry of Public Health declared four principles as fundamental guidelines in public health work: 1. 2. 3. 4.

Serve the workers, peasants, and soldiers; Foster unity between Chinese and Western-trained doctors; Place primary emphasis on prevention; Rely on mass movements for the carrying out of health work (Wen 198.3:129).

The four principles have not only oriented the theoretical and ideological formations of the Chinese health care system in Mainland China since 1949, they have also been important for developing a wide range of medical and public health services in localities across the nation. "These principles defined the nature of the socialist medical and health services and pointed out their directions: to serve the broad masses of the people and protect their health" (Wen 1983:130). Governed by the four principles and a strong centralized leadership for improving national health, the Chinese have developed a unique approach of "walking on two legs," or the mobilization of both Chinese and Western medical resources "to utilize the best technology available on the one side and to use common sense and improvisation on the other" (Worth 1975:477; see also Lee 1975:234). The "integration of Chinese and Western medicine" was not a simple process. Integration had two meanings. First, Chinese medicine had to be improved and studied by modem scientific methods and technologies. Second, [62]

Health Care in Modem China and Taiwan

Chinese and Western medicines each had advantages as well as disadvantages in treating certain specific health problems; use of the advantages of one to compensate for the disadvantages of the other would form a new and unique treatment methodology, and would contribute greatly to the science of medicine. According to guidelines formulated by the Ministry of Public Health in 1954, the main points of the integration were: l. To strive to inherit, develop, systematize, and raise the level of traditional

Chinese medicine; 2. To unite and rely on the traditional Chinese doctors so as to give full effect to their initiative; 3. To organize ways for Western-trained doctors to learn and study traditional Chinese medicine; 4. To modernize traditional medicine and pharmacology gradually; 5. To develop traditional Chinese medicine and conduct research on the integration of traditional Chinese and Western medicine in a planned and rational way; 6. To protect, utilize, and develop the resources of Chinese medicine herbs (Wang 1983:72). In order to implement these policies, a Bureau of Traditional Medicine was founded in tl1e early 1950s within the Ministry of Public Health. Departments of traditional Chinese medicine were then established in every province and autonomous region across the nation. In 1955 an Academy of Traditional Chinese Medicine was created in Beijing under the administration of the Ministry of Public Health (Liu 1988). Staffed \v:ith both Chinese and Western-trained physicians, the academy directs national efforts in traditional medicine research and education (Croizier 1968; Liu 1988). Chinese medicine hospitals administrated by the central government and provinces and cities were established across the country. According to official reports, in 1983 there were 552 of these hospitals; in addition almost every Western medicine hospital had a department of traditional medicine (Wang 1983:72). Excluding part-time health care providers, in 1988 there were 362,000 Chinese medicine practitioners working in both the Chinese and Western medicine facilities (China Statistics Abstract 1989). Chinese medicine hospitals and doctors enjoy an equal standing with Western medicine facilities and personnel in terms of status and state funding (Lee 1982), and Chinese medicine is part of the free government medical care system (Wang 1983). In many hospitals Chinese medicine laboratories have been [63]

Health Care Concepts and Resources

instituted to conduct research on illness treatment and the integration of Chinese and Western medicine. In these facilities, doctors of Chinese medicine work closely with Western medicine counterparts and refer patients to each other. They also work collaboratively in treating many particular health problems. In the early 1960s, Chinese and Western medical physicians successfully explored the use of acupuncture anesthesia in surgical operations. "The patient under acupuncture anesthesia remains conscious, is able to co-operate ¥.1th the doctor during the operation, suffers less post-operative pains andrecovers faster" (Wen 1983:157). Since then acupuncture anesthesia has been widely applied. It has been used in head, neck, chest, and abdominal operations, and also in more difficult procedures such as cardiac surgery (158). With strong national commitment and a centralized organizational infrastructure, the efforts to develop traditional medicine and to integrate Chinese and "Vestern practice have achieved impressive results, especially in the fields of acupuncture and moxibustion, and treatment of acute abdominal conditions, burns, bone and joint injuries, coronary heart disease, acute bacterial dysentery, gall stones, neural paralysis, anal fistulas, lithiasis of the urinary tract, cataracts, respiratory diseases in infants, and diseases of the ear, eye, lips, nose, and tongue (Wen 1983:157; Wang 1983:73). Research has indicated that the effect of the combined Chinese and Western treatment of such health problems "is much better than that of either system applied alone" (Wang 1983:74). More recently, research and experiments combining Chinese herbs with Western procedures in treating cancer patients have provided promising results. Sun Yen, a Western-trained medical oncologist at the Chinese Academy of Medical Sciences in Beijing, reported a long-term comparative trial in which the five-year survival rate among throat cancer patients who received Chinese herbal medications known as bu xue yao (drugs for stimulating and nourishing the blood) along with standard radiation therapy was twice that of a control group receiving radiation only (Emmett 1992). Researchers at the Chinese Academy of Medical Science, the Nanjing College of Traditional Chinese Medicine, and the Shanghai Institute of Materia Medica have demonstrated that herbal combinations can fortify the immune system to inhibit tumors and complement the cancer-arresting results of Western chemotherapy and radiotherapy treatments. Research at the Nanjing College of Traditional Chinese Medicine have reported that the Chinese herb isatis enlists the aid of macrophages-wan[64]

IIealth Care in Modem China and Taiwan

dering cells that engulf unfamiliar substances-and invokes other immune-system functions to fight tumors in mice. Certain compounds extracted from the herb also boost the immune-system response to tumors in humans, in particular accelerating the production of interferon, a natural substance that stimulates the production of cancer-killing white blood cells (Emmett 1992:52). By the 1990s the forty years of effort in integrating Chinese and Western medicines have resulted in Mainland Chinese perceiving Chinese medicine as an equal partner with Western medicine in this overall health care system. In a recent study of a group of Mainland Chinese graduate students at a university in the United States, Ni Peihua found that these students are quite familiar with the strong points and shortcomings of both medicines, and are apt in choosing one or both of them in order to minimize undesired effects and maximize desired effects (Ni 1993).

Preventive Campaigns Soon after the 1949 Revolution, the new government realized that medical modernization would be a piecemeal process in the Chinese situation. Endemic and infectious diseases were rampant at that time, and the nation had few resources for dealing with these problems. The priority for public health care was to concentrate on preventing and controlling a few infectious and endemic diseases (Wen 1983:140). In swiftly attacking the key identified problems with scarce resources, a national program to mobilize masses of people in health care work was begun by the Ministry of Health (Worth 197.5). This reflected Chinese Communist experiences from before the revolution. In 1934 Mao Zedong declared: "The central task is to mobilize the broad masses to take part in the revolutionary war. If our comrades really comprehend the task, then they should in no way neglect or underestimate the question of the immediate interests, the well being, of the broad masses. For revolutionary war is a war of masses, it can be waged only by mobilizing the masses and relying on them" (Mao 1961:147). The major instrument for mass mobilization for public health was the "Patriotic Health Movement" begun shortly after the Communist Party took power. The first major central government campaign was conducted in 1952 (Chen 1984:197). Since then, health campaigns became regular events in the life of the Chinese people. The National Committee for Patriotic Health [65]

Health Care Concepts and Resources

Campaigns was once headed by Premier Zhou Enlai, and subcommittees were established in every province, municipality, autonomous region, prefecture, and county, and also in government departments and enterprises, in urban neighborhood organizations, and in agricultural cooperatives (Wen 1983:138). The focus of the patriotic health campaigns was on immunization, environmental sanitation, protection of sources of water, house cleaning, and elimination of the "four pests"-rats, flies, mosquitoes, and bedbugs (Chen 1984:196). The Patriotic Health Campaign in the rural areas was focused on "two controls"--of drinking water and manure-and "five reforms"-repairs of wells, latrines, animal pens, stoves, and the general environment (Wen 1983:138). Prior to and during these campaigns, people of every social level were mobilized. Propaganda means such as radio, newspapers, film, wall posters, school bulletin boards, slide shows, cartoons, lectures, plays, public forums, group discussions, mass parades, exhibits, and television were used to activate people to conduct public health activities of all types, including street cleaning and even personal hygiene. Schools, communities, workplaces, communes, and production brigades were required to educate people on improving sanitation and destroying the sectors of communicable diseases, and on the genn theory of infection. Hospitals as well as health care professionals and medical school students were actively involved to provide technical support. At the same time as the mass campaigns, hundreds of health care workers \Vith limited training traveled to rural and urban areas to construct and "serve the people" in local health care facilities (Lee 1982; Lucas 1982; Worth 1975). As early as 1954 nearly every factory and mine '.'.cith one hundred workers or more had its own medical center (Hillier and Jewell 1983:77). These health clinics, stations, and centers were directed by the few formally trained and experienced doctors, who provided primary health care and supervised various preventive programs at the local level. In 1960, to further reinforce health care provision in rural areas, thousands of high school graduates as well as young medical college students were sent to the countryside following short periods of training to serve as "barefoot doctors" (New 1974; Rifkin 1977; Rosenthal and Greiner 1982). Trained with simple skills in both Chinese and Western medicine, they worked alongside peasants in the fields. This campaign greatly facilitated the expansion of a health care infrastructure in the rural areas. [66]

Health Care in Modem China and Taiwan

Each commune typically had a three-level health network. At the highest level was the commune health clinic staffed by professional doctors, nurses and paramedical personnel. It served as the center of the commune health network, providing a wide range of preventive and curative (both outpatient and inpatient) services. At the middle level was the medical station in each production brigade of the commune. It was staffed by several barefoot doctors responsible for the prevention and treatment of some common and relatively minor illnesses. At the bottom level were the health aides of the various production teams of a production brigade (Lee 1982:633).

The estimated 1.6 million barefoot doctors played an important role in reinforcing the mass mobilization policy (Worth 1975), as well as in reconstructing the Chinese rural health care system and overcoming the shortage of doctors in the countryside. Besides providing immediate care, they were also responsible for government prevention efforts such as immunization and physical checkups (Chen 1984). The policy of prevention, which combined professional efforts with mass mobilization, remained a key element in the Chinese health care system. By encouraging the masses to participate in public health activities, the nation's health consciousness was raised to a new level, and the ideal of prevention was strengthened among the people. Most important, the role of the general public in improving its own health was reinforced. In 1951 one of the most ambitious schemes of the new government, the Labor Insurance Regulations, was enacted to protect factory workers when they become ill. In the following year the insurance program was extended to government employees and teachers. From 1952 onward the free medical service for workers and government employees in cities and towns was gradually extended. Medical institutions at the county level and higher were generally operated and financed by the central government. Before the commune system was abolished in the late 1980s, two-thirds of the rural hospitals were run by people's communes, and the remainder by the government. Under this system, provision of health care services was practically free of charge to the individual patients. The modem health care system developed in Mainland China has put great emphasis on prevention from the individual perspective. Under the circumstances, with an enormous population and a severe shortage of health care resources, the approach that combines both individual and professional efforts to mobilize every means to deal with health problems was the only [67]

Health Care Concepts and Resources

conceivable strategy. After more than forty years of implementation, the success of this approach has strengthened the people's resilience and endurance-two main characteristics of the tradition of Chinese health culture.

Health Care in Taiwan The island of Taiwan is located south of the East China Sea, with the Pacific Ocean to the east and the Taiwan Strait and Mainland China to the west. Since 1949, Tai~an has been administered by the Chinese Nationalist Guomindang Party. Both politically and economically, Taiwan adheres to a system based on Western capitalist principles. In recent decades Taiwan has undergone rapid industrialization and urbanization. Its population also has shown dramatic growth, and is now approximately eighteen million. During the half century of Japanese occupation (1895-1945), the Japanese policy was to "Japanize" Taiwan's social and political structures. As they attempted to modernize the island, many practices were replaced by Japanese versions of modern science and technology. Chinese medicine, as part of Taiwan's Chinese cultural heritage, was restrained or downgraded. By 1949 when the Guomindang retreated to Taiwan from the mainland, the health care system was already Westernized, and the practice of Chinese medicine was severely suppressed (Unschuld 1976:301). After the Guomindang government gained power in Taiwan, all laws established by the Japanese aimed at suppressing the practice of Chinese medicine were abolished. One of the major reasons for this was to satisfY the sizable population which followed the Guomindang government from the Mainland. Some of these followers "had never acted as physicians on the mainland, [but] lacking in employment, they wanted to try their hand at medicine by claiming family skills or knowledge from independent readings" (Unschuld 1976:303). Despite the legalization of Chinese medicine, the government neither integrated it into the state health system nor actively supported it. Two of my key informants in Flushing were from Taiwan, and they offered reasons why Chinese medicine was not integrated into the state health system there (one had served many years as a military physician, and the other was a university professor). First, long before 1949 the Guomindang government had lost interest in promoting the practice of Chinese medicine on the mainland. Although [68]

Health Care in Modem China and Taiwan

there were arguments about the role and the value of Chinese medicine in Chinese society, both within and outside of the nationalist government, the debate was overshadowed by war efforts first against Japan and then against the Communists. The government, then in a process of decline, had only one hope-to reestablish its power through Western support. They expected in time to introduce Western medical modernization. Then, when the Guomindang arrived in Taiwan, they found that Chinese medicine had been severely suppressed during the decades of Japanese occupation. Most of the individuals who followed the Guomindang to Taiwan, moreover, were either military personnel or professionals with Western training and had little contact with Chinese medicine. Within the government, the majority never thought Chinese medicine was scientific, and there were few advocates for it among this ruling elite. Those few professionals who supported the practice of Chinese medicine did not have the resources to promote it in Taiwan. Guomindang policies in Taiwan all supported Western medicine. At the same time, the government did recognize and legalize Chinese medicine, even if it gave little support for its development. Because of the relatively low position of Chinese medicine in Taiwan, its popularity has been limited. The 1970 health statistics of the Taipei City Health Bureau showed that in this capital city of 1. 7 million people, there were 1,862 Western medical doctors and 1,090 pharmacies selling Western medicines compared with 348 registered Chinese medicine practitioners and 515 traditional pharmacies. According to Paul Unschulcl, the urban public substantially favored Western medicine, and the practice of Chinese medicine was just as unpopular among the rural Taiwanese population (Unschuld 1976:312). Nevertheless, Chinese medical practice has been struggling to grow in Taiwan. Because Chinese medicine is deeply rooted in the cultural system, the people's basic interest in it has not totally disappeared. Particularly since the mid-1970s, and due to growing worldvvide interest, Chinese medicine in Taiwan has received increasing attention at every social level (Kleinman 1980:63). The health care system in Taiwan during the Japanese colonial period was dominated by a developed Western-style medical and public health network with extensive impact upon the population (Unschuld 1976). Since 1949 Western medicine has continued to flourish. Improving the Western health care model has been the central aim of Taiwan's health care policy. After forty years of development, Taiwan's health care system now mirrors that of developed Western societies in its scope of services and medical technology [69]

Health Care Concepts and Resources

for diagnosis and treatment (Lin 1984). According to one recent medical school graduate from Taiwan who arrived in the United States to obtain a dentistry degree at the University of Connecticut, In general there is not much difference between Taiwan and America. Most of the doctors in Taiwan are either those who graduated from American medical schools [and] then went back or those who graduated from the few very good medical schools in Taiwan. The teaching texts and equipment in medical schools of Taiwan and here are very similar. So there should not be much difference in terms of knowledge between doctors in Taiwan and here. The health care facilities are as much high tech as you can find here since there is no restriction at all for Taiwan to get the most advanced medical technology from here, and because money is not a problem for Taiwan to buy anything. In addition, Taiwan is also capable of producing some high tech equipment. Dominated by the Western health care model, the Taiwan Department of Health designs, installs, monitors, and assists health programs throughout the island. In each of the two dozen cities of Taiwan, a bureau has been set up to carry out health programs. In rural areas, at least one health station was established in each of 336 townships. In some aboriginal and other remote areas, "health 'rooms' are scattered throughout" (Lin 1984:102). Unlike the situation in Mainland China, in Taiwan the health care system relies heavily on private providers. In 1982, for instance, there were 958 public hospitals and clinics in Taiwan, as contrasted to 10,532 private health care facilities (Lin 1984:101). As Chinese medicine has been excluded from the public health care system in Taiwan, and Western medical professions have had absolute power at every level of Taiwan's health care system, the relationship between Chinese and Western medical practitioners is one of competition rather than cooperation (Kleinman 1980; Lee 1982). Western medical professionals have enjoyed much higher prestige in Taiwan than traditional medical practitioners (Lee 1982:634). Still, although Chinese medical pi·actices are considered to be nonscientific, a considerable number of people choose them as alternatives.

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[8] Health Care Resources in Flushing

Soon after I arrived in Flushing, I spent a morning walking throughout the area. Everywhere I caught the wafting odors of food markets and of seasoned dishes cooked in countless Chinese restaurants, and everywhere I saw the signs of doctors' offices. I found myself wondering if there were more Chinese restaurants than doctors' offices or if it was the other way around. After inventorying the rich variety of health care resources, it became evident that the health care system in Flushing was a complex, pluralistic one, with the ample number of health care providers falling into three groups: (1) allopathic Western health care providers, (2) non-allopathic health care providers of mostly Chinese traditional medicine, and (3) other channels and means of obtaining health care.

Western Health Care Providers

Allopathic providers supply the majority of health care in Flushing. This resource system includes two private hospitals; about two hundred private Western-trained and licensed Chinese physicians; more than fifty Westerntrained but unlicensed Chinese physicians; five Chinese-owned Western medicine pharmacies; and at least fourteen Chinese-owned grocery stores and food markets that carry Western medicines as well as Chinese herbal remedies. The two private hospitals are located in the central district of Flushing. One has 463 beds, the other 487. These two hospitals, equipped with some of tl1e most advanced medical instruments, are capable of providing a wide [71]

Health Care Concepts and Resources

range of services. In both hospitals there are bilingual or trilingual signs at the entrances of the various departments. One hospital has signs in English, Chinese, and Korean; the other, signs in English and Spanish. During my fieldwork I discovered that very few Chinese elderly utilized either of these two facilities. Interviews with staff and social workers of the hospitals revealed some of the reasons. One social worker stated, "Except for the emergency situations, few Chinese elderly come here. I am not sure about the reasons. But from what I have heard, it is that they like to see their own Chinese doctors, and probably they do not see doctors unless they have to." In an interview with another social worker I asked why no bilingual patient registration form was available, despite the fact that so many Chinese, Korean, and Indians lived in the area. She commented, "We are aware of that, but we have not developed one yet." According to this staff member, the administrators of the hospital realized the need for provision of services to the growing Asian American population. They had tried to form an outreach program to target Asian Americans, but the program had not been implemented because of lack of financial resources and personnel. Although the two hospitals are in convenient locations, elderly Chinese are likely to go there only under emergency circumstances. The major barriers to utilization, according to my elderly informants, were that the hospitals had few Chinese doctors and were too expensive. If individuals felt they had to go to a hospital, they traveled to two lower Manhattan city hospitals where there was financial assistance for low-income individuals and bilingual staff. However, the trip usually took an entire day, and appointments had to be made several weeks in advance. The two hundred licensed Chinese Western-trained physicians in Flushing represented eighteen specialties ranging from allergies to surgery (Chinese Business Directory 1993). A large number of these physicians were American trained. They came from either Taiwan or Hong Kong and settled in the United States after receiving their medical degrees. As more and more Chinese have migrated to Flushing, physicians have located there to establish medical practices. Some were also American-born Chinese (knmvn as ABCs). These individuals decided to start their medical practices in Flushing because of the increasing Chinese popnlation and because they are able to speak Mandarin. Most of the physicians I visited had fairly successful practices. Every doctor I met had a private office; some had more than two offices. Most of these offices were located in relatively new apartment buildings. Some of the offices I visited were quite impressive in their size and the range of health care [72]

Health Care Resources in Flushing

equipment they held. Non-Asian patients made up a large percentage of their patients. Few of these physicians recommend any Chinese medicine to their patients. Most of them are skeptical of Chinese traditional health beliefs and medicines. Many feel that traditional practices lack scientific foundation, and this is especially true of physicians from Taiwan. Among the two hundred licensed Western medicine physicians, only forty-five accepted Medicare payments, and only three would accept Medicaid patients. None specialized in geriatric medicine. There are many professionals among recent immigrants from Mainland China, and medical doctors are not uncommon among them. Some of these individuals are Western medical doctors who graduated from Chinese medical schools. Some were quite successful in China, but most are unable to pass the medical examinations in North America because of the language barrier. Their unlicensed practices in Flushing operated through word of mouth. Although they could not accept Medicaid, Medicare, or health insurance of any kind, they offered very low prices. For example, a doctor I interviewed who was formerly the chief surgeon of an urban hospital in China charged between $20 and $40 per visit. Besides giving diagnoses and making suggestions of further treatment, these doctors tell their patients which medications they should take. The patients then obtain the medications through the black market, including mail order sources.

Traditional Chinese Medicine To discover the range of traditional Chinese medicine practitioners in Flushing, I examined local Chinese newspapers and magazines in which many traditional Chinese medical doctors advertise, as well as a newly published Chinese business directory. I was able to find seventy-four doctors of traditional Chinese medicine, of whom only fourteen had either state or city acupuncture licenses. The number of traditional Chinese medicine practitioners and healers listed in my sources may still be far short of the actual total, since many do not want to publicize their services. Among the fifteen Chinese traditional doctors that I eventually interviewed, only four advertised in the newspapers and directories. Most traditional medicine practitioners claim to treat a wide range of health problems, from foot pain to stroke rehabilitation, to skin infections, to [73]

Health Care Concepts and Resources

heart disease. Some advertise specialties, such as body injury, arthritis, high blood pressure, lack of energy, hemorrhoids, anemia, kidney insufficiency, lever diseases, and cancers. The methods of treatment are various and include acupuncture, cupping, herbal treatments, and Chinese hand manipulation massage (tui na). Some practitioners specialize in one or two of these treatments, and others claim to have mastered all of them. Most doctors of Chinese medicine see patients in their own apartment, but they also rent a small room in a herbal store. A large number of them make home visits. The charge for each consultation varies from $25 to $60. In Flushing, at least five health care facilities advertise "integrated" practices. In Mainland China, the term "integrated medicine" was developed in the 1950s to refer to the integration or combining of traditional Chinese and Western medicine. The "integrated" facilities in Flushing sell herbs, Westem drugs manufactured in China, and ordinary over-the-counter drugs; they also have attending physicians. In one such facility, there were three doctors. One was a woman who had just graduated from a Chinese traditional medical college before arriving in the United States. Another was a middle-aged man who claimed he was an "integrated" doctor in China, The third, also middle-aged, told me he was good at Western medicine but used Chinese traditional medical methods as well. During one visit I made to this facility, one of the male doctors explained, "Chinese traditional medicine is very good at treating disease, since it tends to get rid of the problem from its root, yet with minimal side effects. \Vestem medicine has very advanced diagnosis technologies, but the drugs are too strong, and they often cause other problems. Integrated medicine is better because it applies the advantages of both." "Amateur doctors" were persons who occasionally provided free services for people they knew. I interviewed one amateur healer who was sixty-seven years old. He learned acupuncture and Chinese traditional medicine diagnostic methods from his father. After he graduated from a Chinese school of Western medicine, he worked in a hospital in Shanghai as an internal doctor. He gave up his medical practice after he immigrated to the United States in the 1980s, since he did not need the money.

Channels of Obtaining Health Care Traveling to Mainland China and Taiwan to receive medical treatment was also common among the elderly people I surveyed. I found that a fifth [74]

Health Care Resources in Flushing

of them had been to Mainland China or Taiwan to seek health care within the past three years. Many immigrants who came from Taiwan and Mainland China after retirement were still covered by medical insurance under the retirement policies of these countries. For some, trips back to their homelands were for receiving free treatment; others, however, went for the relatively low costs of medical care and the respect they were able to receive there. Mother Chen is a seventy-one-year-old woman who immigrated to the United States from Mainland China in 1970s. Although she is not covered by any health care insurance in China, she goes back every year to visit and for health care reasons as well. In 1992 she had a mastectomy in Shanghai. The Chinese government [she said] has many good policies toward people like us. Hospitals are especially careful when they are treating people who come back from abroad. Sure, the cost of an operation for me was much more expensive than for other Chinese, but there is still no comparison if I had it done here. Since I am an overseas Chinese, they put me in a special room which provided luxuries only certain individuals would have. They sent their best doctors to view my case. They do not want to make any mistakes, because they want me to tell others how good they are when I come back to the United States. I did not feel that I was in a hospital; I felt as if I was in a hotel room. Where would I have gone here? Of course I would have ended up in one of the city hospitals, because I could not afford a good hospital. Nobody really pays attention to you there since they know the reason I was there is because I could not afford a better hospital. ... Why is it that these city hospitals are not good? Because they do not make money, and good doctors do not work there. To obtain prescription medications without a prescription is not a difficult thing to do in Flushing, and there are three common ways to do so. Pharmaceuticals made in Mainland China, Hong Kong, and Taiwan are easy to find in Chinese grocery markets and herbal stores in Flushing. Although the range of drugs is limited, many of them are equivalent to American-made prescription medications. Mail order is another means to get medications from outside the United States. In Flushing, even though some Chinese-made Western prescription medications are available in stores, their range is limited and the prices are high. Most of these medications are available more cheaply if bought directly from China or Taiwan. Especially in Mainland China regulations are relaxed, and anyone can obtain most medications, even powerful ones, in [75]

Health Care Concepts and Resources

large quantities and at a very low cost, or even free if one has connections with a doctor. Friends in China can be asked to mail medicines Travel between the United States and China or Taiwan is another channel for obtaining prescription drugs. One elderly woman in Flushing who was going to Mainland China for a visit received a call from a friend who asked her to bring back several kinds of antibiotics. I asked her, "How do you do that?" She replied, "I do not have to do anything; her relatives have already prepared them." As one of my key informants told me, "When I go to China, most of the items in my baggage are gifts. But when I come back from China, most items in my luggage are medications. Some of them are for my family, but most of them are for other people."

Published Resources

Books, newspapers, and other publications are another source from which people, including the elderly, obtain health care information. In one of the largest Chinese bookstores in Flushing, health-related publications occupy several sections. The Literature of Classic Medicine section includes theoretical literature on internal medicine, yin-yang theory, and the Five Elements philosophy. Most of these books are distributed by publishers in Taiwan, Hong Kong, and Mainland China. A few, hovvever, arc published in the United States. Among the hundreds of items in the bookstore's section on Medical and Health Knowledge are works on medical developments in the diagnosis and treatment of common health problems such as heart disease, diabetes, and cancer, as well as introductory texts bearing titles such as "What is Diabetes?" 'What is High Blood Pressure?" A third section, Self-Care and Healthy Foods, contains an extensive array of publications for self-care from the perspectives of both Chinese and Western medicine, including how to use Tai Chi, Qi Gong, and other daily regimens to maintain health and treat certain health problems. Interestingly, among the books on how to utilize Western medicine in self-care there are quite a few publications expressing opposition to Westem medications, with titles such as "Treat the Health Problems without Medication" and "Drugs Are Poisons in Nature." One further section of health care literature, Healthy Habits and Longevity, includes Chinese and Westem books on how to maintain good health in old age. Most of these books were written by well-known physicians in Taiwan, Hong Kong, and Mainland China. There are also a few publications written by \Vestern physicians and translated into Chinese. [76]

Health Care Resources in Flushing

In the other two Chinese bookstores in Flushing, medicine and health care books also occupied a large space. The extensive offerings of healthrelated publications in Flushing's Chinese bookstores reflects the strong demand for such resources. According to the \Vorld Journal Bookstore, among their best-selling books in 1992 Qi Gong and Health ranked fourth, and Healthy Cooking ranked seventh. There were three Chinese daily newspapers and approximately ten weekly newspapers available in Flushing. The weeklies, predominantly published by political, religious, and nonprofit organizations in North America, could be obtained free of charge in various locations, such as the entrances to restaurants and grocery stores. The three nationally distributed dailies were the World Journal, Overseas Chinese, and Sing Tao. The Chinese newspapers carried articles by well-known Chinese and Western medical doctors. Most articles, in addition to advertising their authors' specialization, offered basic knowledge on common health problems and their pathology, symptoms, treatment, and prevention. Many elderly readers collected these articles and used them as a resource for health care activities. One day when I was eating in the Chinese senior center, I noticed that Mr. Ma, a seventyfive-year-old man, made his tea with half a cup of milk. I asked why he put so much milk in his tea, and he replied, "The World Journal says older people should drink milk regularly. But I cannot drink cold milk so I decided to drink milk-tea instead." The three major dailies and almost all weekly publications also carried extensive medical advertisements of local practitioners of both Chinese and \Vestern medicine. These advertisements provided an easy source of information on health care providers for Chinese residents, especially for new arrivals. During my fieldwork I often heard discussions among elderly Chinese about doctors who advertised in newspapers. While I was having lunch \vith a group of people in the Nan Shan Senior Center, three women discussed one such physician:

MOTHER YUAN:

Do you know where he came from?

No, I do not know. But someone said he came from Taiwan. Right, you see here, it says he has a degree from Tai Dai [Taiwan University].

MOTHER CHANG:

My daughter mentioned his name to me before. He is a very good person. Especially his wife, they all say she is very friendly and helpful.

MOTHER GAO:

(77]

Health Care Concepts and Resources MOTHER YUAN:

Does he take Lao Ren Ka [Medicare or Medicaid cer-

tificates]? MOTHER CHANG AND MOTHER GAO:

I do not know.

One day I was invited to visit the home of an informant. While watching Mother Jian prepare lunch in the kitchen, I noticed that there were several doctors· names, obviously cut from the newspapers, taped to the refrigerator door. "Where did you get these?" I asked. "Ho, they are from the World Journal." 'What happened, have you been seeing doctors?" She smiled and said, "No, they are not for me. A while ago I met several people in church who have just come here from China. They asked me about doctors they could see. But I could not remember any names and addresses of the doctors I know, so I cut these advertisements from the newspaper." "But, how do you know they are good?" I asked. "What's good or bad? They are all about the same. But the ones that are always in the newspaper could not be that bad," she said. The World Journal is the largest Chinese daily in North America with several distribution centers in the United States and Canada. Often viewed as favorable to the Taiwanese government, it has the reputation of being the Chinese equivalent of the New York Times. It is the most detailed source of local and United States news, and also news from Taiwan, Mainland China, Hong Kong, and Chinese communities throughout the world. Every day this sixty-page paper provides a large amount of information on financial investments and jobs, and six or seven pages of medical advertisements. The ·world Journal devotes an entire section to health care advice, herbal remedies, and guidelines for seeking a doctor. It also carries news about health research. During March and Aprill993 I collected a weekly set of World Journal medical advertisements and categorized them. (Tables 5 and 6 list the number of Chinese practitioners of medicine, both traditional and Western, in Flushing.) It is not always easy to classify Chinese medicine providers and their specializations, as some claim several specializations. In one advertisement, for example, a well-known doctor describes her practice in this way, Treat various health problems:

Internal, External, Injury, Gynecology, Pediatric, Acupuncture, Physical Therapy, Tui Na, and for other unknown symptoms. [78]

Health Care Resources in Flushing Specializing in:

Allergy, Liver, Kidney, Stomach, Heart, Fertility, Stroke, Diabetes, Arthritics, Menstrual Disorders, Climacteric Syndrome. The health care system used by Chinese residents in Flushing thus is one of great diversity. The form it takes is far from accidental. It reflects the health care needs and demands of this population and also the history of health cultures and institutions of their home countries.

Table 5. Examples of Chinese medicine providers Specialization & methods of treatment

Area of treatment

Gou shang ke (bone and muscle Fractures, various bone and muscle injuries, bone spurs, chronic arthritis, tennis shoulder, injury): Acupuncture, Tui Na, concussions, back pain, sprains, lumbar disk moxibustion, herbs, Qi Gong dislocations, spine problems, internal injuries, (16 practitioners) rehabilitation after automobile accidents, strokes, sports injuries, "fifty shoulders" High blood pressure, cardiovascular diseases, General practice: Acupuncture, herbs and Chi headaches, lack of chi, chronic coughing, internal secretion disorder, colds, derangement of chi and Gong, Tui Na (9 practitioners) blood, hayfever, diabetes, bronchitis, asthma, lack of energy, loss of sleep Liver & kidney specialists: Cirrhosis, chronic and acute hepatitis, nephritis, Acupuncture and herbs cystitis, blood in urine (7 practitioners) Skin diseases specialists: Lupus erythematosus, black mole, freckles, skin Acupuncture, herbs, and rashes, dermatitis, psoriasis, Hong Kong foot (athlete's foot), eczema, corns, furuncle integrated methods (5 practitioners) Proctalgia, fissure in anus, anal fistula, internal and Hemorrhoid specialistsintegrated method: external piles Non-surgical, herbs (4 practitioners) Cancers of various kinds Tumor specialists: Acupuncture and herbs (1 practitioner) Problems with fertility, various sexually transmitted Venereal specialists: diseases, impotence, sexual function disorder Acupuncture and herb (1 practitioner) Irregular menstruation, menstrual disorders, Chinese OB-GYN: miscarriage, climacteric syndrome, sterility Acupuncture and herbs (7 practitioners) Source: World Journal, March and Aprill993.

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Health Care Concepts and Resources Table 6. Chinese Western-style health providers Type of physician Dentists Oral surgeons Obstetrician & gynecologists General practitioners Internists Urologists Ophthalmologists Cardiologists Gastroenterologists Neurologists Pediatricians Dermatologists General surgeons Plastic surgeons Venereal diseases specialists Chiropractors Otolaryngologists Allergists Podiatrists Speech pathologists Total

Number 26

13 12 9 8 8 8 7

7 7 6 5

5 5 4 4

3 3 3 2

145

Source: World Journal. March and Aprill993.

The Adaptation Strategy of Traditional Chinese Medicine

Many Chinese medicine practitioners seemed to be managing quite successfully in their Flushing practices. The range of their practices clearly did not fit the stereotypical image of traditional Chinese medicine practitioners-who only know how to treat muscular-skeletal problems, for example. The specialization of treatment among these Chinese medicine practitioners is extremely intensive. Some even specialize in treating HIV patients (Hare 1993). The prevalence of Chinese medicine practices in Flushing and elsewhere in New York City demonstrates that there is a great demand for alternative health care services; on the other hand, it also shows the progress that the practice of Chinese medicine has made in adapting to American health culture. Put in a generic perspective, the adaptation strategy of Chinese Traditional Medicine practice in Flushing, as well as in New York City in general, can be examined at both macro and micro levels. [80]

Health Care Resources in Flushing

At the macro level, many practitioners of traditional Chinese medicine who have arrived in the United States in recent years came with the intention of opening practices of traditional medicine. They have also formed several traditional Chinese medicine organizations, which may include nonChinese medical professionals. Thus, the practice of traditional Chinese medicine has become a collective effort, and wide networks and institutions '.'.ithin the United States now pursue effective strategies to obtain popularity and legal recognition. Despite some ideological differences between Chinese and Western-trained acupuncturists in defining the scope of nonWestern medical practice, and resistance from some \Vestern medicine physicians, the efforts of both patients and Chinese medicine practitioners have resulted in the establishment of a New York State Board for Acupuncture in 1991 (New York State Education Department 1991:15). During my fieldwork, traditional Chinese medicine associations and groups were lobbying frequently for certification of herbal medical practices and for insurance coverage of traditional Chinese medicine treatment in New York City. In addition, professional conferences and seminars were also held frequently to publicize Chinese medicine. In the spring of 1993 an international conference on Chinese medicine was held in Flushing. Hundreds of health professionals and people interested in Chinese medicine from all over the world participated, including internationally known Chinese medicine experts and practitioners from the United States and China, and representatives of health research institutions within the United States, Mainland China, and Taiwan. Ongoing research on the integration of Chinese and Western medicine to treat various health problems, including HIV and AIDS, was presented. Discussions regarding further development of traditional Chinese medicine within the United States were also on the agenda of this conference. At the micro level, many Chinese medicine practitioners frequently invite newspaper reporters to their offices to interview their patients. Dr. Wang, a former director of the Coronary Heart Disease Division in the Academy of Chinese Medicine in Mainland China, published five research articles in both Chinese and English newspapers in New York City, featming his successful use of acupuncture to treat coronary diseases. Patients are also encouraged to write to newspapers expressing satisfaction over their experiences with doctors of Chinese medicine. Many practitioners have formed clinics where several doctors, each with his or her own specialty, work together to treat patients. In Flushing, some Chinese medicine practitioners [81]

Health Care Concepts and Resources

even team up with Chinese doctors licensed in Western medicine to provide health care services. For patients, this means that some of their Chinese medicine treatments can be covered by health insurance, if the practitioner they see works under the supervision of a licensed doctor of Western medicine. For doctors of Chinese medicine, joint practice provides an opportunity to establish themselves; for doctors licensed in Western medicine, a Chinese medicine associate working in their office may attract more patients.

Long-Term Care At the time of this study, there were several nursing or long-term care facilities in the Flushing area. All were owned and operated by non-Asians. Although they had diverse resident populations, Asians, and Chinese in particular, were not a major part of them. During interviews with nursing home managers, I was often asked why so few Chinese inquired about their services, despite the fact that some of these facilities had attempted to target Asian groups and had recruited Asian staff. In general, the low utilization of long-term care services by the Chinese in Flushing can be attributed to several factors. First, many elderly Chinese in this community had only recently immigrated and were still ambulatory and able to live in the community. In addition, many elderly Chinese were not eligible for government health care benefits and could not afford long-term care on their own. Third, many Chinese attach a social and cultural stigma to living in a nursing home or sending their elderly parents to one. In fact, I quickly learned that the issue of long-term nursing home care was not a favored topic of discussion for elderly Chinese and their family members in Flushing, although this reluctance does not necessarily reflect a lack of need for such residential care services. People expressed significant reservations about the prospect of spending the last moments of one's life in a nursing facility. As one informant said to me, "Luo ye gui gen (leaves always fall around the roots of a tree)-this is the Chinese way to close one's life. If I come to that point, I will go hack home [to China] and die where I was born." Discussions with Chinese health care providers and social workers in the community confirmed this reluctance to consider long-term care as an option. From the children's viewpoint, sending an elderly parent to be cared for by strangers goes against the tradition of filial piety. And the elderly [82]

Health Care Resources in Flushing

themselves would feel they were being punished for not having properly raised their children if they were sent by them to a nursing home. During an interview \vith the director of a nursing care facility a few blocks from the center of Flushing, I learned that there was a Mandarinspeaking resident in the facility. I asked if I could meet her, and the director agreed, saying that it might be a very good idea since this Chinese lady had not been very communicative since moving in about a year ago. "She may be very happy to talk to someone who knows her language." When we arrived at the recreation area on the third floor, I saw a Chinese lady sitting quietly, with her eyes closed, in a wheelchair at one corner of the room. She appeared to be close to 90-much older than what I had expected. She looked worn, but peaceful. The director walked over to her and said: "Mrs. Zhou, someone would like to talk to you." Mrs. Zhou opened her eyes slowly, but there was no focus. I moved close to the wheelchair, and greeted her in Mandarin. She did not say anything, and I could not tell if she was looking at me. After I had tried to greet her in all the Chinese dialects I knew, Mrs. Zhou's eyes were teary but there was no audible response. On our way back to the office, the director recounted the history of Mrs. Zhou. Mrs. Zhou lost her husband a long time ago, and has only one child. This daughter married an American and immigrated to the United States in 1984. In 1989 they divorced, and the husband disappeared, leaving Mrs. Zhou's daughter in Flushing with two young children, one two years old and the other three. The daughter was barely able to support them despite working long hours as a waitress. At her daughter's request, in 1990 Mrs. Zhou came to Flushing from China to help take care of her two grandchildren. The whole family lived in a small one-bedroom apartment in Flushing where during the day, besides watching the two grandchildren, Mrs. Zhou sewed to earn extra money for the family. Mrs. Zhou's arrival did help her daughter get on with her life, but a year later Mrs. Zhou fell and broke both hips. Now here daughter had to work and to take care of both her children and her mother. As the situation became more and more unmanageable, she thought about a nursing home. "She visited us many times and asked many questions before she brought her mother in for the first time in 1991," the director told me. Mrs. Zhou's daughter decided upon this particular facility mainly because it was close, only half a mile from their apartment. But after only a week, the daughter came and took her mother back home. Then, a few weeks later, she brought her mother back. "I can tell it was very hard for her to make the decision," [83]

Health Care Concepts and Resources

the director said. "As many of my Chinese friends told me, it is not a nom1al thing to do in your culture." Every time the daughter came to visit, Mrs. Zhou cried and asked her daughter to take her home. "She cried all the time during the first several months here. We tried to talk to her and comfort her, but no one was able to speak her dialect. We only have someone who speaks Cantonese," the director said. Finally, Mrs. Zhou managed to run away from the home after her hips had healed a little bit, and her daughter brought her back. After this incident, the facility decided to give every resident an electronic bracelet. Somehow, Mrs. Zhou managed to get to her daughter's home once again, even with the bracelet. After this, the daughter moved away from Flushing. "Ever since she was brought back for the second time, she has hardly talked, and soon we had to provide her with a wheelchair," the director said. In contrast, demand and utilization for in-home services provided by home-care agencies such as the Visiting Nursing Association were substantial among the Flushing Chinese population. Many of these agencies had Chinese-speaking home health aides on staff and were able to provide services that met their elderly clients' language needs. Most of these aides were recent immigrants from China and worked as home health aides mainly because of economic reasons. Few among them had any advanced home-care training before they became a home health aide. But, despite the frequently raised concerns by Chinese regarding the quality of in-home services, the demand for them was great and the waiting period was often long.

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PART III.

Aging and Health among the Chinese Elderly

[9] Concepts of Aging

Traditional Chinese culture values age as a source of wisdom, and the elderly in Chinese society are accorded prestige. As a result, it is considered inappropriate for elderly people to express concerns about aging or worries about being unhealthy. But the data I gathered from conversations with Chinese elderly in Flushing reveal that a large number of individuals connect their health problems directly to old age. This association of health problems with aging also affects the way they maintain their health and seek health care.

"You Will Know What I Am Talking about When You Get Old" A large number of the elderly people I encountered believe that health problems always appear when people grow old. Mr. Fan is a seventy-oneyear-old man who immigrated to the United States from Taiwan in 1988. In Taiwan he had been a successful businessman. The first time I asked him about his health, he replied, "Marna hu hu." 1 Later, when asked what kind of health problems he has, he said: "I do not have any serious problems yet." Then in a discussion on the subject of how a person feels when old age approaches, he said, "You are getting old when your ears cannot hear things as clearly as they did before, when your eyes no longer can read anything vvithout wearing glasses, when your legs become heavier as the day goes by. These are the signs of being old." 1 Ma rrw lm hu means "not too bad." However, it is also considered a modest response to questions regarding one's success. For example, the usual reply to the question, "How is your business?" is "Marna hu hu" even if one is doing well.

[87]

Aging and Health among the Chinese Elderly

The ability to handle these problems is also associated with age. Mother \Ven, a 75 year-old lady commented on this with a personal example: I am old. Before, I could do all kinds of things. I could walk ten miles a day. But now, I have to take a rest every fifty meters. It is true, age does make a difference. Several years ago, I still could do many things even though I had arthritis. But now I just can't tolerate the pain anymore. I feel my whole body suffers the pain. Even the painkiller does not do anything anymore. Probably I have had too many painkillers. My whole body is quitting. I know I am getting old. Mother Zhang, a seventy-three-year-old woman who immigrated from Mainland China in 1985, told me: "Before, when I had a cold, or a bad stomach, it only took several days to recover. I did not have to do anything about them. Now if I get it, even when I take many meclications, it still takes a few weeks to get better. My body is no good anymore. I am old." Mr. Chen, a seventy-six-year-old Mainland China immigrant told me: "I never had any health problems before, never even caught a cold. All of a sudden I started to have all kinds of problems two years ago. I am a 'meteorologist' now. I will know if tomorrow it is going to rain-my legs will tell me. You probably would not understand. Wait until you get old, then you will know what I am saying."

'"When You Have to Be Careful about \Vhat You Eat"

While being able to eat what you want and sleep without interruption are considered signs of good health, many elderly Chinese consider the opposite to be the first signs of being old. Mother Qian, a seventy-year-old Taiwanese immigrant, explained: I love to cook, and I enjoy eating all kinds of foods. That is why my children asked me to try to lose some weight. I did not care; they are Americanized anyway. I never believed that I had become an old woman. A lot of my friends, they are younger than I am, yet they cannot eat this and that. But I could-until one year ago, I could still eat pizza and salad. They never gave me problems. But now, it can give me a had stomach if I eat something not warm enough. I have to admit I am old now. When you are old, you have to be careful about what you eat. Right, I still do not want to [88]

Concepts of Aging

think I am an old woman. That is in my mind, hut my body does not agree with it. Mr. Liang was an educator before he came to this country in 1988 from Mainland China. During the past two years he has had difficulty sleeping. He said that the problem he is having has much to do with his aged body: Now I am seventy-two years old. Many people look old when they are only in their sixties. I do not. People still guess that I am around fifty. But, only I myself know I am old now.... How? When I first came to America, the situation was very hard, but I never had a problem ·with sleeping. No matter what happened, how noisy the room was, I would go to Su Zhou2 immediately after I got in bed. A lot of my friends admired me so much. Just starting two years ago, things changed .... I could not have a good sleep even when I took sleeping pills .... Age does not lie to you. When asked if he ever used medication or saw a doctor, he said: "What can a doctor do? The sleeping pill will cause other problems for me. It is only because I am old."

«The Body Is Just Like a Machine" One of the characteristics of Chinese culture is that people often view themselves as part of the natural and material world. They believe that laws applying to all other things in the world will also apply to them-that they, like all living things, go through a cycle from being born to dying. During my fieldwork in Flushing, I often heard people say: "the body is just like a machine, sooner or later it will break down." Now, using a machine as a metaphor to describe the human body-a part of the natural world-may sound contradictory. What most elderly people meant, however, was not that they saw the structure of the human body as a machine but that both machines and bodies eventually break down. The first time I encountered this metaphor was in a conversation with Mr. Mei, a former military officer in Taiwan. Mr. Mei is eighty and came to this country in 1985. He is a tall and quiet man. He walks with an erect posture 2 "Su Zhou" is a beautiful small city in China. It is referred to as a heavenly place. The metaphor "Go to Su Zhou" means that one falls asleep and dreams of this wonderland.

[89]

Aging and Health among the Chinese Elderly

and never speaks to people while he is walking. Even when he sits down, he demonstrates the years of military training. One day, at the Chinese senior center, Mr. Mei walked out from the mahjongg room with both hands massaging his back. "What is wrong, Mr. Mei?" I asked. "No problem. I have been sitting there for four hours,'' he said. "You do not look like a person who has a back problem," I responded. 'What makes you say that?" He laughed, and sat down next to me. The following conversation ensued. You know, it is not easy to judge if people are in good health or not, just from the way they look. Not always anyway ... GUO: Why is that?

MR. MEl:

with a smile: You are giving me an examination. That is all right. ... There are a lot of people who may not look healthy, and they can live for a long time. Well, there are also many others who may look so healthy, but one day they are gone. I have a friend who twenty years ago was very healthy, very strong. He always worked, and worked hard. He always laughed at doctors. He thought they were useless .... Why? He never went to see a doctor in his whole life. I think that is why he thought that. He drank and ate a lot. But one morning they found him dead in his bed. He was only fifty-five. GUO: Did they find out the reason?

MR. MEl,

Heart attack. Nobody believed it. We all thought he could live a long time. His body was like a rock. But ... GUO: This kind of thing happens a lot. People usually say, "He died from a heart attack," but not "He died from illness." Why is that? MR. MEl: Do you drive? MR. MEl:

GUO:

Yes I do, I drive a lot. Well, you must know a lot about cars? A little.

MR. MEl: GUO:

MR. MEl: GUO:

Do you know when your car has a problem?

One way to know is when it does not run well.

So, the minute before that happened, you thought your car has no problem, right? GUO: Yes.

MR. MEl:

[90]

Concepts of Aging

When you can feel your car has a problem, it may have had a problem for a long time, but you did not know it. It could not tell you either. Some cars run longer than others, and some cars have all kinds of small problems, but they still can run a long time. My son bought a new car several years ago, and one year later the engine went bad. He had to replace it with a new one. You understand? It all depends on how you take care of them. So what I want to say is, the body is just like the machine, a very complicated machine.

MR. MEI:

After this conversation, I asked several informants about their views of this "machine theory." Mr. Cai, a sixty-six-year-old retired government worker, said: "It is exactly right. Our body is a machine; it will have all kinds of problems when it runs too long. You see everyone in this center has mao bing (health problems). Our generation went through so much hardship that your young generation could not imagine. Now we are breaking down." In designing my questionnaire, this "machine" concept statement was included to determine how common it was among elderly Chinese in Flushing. The results showed that 77 percent agreed that "the body is just like a machine."

"People My Age Are the Setting Sun" Quite often conversations turned sentimental when people were discussing old age. Mother Zhang began to cry during one two-hour conversation. She had come to the United States from Mainland China in 1983 when she was sixty-five. Her husband was an officer in the Department of Defense for the Guomindang government. In 1949, instead of following his unit to Taiwan, he decided to remain in Mainland China since he believed that "he never did anything wrong to the people." In 19.58, he died in jail from illness. After that, Mother Zhang had to work as a street cleaner for twenty years in Shanghai because her husband had worked for the Guomindang. "I was married to him when I was twenty. After his death I dreamed about him, even now. I dream about the happy time we had together. It was the best time I had in my life." Mother Zhang looked out tl1e window, then took out her handkerchief to wipe her eyes. [91]

Aging and Health anwng the Chinese Elderly

I never forgot that. He was a nice young man. He was smart too. But that time was too short. I always thought that someday I could get my happiness back, I did not know how, but I always thought so. But the time passed so fast. ... I was so happy when I heard from my brother eleven years ago. My brother also worked for the Guomindang. But he left Shanghai for Taiwan in 1949. He was my husband's best friend. He immigrated to America from Taiwan in 1977. Then he went to Shanghai to see me in 1982, coming from America. He cried when he saw me .... Then he asked me to come to America. Although I loved Shanghai, I had too much hardship there. I thought I probably would still help my children to change their life if I came to America first. Because of their father and me, they had too much bitterness. They did not have a chance to go to college. That was why I decided to come here .... It is easy to make me cry. I was not like this before. Mother Zhang wiped her eyes again, then looked out the window. But not too long after I got here, I thought I cannot live on my brother forever. He has his family and his difficulties too. So I decided to move out. But what can a seventy-year-old lady do? I do not know English, never learned anything. So I started to clean people's houses and cook for them. I worked very hard to save money, to help my three children come to America. Now they are all here. But they nm into the same problems-the language, the [lack of] skills .... Now one is working in a restaurant, another one is a housekeeper in a rich family's house. The other one-I do not know what she is doing. It did not help them much to bring them here. But I cannot help them anymore .... I am old, no use to anyone anymore. Hai (Oh), people at my age are the setting sun, and pretty soon it will be dark. I learned that Mother Zhang had not seen a doctor in the past two years. I visited her the day after I heard that she had fallen while walking and was seriously injured. Her body was covered with bruises and she could hardly walk for three days. She didn't go to see a doctor, but only apphed some Chinese herbal remedies. "Why didn't you go to see a doctor? It could be serious, you know that?" I asked, a httle upset. "What is the use of seeing a doctor?" she said. "I am old, there is no need to waste money on old bones." Several weeks later, Mother Zhang said that she had been in her bed for a month because of a foot injury. Again, she never saw a doctor. "I use home medicine," she said. [92]

Concepts of Aging

"I Am Not Old" In Flushing, there are many elderly Mainland Chinese who followed the Guomindang to Taiwan in 1949. "Going back to the homeland [one day] is the thing that keeps one going," said one of these "Mainlanders," but many of them are unwilling to return to China because "the Communists are still there." They remain waiting for the day that their wish can be realized. In discussing why many elderly people do not come to the senior center, Mr. Fan remarked: They do not want to be constantly reminded that they are old. Since we left Mainland China in 1949, we were always told that we were going to guangfu (reoccupy) the mainland. We waited for more than forty years. Some of us were so stubborn, we did not see the future .... So for years they have kept the dreams of going back before dving .... Some of them died before they had a chance to do that. ... We saw too many of them, it was sad .... We are afraid of seeing ourselves as old persons; that means we are going to die, and could we die before we see the homeland? For many elderly, a fear of acknowledging old age and incompetence are often reasons for refusing to seek medical attention when it is needed. On one family visit, I noticed that a ninety-six-year-old man had difficulty hearing what was said. I asked his wife if he had a hearing impairment. She said that he started to have hearing problems two years ago. A family member then had ordered a hearing aid for him, but he refused to use it because he does not want to believe there is anything wrong with his hearing. 'When he cannot hear what we say, he blames us for not speaking clearly enough because we really do not want him to know anything," she said.

Sheng, Lao, Bing, Si Sheng, lao, bing, si (birth, aging, illness, death) is a common Chinese saying originating from the Buddhist tradition. It suggests that every person has to go through these four processes, no one of which is better or worse. Elderly Chinese in Flushing hold the belief that being born, aging, getting ill, and dying are the natural fate of all human beings, and they have integrated this belief with the modem perception that "the human body is like a machine, it sooner or later will break down." It is pointless therefore to worry [93]

Aging and Health among the Chinese Elderly

about being ill. One of my informants said: "It is sad to be ill in old age, but that is the way life goes." Individuals sharing such beliefs are usually those who have been suffering from chronic health problems for some time. They tend to be unwilling to seek medical help. They will see a doctor only if unbearable pain, sleepless nights, or some other crisis has interrupted their life pattern. They will try some pian fang (secret remedies) learned from their friends or family members, but they often give up after a short period of trying them out because they believe "it takes too long to see the effect" or "there is nothing that can work for me." After learning that one of my informants had fatty pork for dinner, I asked him, "Do you know that fat is not good for your high blood pressure?" He replied, "There were many things I loved to do before, but there are only a few left. I love to eat fatty pork. I had to take so many drugs, and they did not cure my high blood pressure, but they created so many other problems for me. So what is the difference?" There are also many who suffer from multiple health problems but maintain active lifestyles and have an optimistic attitude. Mr. Hu, a seventy-oneyear-old Taiwanese immigrant, is a devotee of ballroom dance. He goes dancing with a group three times a week. At a dance studio, we chatted during a break. You probably will tell me that I am very healthy because I am always everywhere, but you would be scared if I told you how many problems I have .... I know that I feel pain. I cannot do anything about it, but I can forget it. I cannot sit tied; if I do I will feel the pain. If I had stayed home all the time, probably I would have died twice. Everyone has problems, because we are old, because we had very hard lives. That is the way life is. It is no use to sit there and be depressed. Go out and have fun, then you will feel better. His dancing partner, Mother Xu, a seventy-five-year-old lady, added: You can see people die in the hospital every day. Many of them did not die from their diseases, they died because their mind had died first. Many laoren (old people) here worry about illness and dying. What is the use of worrying? Illness and dying are the laws of life. Our ancestors told us a long time ago: everyone will have illness, and everyone will be gone someday. Worrying and relying on doctors and medication are not the smart way.

[94]

[10] Big and Small Problems

One of the most common beliefs held by the Chinese elderly in Flushing is that "for an aged person there is nothing more valuable in the world than to have good health." However, throughout my investigation on this subject, I found that jian kong (healthy) and bu jian kong (unhealthy) are ambiguous concepts among elderly Chinese, and health and illness are often not clearly distinguished. Few people would define a healthy body as one totally lacking in health problems. To most people, to he healthy or unhealthy depends upon one's level of functioning. Many people tell others that they are in good health, yet they still have health problems. These problems are usually called xiao r;wo bing (small problems). There is no standard definition, however, of what health problems should be categorized as xiao mao bing. For some, to have a week-long "bad stomach" is a minor problem, yet for others it may be a major problem since they never had this difficulty before. Some people would even say that they are in good health despite the fact they have suffered from arthritis for a long time. One sixty-year-old woman said that the reason that she is not in good health is because she just had a cataract operation. "I never had any operations in my hfe," she explained. I recorded the following discussion with a key informant, Mr. Fan, after learning that he suffered from serious arthritis, especially during wet weather. GUO:

Why do you tell me you are in good health when you have arthri-

tis? [95]

Aging and Health among the Chinese Elderly

I do have that problem. But it does not trouble me much. I can handle it. I still can walk well and eat well.

MR. FAN:

So despite just saying that you have this problem, you still think you are in good health. Do you think that arthritis is a problem?

GUO:

According to the medical book, or the doctor, it is. But there would be no one who is truly healthy if the decision is made according to [doctors].

MR. FAN:

In another conversation, Mr. Yang said, "I am eighty-one years old. I cannot compare with you young people. But considering my age, and compared with most people my age, I am very healthy. I do not have to rely on anyone. I can go where I want to go, and do things on my own." Many people also believe that not seeing a doctor, and not taking any medication, were signs of being healthy. When asked how his health is, a seventy-seven-year-old man said, "I am very healthy, I never see a doctor." When I asked how he knew he was in good health if he never saw a doctor, he replied, "because I do not have to." For many individuals, having a continuing chronic health problem such a arthritis, stomach problems, constipation, or even high blood pressure does not make one unhealthy, as long as the problem does not affect their ability to take care of themselves. A seventy-eight-year-old man explained: "All old people have pains here and there, or organs which are not working as well as they did before. That is normal, because we are old. As long as these mao bing are under control, and I do not have to go to see the doctor all the time, I will be happy. That is vvhy I said I am healthy."

Body and Mind A central concept related to the view of being healthy or unhealthy is the notion that mind and body cannot be viewed as two separate entities, and that mental and physical health affect each other. Still, many of the elderly do not look at such problems as unhappiness, lack of interest in things, feelings of loneliness, or even depression as identifiable health problems. For example, one sixty-five-year-old woman said, "If people worry too much, they are not going to be happy, [and] then they will easily get sick." However, in another discussion, I asked Mother Zhou, a retired teacher, why she did not think that people who are suicidally depressed should go to see a doctor. She said: "These are not health problems. They are depressed because they [96]

Big and Small

Problen~~

are not being open minded. That is a mind problem, no drugs can help. They will be fine if they open their mind and think widely." A large number of people claim that they are healthy because they are optimistic about things despite various health problems. According to Mr. \Vang, a retired restaurant worker who suffers from several types of arthritis, high blood pressure, and diabetes, "I have seen many things in my life. A truth I have learned is that nothing matters much if you do not have good health. To be healthy, the most important thing is to be optimistic, and to be open minded about everything." It seems that the majority of Chinese elderly believe their state of mind and the level of self-reliance are the two main prope1ties that define health. It is possible to be healthy even with various xiao mao bing as long as one has the ability to take care of oneself, to take part in daily activities, to be useful to family and friends, and to be optimistic and not consumed by worry.

The Causes of Poor Health Among the Chinese elderly there were great variations in identifYing the causes of health problems, as well as the factors that contribute to poor health. Although there was a consensus that factors such as bacteria, internal and environmental imbalance, intake of unsanitary food, unbalanced lifestyle and diet, poor environmental conditions, and a harsh personality all play a role in contributing to the presence of illnesses, the roles attributed to these factors in the onset of poor health or illness vary from individual to individual. Poor health is commonly considered to be the result of an internal imbalance among the organs or body systems. However, people have different views about which factors cause an imbalance. Some believe improper diet is the fundamental cause. Others regard the imbalance as the result of hardship experienced early in life. Still others think it is the result of a lack of exercise. In addition, some attribute the imbalance to not adjusting to a new living environment. During my h\'enty-five structured inte1views, a list of thirty-four common health problems was presented and informants were asked to select from the list those health problems and symptoms they had experienced in the previous twelve months. Five individuals claimed that they did not have any health problems or symptoms within this time period. During this exercise, fifteen people asked, "Is this a health problem too?" when asked about such items as "low mood," "no spirit," "always worried and [97]

Aging and Health arrwng the Chinese Elderly Table 7. Common health problems and symptoms Symptom Leg pain High blood pressure Back pain Senile arthritis Cold/flu Loss of memory Low mood Feeling of exhaustion of nervous system Hemorrhoids No spirit No strength, fatigue Constipation Diarrhea Headache Heart disease Indigestion Loneliness Loss of interest in everything Loss of appetite Sleeplessness Toothache Worrying Cough Neck pain Deficiency of chi

Frequency

14

12 9 9 8 8 8

7 7

7 7 6 6 6 6 6 6 6 6 6 6 5

5 5 5

sad," or "loneliness." I explained that if these problems had lasted for a long period, and had affected activities of daily living, then they should be considered health problems. Table 7 lists the twenty-five most frequently mentioned health problems and symptoms. More than half of the twenty respondents had leg pain and high blood pressure problems. Among the twenty most common health problems and symptoms, ten items were associated with mental health, six items with hotcold imbalance and indigestion, four items with musculoskeletal problems, and two items with cardiovascular disease. I shared these results with five medical practitioners-three of Chinese medicine and two of Western medicine-and they found them in accordance with their own experience, even though two practitioners expressed surprise that diabetes was not listed. [98]

Big and Small Problems

Mental Health Problems During the structured interviews, the twenty individuals were questioned about their perception of the causes of the health problems they reported, and some indicated more than one cause for a particular problem. Eighteen of the twenty chose two or more items associated with mental health problems. The causes of these problems, as the informants saw them, were concern over family matters, problematic intergenerational relationships, worries about health problems, and advanced age (see Table 8). Very few, however, thought that such mental health problems should be regarded as Table 8. Problems related to mental health Cases

Self-reported causes

N

Feeling of exhaustion or nervousness

7

.5 5

Loneliness

6

Loss of appetite

6

Loss of interest in things

6

Not sleeping well Too many worries Old age Unfamiliar with environment Lack of attention from children Nobody to talk to Missing homeland Poor health Old age Not in a good mood Worries Old age Poor health Conflicts with children Old age Thinking too much Old age Other health problems Concerned about family affairs Concerned about poor health Too many difficulties Conflict with children Old age Old age Other health problems Difficulties in family OveJwork Conflict with children Poor health Family difficulties

Symptom

Loss of memory Loss of sleep

8 6

Low mood

8

No spirit

7

No strength

7

Worrying

5

[99]

4

6 6 6 4 4 3 3 3 4

4 2 8

5 4 4

7 5 6

5 5 6 3 3 2

5 4 2

Aging and Health arrwng the Chinese Elderly

illness, or that medical attention should be sought to treat them. I discovered that there was an important difference between individuals who were troubled by mental health problems and those who were not. This latter group tended to view such problems as the result of poor self-control, and they did not have much sympathy toward individuals or even friends who experienced such difficulties. These elderly Chinese believe that persons who suffer mental health problems do so because "they worry too much," "have too much money and worry about losing it," or "are narrow minded." In one discussion Mother Jian stated, "Every family has its own difficult bible to read. 1 These people just could not face the reality. They have too high expectations for everything. No one says life is easy; everyone's life has its own difficulties. Do not think that I do not have problems just because I am usually happy. But I believe it is usual to have problems. These people who are sad all the time are just not wise." Mother Lou, a sixty-nine-year-old Mainland Chinese immigrant, agreed: I know some people who have that kind of problem. A couple of months ago, I heard one of them was taken to the hospital by her son because she cries all the time. They are all richer than me. I do not understand why they could not be open minded. It is a problem for people who have too much. They are afraid everybody in their family is trying to take their money away. I have my family problems too, but I am too busy to sit around worrying. The other, less stoic, informants acknowledged their mental health concerns. Mr. Yang, a sixty-seven-year-old Mainland Chinese immigrant, related his story: I was very optimistic and active until I learned my son's business went bad a year ago. I started to have nightmares about it, and later I just could not sleep. I never used sleeping pills before, but my wife insisted that I must take them. So I took them. But I still could not fall asleep after I took them. I did not sleep well at night, I always felt tired. One day, I had an argument with my wife .... Why? She said I did not answer her question. But I did not hear. It turned into a big argument. We never argued before. After that, things got worse. I was not interested in doing anything. I gave up many hobbies. I used to sing Beijing Opera with a group of Beijing ' This is a common usage in China. It means that each has his own hard nut to crack, or that everyone has problems to deal with. Therefore, one should not feel unusual if one has difficulties.

[100]

Big and Small Problems

Opera fans once a week. I gave that up too. But two months ago, my son found a new job, a very good job. It is very interesting, and I have been feeling better and better every day since then. My sleeping is getting good, and I can eat more too. You know, parents always worry about their children. If they are doing well, we feel happy too. That is a Chinese parent. ... My son asked me to see a doctor when his mother told him about me .... I did not go. It is a joke; there is no pill that can treat this problem. And in the course of responding to my questions, Mother Tang shared these problems. Ever since my son got married to a Hong Kong girl, I have changed a lot. My son was very close to me. He always made dinner for me when I was tired. Every weekend he would drive us around. But now he rarely comes to see me. I do not get along with my daughter-in-law, because she does not speak Mandarin, and I cannot speak English. She has a strange personality that I cannot stand. She is not the type of daughter-in-law I wanted. I did not favor their relationship in the first place. But my son married her just because she is pretty. Later, my husband convinced me to be open minded. It is their life; if they really love each other, we should feel happy for them. But now, if I ask my son to come over to help me, he has to get approval from his wife first. Once, I told him I made an appointment with a doctor, and needed him to drive me there. I know he has that day off. But he told me to change the appointment because he had to go to a fdend's house for dinner with his wife .... Both my husband and I do not speak English; we do not know how to get around either. Now I feel I have to beg him to come over. He is my son, but I feel I am losing him. Mother Cao is a sixty-six-year-old Taiwanese immigrant. She identified herself as being disturbed by choosing nine of the ten interview items related to mental health problems, and she spoke very frankly about her life. Five years ago she first noticed an unusual pain in both legs. The pain soon became so severe that she had to stop her daily walks. Even during the summer, her legs would feel so cold that she had to wear thick quilted down pants. She had been seeing doctors of both Chinese and Western medicine, but nothing had changed. After a series of tests doctors told her that they could not diagnosed any cause. "How can I make myself be happy?" she asked. I spent most of my savings on it, and the problem is getting worse .... I have not had a good sleep for a long time. My legs hurt so much during [101]

Aging and Health among the Chinese Elderly

the night. Now I have to stop four times when I climb up two flights of stairs .... I know I am in a very low mood .... Two weeks ago, I started to hear voices I never heard before in my home. My daughter already took a lot of time off for me. I could not ask her anymore .... Hail When asked if she felt that she needed to see a doctor about the strange voices she heard, she smiled, saying: "No, no. It is just a moment of confusion. As soon as they find out what is wrong with my legs, I will be fine again." When another interviewee, Mr. Zhang, indicated he had experienced "loss of memory," "no strength," and "loss of interest in things," I asked him why he had these problems. He replied without hesitation, I am old. These problems are old people's problems. I have seen so many things in my life, good and bad. They are all the same. When I was young, I was just like you, interested in everything, and thought that I could change the world. I joined the Guomindang because I thought they were good for the people. I fought the Communists because I thought they were bad for the people. What happened? I am the enemy of the people on the mainland. In 1950 two of my brothers in Mainland China were executed by my village because I was in the Guomindang army. Ten years after I went to Taiwan, the Guomindang army kicked me out because I did not have an education, and I was too old. So I had to come here to make a living working in restaurants.

Physical Health Problems The next group of health problems reported was illnesses caused by hotcold imbalance and indigestion. They included: cold and flu, diarrhea, constipation, indigestion, deficiency of chi (body energy), headache, cough, toothache, and hemorrhoids. The perceived causes of these problems are listed in Table 9. Body pain was a rather common health problem among the Chinese-American elderly I encountered, yet in the structured interviews this problem received little attention. During the course of my research, I often heard people say, "All old people have some pains here and there." When asked if they would see a doctor for such pain, most said that it was an old person's problem, and there is no cure. One seventy-eight-year-old man exclaimed: "See a doctor? I started to see a doctor ten years ago. What can they do?" [102]

Big and Small Problems Table 9. Problems related to hot-cold imbalance Health problem Cold I flu Constipation

Cases

8 6

Self- reported causes Did not wear enough clothes Got from others Unbalanced diets Old age

Shui tu bufu Cough

5

Deficiency of chi

.5

Diarrhea

6

Headache

6

Hemorrhoid

7

Drink too little water Cold I flu Weakness in lungs, throat Poor health Old age Poor health Cold foods Bad foods

Shui tu bu fi.t

Indigestion

6

Lack of good sleep Old age Caught cold Overworked Worries Excess of "hot" energy Eating too much spicy food Old age Sitting too long Old age

Shui tu bufu Toothache

6

Unbalanced diet Excess of "hot" energy

N

7 6 6

5 4 2

5 3 2

5 5 6 4 3 4 3 2 2 2

7 6 4 2 6 4 3 6

Note: Slwi tu bu j11 (.1hui ~water; 111 ~ soil: lm fu ~ docs not fit) connotes that one's illness was caused by an unEuniliar physical environment.

All fourteen individuals who had leg pain believed that old age was the primary cause (see Table 10). In addition, hardship in their earlier life and overwork were also considered causes of leg and back pain and arthritis. Mr. Chu was a veteran of the Guomindang army. He had back pain and was also suffering from rheumatism. He sought treatment in Taiwan, but his condition did not improve. After he migrated to Flushing, he visited a well-known Chinese acupuncturist. Within six months of treatment, he now felt pain only during rainy periods or when he sat for long periods. He explained, When I was fighting the Japanese our troop always marched toward the Japanese line in bad weather because it was the least expected time. Sometimes I wore my wet uniform for several weeks without changing. It [103]

Aging and Health anwng the Chinese Elderly

got wet, dried out, and got wet again. Sometimes we had to sleep in the rain .... But then I was young and strong, so I did not feel anything. About twelve years ago, it started to hurt me .... For my kind of problem, the only thing the best doctor can do is to ease the pain. They can not get rid of it. High blood pressure is the second most common health problem among the Chinese elderly. Among the twenty structured interview respondents, twelve reported high blood pressure, and six indicated they had heart disease. The perceived causes of these two health problems are presented in Table 11. For high blood pressure, old age is listed as a primary cause by all but one participant. The second cause was "nervousness," and the third was diet. "Nervousness" to these elderly Chinese meant the anxiety caused by unpleasant emotional experiences after they immigrated to the United States. Many people have to deal constantly with problems that they had never en-

Table 10. Musculoskeletal problems Health problem Leg pain

Cases

14

Arthritis

9

Back pain

9

Neck pain

5

Self-reported causes

N

Old age Old problems Hardship in the past Old age Hardship in the past Damp environment Arthritis Old age Overwork Arthritis Old age

14

Self-reported causes

N

Old age Nervousness Fatty diet Old age Hardship in the past Fatty diet

11 9 6 6 6

8 7 9

4 4

9 8

5 9 7

Table 11. Cardiovascular diseases Health problem High blood pressure Heart disease

[104]

Cases 12 6

4

Big and Small Problems

countered before. Language barriers, a new cultural environment, unsettling family relationships, financial difficulties, and obtaining health insurance all played a part in creating pressures on them. Loss of sleep was common for many people, especially during the first several months after immigration. Mr. Wang stated: "My v;rife and I never expected to end up in a foreign land in our old age. We thought we were here to enjoy a few years of our lives. But now I feel I have walked onto another battlefield, a field I do not know anything about. I survived many battles in my life, but this one is different. I am too old for this battlefield. This one is for you young people, but not for us." A considerable number of Chinese elderly came to Flushing in the late 1970s, and to make a living many opened small businesses such as grocery stores and restaurants. After years of hard work, they saved enough money to send their children to top-ranked schools. "That is why I worked so hard; it is not for me, but for the children," said Mr. Pan, who arrived in Flushing in 1978 mth his \\rife and three daughters; the oldest was then four years old. He had a stroke in 1988 when he was sixty-four, and his body has been partially paralyzed ever since. Although he had been a professor at a university in Taiwan, he had not learned English, and neither had his \\rife. They bought a grocery store in Flushing. Mr. Pan's \\rife had grown up in a wealthy family, and had never worked before. Mr. Pan tried to do everything himself since he did not want his \\rife to suffer. I had to get up every morning at 4:30 A.M. to get the newspapers to the store, and we closed at 10:30 at night, seven days a week V>rithout a holiday. My children helped me a lot. But when they were grown up they did not want to come to the store anymore. They do not want their friends to know their father is a small shop owner.... The business was so small I could not afford to hire anyone. I had to take care of everything, from ordering goods to watching out for shoplifting. That was a difficult time. "Did you ever have a concern about your health when you were working so hard?" I asked. "No, I did not care about that, and I did not want to know either. It is hard for you to imagine, but I felt there was a strong power pushing me-survival, that's it." After the stroke Mr. Pan sold his store. "Do you regret the price you had to pay?" I asked. "No, although I paid a big price [his stroke] for all the years of hardship, I am happy. At least I did not die. The most important thing is that all of my daughters went to good colleges. I feel satisfied because I know they \\rill not have to go through what I did." [105]

Aging and Health among the Chinese Elderly

Health Problems-Small and Big In Chinese, mao means hair, and bing means illness. In Chinese etymology, mao bing originated in ancient times among peasants who used the term for illnesses of their domestic animals; later the term was adapted to describe abnormal human physical conditions. Although in contemporary Chinese usage, the term mao bing can refer to any irregular condition such as trouble with a machine, a mistake in a course of action, or the illness of a person, it does not indicate the seriousness of the problem. When a person tells his friends that his stomach has mao bing, for example, it could be interpreted as a minor difficulty with digestion, even if in actuality it is an ulcer. One would not use the term mao bing if diagnosed with cancer, however, since cancer is perceived as a deadly disease. There are three variant forms of mao bing, each indicating the degree of seriousness of a problem: xiao mao bing (small problem), dai mao bing (big problem) and hu dai bu xiao de mao bing (problems between small and big). These three terms were the most frequently used expressions for health problems I encountered among elderly Chinese in Flushing. Although the range of application of each of these terms may vary somewhat from individual to individual, their meanings are usually well understood even without mentioning the specific health problem referred to. The following two conversations illustrate the usage of xiao mao bing: I heard you did not feel well a couple of weeks ago. What

MOTHER H:

happened? MOTHER GUO:

c:

What was it?

MOTHER C:

MR.

z:

GUO:

Oh, it was a xiao mao bing. My high blood pressure went back up again.

My tooth pain is killing me again. Why don't you go to see a doctor?

z: No, I don't need to-xiao mao bing. It happens a lot. It will get better by itself after a couple days.

MR.

During the twenty-five structured interviews I asked my elderly Chinese informants to assign a set of health problems and symptoms into the three categories-xiao mao bing, dai mao bing, and bu dai bu xiao de mao bing. The fifteen health problems which were most often considered xiao mao bing (by twenty-one individuals-four did not provide any answer) are pre[106]

Big and Small Problems Table 12. Illnesses and symptoms identified as small problems

Item Hemorrhoids Constipation Hong Kong foot (athlete's foot) Feeling of disgust Psoriasis Loss of appetite Loss of interest Loss of memory Fatigue Lack of strength Deficiency of chi Loneliness Headache Flatulence Cough

Frequency (N = 21)

21

20 20 19 19 19 18 18 18 18

17 17 17 17 17

sen ted in Table 12. The results showed that eight of the leading "small problems" were related to hot-cold imbalance and indigestion, and six were associated \vith mental health. After each informant completed this sorting, they were asked why they categorized certain items as small problems. Among the most common reasons were: Many people have it. It comes from old age. It comes and goes. It \vill be better after you rest for a while. I can handle it. No need to see a doctor. It is because you worry too much. It does not bother me.

Mr. Mei put hemorrhoids into the "small problems" group because "This kind of problem is very common in the people of our age. I know many people who have it. 'Out of ten men, nine will have hemorrhoids.' 2 If you

2 It is a popular belief in Chinese society that almost everyone, especially men, will have hemorrhoids in adulthood.

[107]

Aging and Health among the Chinese Elderly

avoid eating too many hot things and sitting too long, it will not bother you much at all." When Mother Cheng was putting such items as constipation, loss of memory, fatigue, no strength, and deficiency of chi in the xiao mao bing category I asked why she considered them small problems. She answered: "All of these problems I know very well. They come with age." Mother Shi did not think that she had any mental problems, and put all ten items related to mental health in the category of "small problems." "These are not health problems," she stated. "People have these problems because they worry too much." The list of health conditions recognized as "big problems" by the elderly Chinese is presented in Table 13. Most are related to body organs. Among the common reasons individuals classified these problems as dai mao bing were: You could die from it. It needs an operation. You cannot move any more. You will be put in bed for a long time. You will be hospitalized. Many of these items listed as big problems were not problems the informants had experienced themselves. Many of them thought these problems Table 13. Illnesses identified as big problems Frequencv Item Heart diseases Heart pain Tuberculosis Urinary tract infection Kidnev disease Liver disease Pneumonia Lung disease Bladder disease Diabetes Ulcer Hardening of arteries Pancreatic diseases Coughing up blood Gallstones

[108]

(N

=

21)

20 20 20 19 18 18 18 18

15 14 12 12

ll ll 11

Big and Small Problems

were very serious because they knew or heard about people who died from these diseases. Others thought that immediate medical attention should be sought if people experienced such symptoms as heart pain or coughing up blood. Several stated that it was troublesome to have these big problems because patients had to see doctors regularly and also had to watch carefully what they ate and what they did. Moreover, quite a few individuals, especially those few who did have these health problems, believed the medications taken to treat these disease were harmful to other body organs and systems. Mother Gao told me she was diagnosed with kidney disease a few years ago. She was put on regular medication at that time, and since then she has suffered from new symptoms she had never experienced before. "Now I cannot sleep well; my blood pressure is up as well. So two months ago I decided to cut down on some medications. Guess what happened? My blood pressure went down, and I had fewer problems with my sleep. But two weeks ago, I started to feel weak, dizzy, and have back pain. I knew that was my kidney problem. So I put my medication back on. Now I have the exact same problems again." As Table 13 illustrates, there was no unanimous agreement that all of these are indeed "big" problems. Nearly half of the elderly Chinese did not recognize ulcers, hardening of blood vessels, pancreatic disease, coughing up blood, or gallstones as dai mao bing. Interestingly, most of the individuals who considered these particular conditions "big" were persons who themselves had these problems. Mother Zhang said, "I cough up blood all the time, especially when I have a cold for a long time. I am old, so my windpipe is getting weak as well." And Mr. Xue shared his experience. Gallstones could be serious, or they could be very minor too, it all depends on the size and the number of stones. I had some stones three years ago. My [Western medicine] doctor suggested an operation. I did not like the idea, I thought I should try other methods first. My friend introduced me to a Chinese herbalist. Two days after I used the prescription he gave to me, all the stones came out. One month later I had another X-ray, and the [Western medicine] doctor told me he did not find any stones from the test. Usually it was not difficult for most elderly Chinese to determine which health problems were big and which were small, but it took much longer to decide which should remain in the bu dai bu xiao de mao bing, or intermediate, category. Sometimes items were switched back and forth among categories before they made their final decisions (see Table 14). The reason that [109]

Aging and Health anwng the Chinese Elderly Table 14. Illnesses and symptoms identified as intermediate problems Frequency Item

(N

Rheumatic arthritis Chronic bronchitis Neck pain Asthma Fractures Kidney insufficiency Fever Senile arthritis Hyperplastic arthritis Rheumatoid arthritis Stomach diseases Swollen skin High blood pressure Low blood pressure Anemia

=

21)

17 15 15 15 15 15 14 14 14 14 13 13 12 12 12

the severity of some health problems was difficult to grade was, most often, because "it all depends." As Mr. Mei explained, "Some of the problems could become big problems if people do not pay enough attention, and some depend on the degree. For example, heart disease, and tuberculosis obviously are serious problems-they could kill you. But high blood pressure does not necessarily have to be a serious problem. It depends how high it is." Mother Shi first put bone fractures into the "big problem" group because "the worst thing that could happen to an aged person is a fracture." A few seconds later, she changed her mind. "I broke my \Vrist two years ago. It only took a couple of months to heal. I know another woman, she broke her leg, but she is all better now. I think it all depends which part is broken then. If it is a hip bone, that could be a big problem." Mother Qiang had quite a difficult time deciding if various types of arthritis should he categorized as small problems or not: "I have rheumatism. Although it only bothers me in the wet season, I would not think it is a small problem because I could hardly move when it comes." The most commonly mentioned reasons that health problems should be bu dai bu xiao de mao bing were as follows:

If you are not careful, it could become a big problem. Sometimes it needs an operation. [110]

Big and Small Problems It is a not big problem, but it bothers me. It is not a small problem because it will take a long time to get rid of. But it

is not a big problem because it could not kill you. It will restrict what you eat. It is treatable.

The Issue of Mental Health The somatization of mental complaints has been well documented in Chinese culture as well as in the Asian-American population (Cui and Yu 1984; Lee 1986; Kleinman 1980; Pang 1991; Ying 1988). For example, the term neurasthenia connotes an ailment in Chinese culture with vague, protean signs and symptoms believed to be due to the weakness of the nervous system. According to traditional Chinese medicine, the weakness of the nervous system is usually caused by the imbalance of internal energies. Therefore, proper diet, good rest, and maintenance of peace of mind are essential, not only to prevent such symptoms, but also to reinstall the balance of internal energies (Cui and Yu 1984). As we have seen in this chapter, large numbers of elderly Chinese suffer from depression, anxieties, and other psychological problems. The stresses of adjusting to a totally different culture and lifestyle heighten the psychological problems. However, they consider "loneliness," "loss of interest in things," "loss of appetite," "fatigue," "deficiency of chi," and other symptoms as xiao mao bing, small problems that should not be treated with medication. This tendency to normalize problems or symptoms related to mental health mirrors to a great degree the culturally constructed interpretation of these problems. Yet the commonly demonstrated disposition of denying or suppressing mental problems among Chinese, regardless of age and gender, reflects the way mental illnesses are perceived and what they mean. . One of the frequently discussed issues in cross-cultural mental health research is the stigmatization of mental illness. Stigma, which we can define as viev.cing a person ''cith a set of powerful negative images, is often rooted in cultural beliefs and shaped by norms of social interaction. In both Western and non-Western societies symptoms of mental illness are often characterized as frightening, shameful, dangerous, imaginary, feigned, fantastic, or incurable. Individuals who are labeled with mental illness are frequently described as lazy, idle, weak, helpless, unpredictable, unstable, dependent, and irrational, and therefore are stigmatized (Fabrega 1991). Although stigmati[111]

Aging and Health among the Chinese Elderly

zation of mental illness and of the individuals who are labeled with mental illness exists in all societies, the rationale behind stigmatization varies from culture to culture. In examining the causes of social stigmatization of three age-related health problems, including mental illness, in American society, Elizabeth Herskovits and Linda Mitteness (1994) found that the transgression of American values of mastery, productivity, autonomy, self-control, and individual responsibility result in increased social stigma toward mental illness and old age. In a more "sociocentric" and less individualistic cultural tradition such as the Chinese, however, the process of stigmatization places more of its significance on the family than on the individual who is labeled with mental illness (Fabrega 1991; Kleinman 1986; Lee 1982; Lin and Lin 1981; Phillips 1993). For many Chinese, acquiring a mental illness implies that the patient and members of the family have behaved incorrectly and have failed in fulfilling their filial piety to the older person or their ancestors (Lin and Lin 1981). As a consequence, it makes both patient and family lose face in their circle of social connections. For Chinese, the concept of face not only signifies a self-affirming social status, it is also an important criterion for judging one's characteristics and conferring one's social standing (Hu 1944; Kleinman and Kleinman 1993). Once a person loses face, that person is condemned by his or her social group for immoral or socially disagreeable behavior (Hu 1944). As Lin wrote: "The moral view, a commonly held etiology, emphasizes 'misconduct' as a cause of mental illness; divination from socially prescribed behavior especially in neglecting the respect due to ancestors. Mental illness is regarded as a punishment for violating Confucian norms governing interpersonal relations, especially filial piety" (Lin 1981:387). Therefore, to prevent oneself or members of the family from being labeled with mental illness becomes of great importance, even when symptoms of such "illness" are observed.

[112]

[11] Self-Care and Home Remedies

Self-care plays an essential role in Chinese health practices. Although wellestablished cultural concepts of self-care are not unique to the Chinese, the degree of their elaboration in Chinese health culture is indeed noteworthy. For the Chinese, both physical and mental health are often viewed as the consequence of an individual's moral conduct in the social context. This idea is based on Chinese Confucian, Taoist, and Buddhist philosophical traditions. Confucius taught that the only way a person reaches a state of well-being is by acting according to the Five Virtues of kindness, justice, proper behavior, sound judgment, and personal integrity. He held that health was based on adherence to this moral code. Lao Tse, the presumed founder of Taoism, taught that good health was guaranteed if natural law was followed, and felt that "human contentment and health are gained through unassertive action, and by simplicity in human behavior and actions" (Grivetti 1991:8). Taoism specifies practices for individuals to enhance health, to prevent siclmess and to treat health problems according to the principle of yin and yang. This ancient Chinese theory explains that the key to good health is a balance between the universal yin and yang forces within the human body and in its interaction with the environment. Once the balance is disrupted, illness is likely to occur. Self-care following the principle of yin and yang requires proper behavior, thinking, and dietary habits; one can repair a disrupted balance by adjusting one's behavior or state of mind and by consuming food items that contain the energy force that the body is lacking (Zhang and He 1992). Self-care practices according to this principle have deeply penetrated Chinese daily life, and they are commonly encountered in Flushing. My interviews indicated that almost all health problems that my informants assigned to self[113]

Aging and Health among the Chinese Elderly Table 15. Self-care beliefs Mainland Small problems should be taken care of by self Agree 26 Disagree 14 Don't know 1 Total 41 Most effective method of treating chronic health problems See doctor 3 Self-care 19 Good medication 1 All the above 16 Don't know 2 No data 1 Total 41

Taiwan

Total

11 29 2 42

37 43 3 83

7 21 2 6

10

40 3

5

22 7

42

83

2

treatment were those perceived as xiao mao bing, or "small problems," and almost half of the eighty-three survey respondents believed that "small problems should be taken care of by yourself' (see Table 15).

Home Remedies

There are four main branches of traditional Chinese medicine: herbal medicine, diet, acupuncture, and manipulative therapy (Lu 1991). In general, however, Chinese herbal and dietary treatment are almost always practiced together. Over hundreds of years the belief has grown that foods are like herbs, and herbs are like foods. This belief reinforces the importance of home remedies in family health care practices. As a cross-cultural concept, "home remedy" is ambiguous, and intracultural meanings and practices may vary from individual to individual. The concept is extremely difficult to translate into Chinese. (A direct translation into Chinese would be "home medication."). In the early days of my research I found that it was a difficult task to explain to informants what I was interested in leaming about within the topic of home remedies. \Vhen I asked, "What kind of 'home medications' do you have'?" the response was: "What do you mean'? I do not-take medications." Then one day I was invited to Mother Chen's apartment. She had stated earlier that she was not taking any medication for health reasons. After she [114]

Self-Care and Home Remedies

prepared a cup of tea for me, I saw that the tea she was drinking was different in color from the tea she had given me. I asked her what she was drinking. "It is Western Ginseng tea," she said. "How often do you drink it?" I asked. She replied, "I started to drink it a couple of weeks ago, but only one cup a day." "Why do you drink it?" "I have been feeling very weak lately, and my heart is not that strong, so I started to drink it." Obviously she felt that this was not a "medication." When someone talks about yao (medication) in Chinese culture, ordinarily they are referring to Western drugs. Yao, to elderly Chinese, connotes a chemical substance prescribed by a doctor or obtained from a hospital. The substances that people use for home remedies are conceptualized differently. They would not be called yao, but rather zhong yao or pian fang. Zhong yao literally means "Chinese medication," and contains herbal and sometimes nonherbal items. It refers to a prescription, usually consisting of a combination of herbal items, provided by a doctor of Chinese medicine and used for a specific health problem vvithin a specific period. Pian fang generally refers to folk methods of health maintenance or illness treatment, and is equivalent to "grandmother's secret recipe" in American culture. Soup made of vvinter melon and seaweed taken to cool the body in summer is considered pian fang. Items which make a pian fang may be both herbal and nonherbal. One of the major differences between zhong yao and pian fang is that pian fang can be a homemade recipe and cannot be obtained at store, whereas zhong yao is a medical prescription provided by a physician-a herbal or nonherbal drug obtained at a Chinese herbal medicine shop. Bu yao and bu pin are two other common terms to refer to home remedy ingredients that can also be pa1t of a zhong yao prescription. Ginseng root, for instance, can be a bu pin or bu yao by itself, but it also can be mixed vvith other herbal items to make a zhong yao prescription. The difference between bu yao or bu pin and zhong yao is that the first two are usually taken to enhance and nourish the body in generaL but a zhong yao prescription is used to treat a specific health problem. Home remedies can thus include Western meclications, zhong yao, pian fang, and bu yao and bu pin.

[115]

Aging and Health among the Chinese Elderly

The Range of Home Remedies Each informant was asked to list the bu yao and bu pin, Chinese herbal items, Chinese and Western medications, and other items that they keep at home for treating and preventing illness and "small" health problems, or for enhancing health. The results revealed a total of 163 items. The fewest home remedy items an informant listed was 38, and the largest was 113. Table 16 shows the twenty-five most common remedies. In addition to vitamins, there were only two Western medications, aspirin and Contac (a cold remedy) among the twenty-five items. Of the others, nine were Chinese herbal medications and thirteen were bu yao and bu pin home

Table 16. Twenty-five most common home remedies Item

Frequency

Vitamins Lian zi (lotus seed)• Yinger (white fungus)• Gon qi zi (matrimony vine fruit)• Xi yang shen (western ginseng)• Wanjin you (tiger bone)• Gui yuan (logan)• Ilei zhi ma (black sesame)• Xiao hui xiang (fennel)• Fen shi gao yao (plaster for muscular injuries) Liu sheng wan (pills made from Chinese herbs, to reduce fever and some intemal and extemal infections) Tian ma. (gastrodia rhz.)• Yin qao jie tau pian (pills made from herbs, for flu and to reduce excess hot energv) Ywz nan bai yao (made from Chinese herbs, for open cuts and to stop ~~

Ren seng (t,rinseng)• Dang gui• Bao ji wan (pill made from herbs, for diarrhea and indigestion) Zheng gou shui (made from herbs, for pain and muscular injuries) Contac Su xiao pian (made from herbs, for flu) Aspirin Shan zha (Chinese hawthorn)• Gan rrwo chongji (made from herbs, for colds) Luo hang guo (fruit of Grosvenor nwmorodica)• Pi pa gao (made from loquats, for coughing and respiratory infections) "Tonics and pantry herbal items

[116]

25 23 23

22 20 20 20 20 19 19 17 17 15 ffi 15 15 14 13 13 13 12 11 11 10 10

Self-Care and Home Remedies

remedy ingredients. Among the nine herbal medications, two were for body and muscle pain and injuries, one for open cuts and bleeding, three for flu, colds, and fevers, one for various internal and external infections, one for diarrhea, and one for coughing and respiratory infections. It was interesting that although every infonnant had vitamins, few actually used them. Most had obtained them from their adult children who believed that vitamins are good for health. One informant said: "I never had vitamins in my life, and I am still doing fine. Plus, since it is also made of chemicals, it probably would have side effects as well. So I only have taken one or two when I did not feel well" Each of the particular thirteen bu yao and bu pin items has yin or yang properties, benefits specific organs, and is used to treat health ailments ranging from energy deficiency to diarrhea and to diabetes (see Table 17). These items are consumed individually or cooked along with other items. Certain Table 17. Thirteen most common herbal remedies

Item

Energy type

Lian zi (lotus seed)

Neutral

Yinger (white fungus) G011 qi zi (matrimonv vine fruit) Xi yang shen (western ginseng)

Neutral Neutral Cool

Wann Gui yuan (logan) Hei zhi ma (black sesame) Neutral Xiao hui xiang (fennel)

Warm

Tian ma (rhizome gastrodia) Ren shen (Chinese ginseng)

Warm Warm

Warm Dang gui (Chinese angelica) Shan zha (Chinese \Varm hawthorn) Cool Luo hang guo (fruit of Grosvenor nwmorodica)

Organ benefited

Used for

Spleen, kidney, Bad appetite, weakness and slackness, diarrhea heart Deficiency of lungs, cough, thirst Lungs Liver, lungs Blood and kidney deficiency, diabetes Lungs Yin energy deficiency, stomach with internal heat, thirst, cough and voice loss Heart, spleen Dizziness, palpitation, insomnia Liver, kidneys Liver-kidney deficiency, headaches, dizziness, ringing in the ears, constipation Liver, kidneys, Hernia, pain in the lower abdomen, stomach rumbling spleen Heart Anemia, headache, deficiency of chi . Weakness with chronic illness, Spleen, lungs vaginal bleeding, diabetes, palpitations Heart, liver, Blood deficiency, abdominal pain, rheumatism, constipation spleen Indigestion, stomach dysentery, Spleen, liver hernia, blood coagulations Lungs, spleen Cough, constipation

Source: Lu ]991.

[117]

Aging and Health arrwng the Chinese Elderly

combinations of these are considered to enhance the strength of each separate ingredient, and are used to treat more serious health problems.

Sources of Home Remedies Chinese grocery stores and herb shops in central Flushing are crowded places even during non-rush hours. In the fourteen Chinese-owned groceries and ten Chinese herb stores I surveyed, hundreds of kinds of herbs and Chinese-made herbal and nonherbal medications were displayed. Many of the medicines are standard products manufactured in Hong Kong. One informant who arrived recently from Mainland China told me, "I was surprised to see there are so many high-quality Chinese herbs and tonic items here. No wonder we could not find these things in China, they are all here." "Running a herb shop is a good business here," one of the owners told me. When she arrived in Flushing in the 1980s from Taiwan she operated a small grocery store. Two years later, she borrowed money and started her own herb-selling business. Now she is the owner of two major herb shops in Flushing. "My store meets our Chinese needs. Many people here do not like to take Western drugs since they are too strong and most of them are made of chemical materials. Chinese herbs and herbal drugs not only treat the disease without damaging your body, they also can prevent you from getting diseases by increasing the good energy of your body." During my observations in herbal shops, I often saw elderly Chinese come in with pieces of paper with prescriptions written on them. The herb seller then prepared packages according to what was written. One herbalist explained to me: "Some people got these prescriptions from their friends who had the same problems and had good experiences with these prescriptions. Some people got their prescriptions from their families. Others got them from Chinese medicine books or newspapers, and some people got them from their Chinese doctors." In addition to local herb shops and Chinese markets, elderly Chinese obtain home remedy supplies from friends and relatives who bring them from Mainland China, Hong Kong, and Taiwan. Many people also received bu yao and bu pin as gifts, since it is a Chinese custom to give these items when visiting an elderly person. I also found that Chinese herbal materials were quite expensive. "Compared with five years ago, everything must have increased three to four times [118]

Self-Care and Home Remedies

in price. It is just like everything else in Flushing,'" one herbalist said. According to Chinese herbal shop owners, there were several reasons for the dramatic price increases of Chinese herbal materials. First, the quality of these materials has improved in order to pass new regulations that United States customs has placed on imported Chinese herbal materials. Second, most of these materials were imported from Mainland China, where prices have increased since the market-oriented reforms of the 1980s. Third, as Chinese medicine becomes more popular internationally, the demand for Chinese herbs and other materials around the world makes them more costly.

Methods of Self-Care One of the most common translations of the term "self-care" in Chinese is zi wo tiao li. Zi wo means "self," tiao li means "nourish, nurse, or regulate," and together the term zi wo tiao li also implies a gradual process of healing. Although this term may also include other self-care practices, it commonly refers to nourishing through dietary methods. When elderly Chinese were asked what was the most important method of self-care, two-thirds responded that shi liao, or curing through diet was most important. The most common dietary method of treating various small problems or health irregularities was to drink herbal teas or soups that would alleviate the particular problem; the earlier example of Mother Chen drinking ginseng tea was very typical. On a daily basis, however, the use of ordinary food items for treatment was preferred over herbal remedies, particularly among individuals who had chronic or hot-cold imbalance problems. Food remedies are generally considered to be superior to herbal ones because their effects are more "natural" and balanced. My interviews with elderly Chinese, and observations in their homes, revealed that classifying foods and utilizing tl1em for treatment based on their yin-yang properties was common. If perceived causes of health problems were due to excess "hot" or "cold" energy, then they were be treated vvith foods of the opposite nature. Various vegetables, for example, were consumed to treat problems of excess hot: constipation, high blood pressure, coughing, hemorrhoids, and loss of sleep. Because of the belief that every food item has a unique ability to benefit the body, elderly Chinese consume a wide range of food items, from rice, vegetables, and fruits to meats. Animal organs are frequently eaten since it [119]

Table 18. Food items and their specific treatment for health problems

Good for

Food Pork, beef, ham, chicken, eggs, fish, turtle, quail, mushrooms, sea cucumber, lotus seeds, dates \'Valnuts, sesame, mushrooms, grapes Celery, spinach, lotus seeds, chrysanthemum, haw, black fungus, watermelon, bananas, seaweed, persimmons, turtle meat Logans, dates, lily seeds, lotus seeds Ginger root, chrysanthemum, green onions, vinegar, garlic, orange peel, pears, loquats, pomegranates Apricots, pears, oranges, loquats, pomegranates, grapes, walnuts, jellyfish, honey, sugar, pig lungs, eggs, sea cucumber Walnuts, lilv seeds Pig blood, ~hicken and duck blood, dates, fish, eel Oranges, lemons, haw Potatoes, black fish, honey Bananas, pears, vegetables, sesame, walnuts, potatoes, jellyfish, eggplant Soybeans, hot peppers, snake Spinach, Chinese yam, pumpkins, balsam pears Figs, persimmons, pomegranate skin

Energv deficiency, fatigue Energv deficiency due to aging High blood pressure Fast heartbeat, sleeplessness Cold/flu Cough, bronchitis Asthma Anemia Loss of appetite Ulcers Constipation Arthritis Diabetes Hemorrhoids

Table 19. Pian fang

Ailments

Pian fang

Cold/ flu

Bean with tofu, green onion with tofu (cold dish), ginger with dried bean curd, egg and sesame oil soup Fever Tomato with sugar (cold dish), watermelon skin stir-fried \vith yellow beans, winter melon and tomato soup, winter melon and fish soup Cough, asthma, bronchitis Lily and pork soup, pumpkin cooked with beef Cough with blood Sugar, vinegar lotus (cold dish) Heart disease Stir-fried eggplant, stir-fried onion, hawthorn cooked with pork Celery stir-f1ied with dried bean curd, seaweed and yellow High blood pressure bean soup Headache and dizziness Walnut with celerv (cold dish) Anemia Chicken and duck blood soup, spinach and pork blood soup Stomach pain Chicken cooked with eel, chicken cooked with dried orange Sesame and spinach (cold dish), fungus and cucumber (cold Constipation dish)

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is believed that they are good for nourishing human organs, particularly so for the elderly. When a health problem occurs, particular food items are consumed intensively during that period. The pooled information from my informants revealed that elderly Chinese have a great deal of knowledge about various food items used to treat health problems. Table 18 presents some frequently consumed food items with their specified treatments for common health problems as reported by my informants. In addition, the elderly Chinese also used various pian fang or "grandmother's recipes" to treat health problems. Table 19 lists the most commonly used pian fang.

The Case of Mother Tan Since arriving in the United States five years ago, Mother Tan has experienced deteriorating health. At first she was diagnosed with diabetes, then high blood pressure. She did not continue to see a doctor, however, because she had to work to make a living and could not afford the expense. The only treatment she used during that period was a Chinese-made medication sent from China. Later she developed a severely arthritic right hip and could hardly walk. She went to a doctor of Chinese medicine, but he could not help her much. "He cannot do acupuncture on me because of my high blood pressure," she explained. Two years ago she went to see several \Vestern-trained doctors after she qualified for Medicaid. The doctors all suggested that she needed hip surgery, but she refused. "I heard American doctors ask their patients to have surgery just like giving out a candy bar." As the hip problem became worse, she also developed bronchitis and heart problems. She decided to go to China for treatment. In China the doctor also suggested that she needed hip surgery. She now agreed. "I trusted their opinion, because they did not suggest an operation to their patients unless it was absolutely necessary." After the China trip, the hip problem was resolved but other problems continued to worsen. She experienced back pain, dizziness, and daily headaches. She had to stop working, and stayed in bed much of the time. I was very frustrated. I was vulnerable to almost everything: food, change of weather, and I could not sleep at all. So I decided to see a Westerntrained doctor again. During five months of doctor hunting, nothing got better but the full bitterness of visiting doctors and hospitals. They could not do anything but give me sleeping drugs and painkillers. They told me [121]

Aging and Health anwng the Chinese Elderly

there was nothing seriously wrong with me; they could not find the solution. When I was suffering from pain they told me that they could not see me. When I was lucky enough to see them, then they would run me through hours of examinations. Every doctor I saw asked to do the same tests, despite my telling them I had done these tests. I cannot remember how much of my blood has been taken by them. She had been told by a doctor in China that the symptoms she was having were due to a kidney problem. So now she asked a doctor to do an X-ray. After the X-ray did not indicate any problem with her kidney, she went to another doctor and had a second x-ray. This time it showed that there was a kidney problem. "I was relieved a little after I learned the result, because I knew what was \Vrong." However, she stopped seeing the doctor after that diagnosis; instead she decided to take care of the problem herself by using a Chinese-made kidney medication. "Every part of my body is not good. The 'Vestem medication would only make things worse since they have some strong side effects." In addition to taking various Chinese-made medications, she also collected and used pian fang recipes from her friends and the Chinese newspapers. "I love pian fang because I enjoy cooking and eating," she said. Interestingly, most of the pian fang recipes she collected were made with meat. "I love to eat the fatty part of meat. I know it is not good for my blood pressure, but I felt weak when I did not have any meat for several days. I need energy to deal with other problems."

Chinese Exercises The practice of various Chinese exercises is prevalent in Flushing. Especially during early morning hours, many Chinese elderly gather in the park, walking and doing exercises. In the Chinese senior center and elsewhere in Flushing, Tai Chi and Wai Dan Gong' classes are among the most popular exercises. These classes, organized and taught by the elderly themselves and free of charge, not only provide another health care alternative for elderly

1 Wai Dan Gong is a form of Chinese breathing exercise. It became popular first in Taiwan in 1970s after many participants and studies claimed it had significant potential to treat various health problems.

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Chinese but also create a social setting in which self-care methods are shared and exchanged.

Continuity and Change Resilience and endurance are the main features of many parts of the Chinese health care system. The Chinese people, especially the elderly, have strong tendencies toward maintenance of their traditional health beliefs and practices, in part because of the richness and complexity of this system of ideas. Chinese beliefs about illness are strongly interwoven with the fabric of daily life. This is particularly evident in the way that health beliefs are interrelated with dietary practices. The idea that "food is medicine, medicine is food" places health care activity in the realm of everyday living; it also makes it possible for everyone to take an active role in their own "medication." Just as individuals decide which foods they wish to eat (,vithin the range of their economic means), so they can also decide on which medications they wish to use. Compared with many other systems of health care, it appears that in Chinese culture the detailed lore concerning health problems and treatments is widely available to ordinary persons. Consequently, every Chinese household has a rich variety of "home remedies" at their disposal. The portability and complexity of this Chinese culture of health care also strongly encourage commercialization. Again in comparison with many other health care systems, Chinese remedies, recipes, and other materials seem particularly suited to the establishment of the wholesale and retail selling of health care. Not just trained practitioners but also ordinary vendors can engage in a varied commerce of herbal materials, books, newspaper columns, and purchasable sources of health care. The prevalence of the belief that "food is medicine, medicine is food" in the Chinese-American population stimulates an enormous health food market. In Flushing, many prepackaged Chinese-made food items are sold in regular Chinese markets. These health foods are made from Chinese herbs. Unlike most Americanmade health food products, which are mainly general in purpose, each of these Chinese-made herbal food items claims to be a treatment for a particular health problem, from high blood pressure to flu. Mr. Wu, a newly arrived immigrant, remarked: "I never saw so many kinds of herbal food products in China. It is probably because people here are afraid of seeing a doctor." [123]

Aging and Health arrwng the Chinese Elderly

It is evident that the rapid development of the herbal food market in Flushing reflects important features of Chinese health culture. But most important, this market effectively facilitates the adaptive behavior of Chinese immigrants by providing a wide range of self-care items. Furthermore, the demand for better health care in Flushing, and in North America in general, has stimulated the substantial maintenance and even the re-creation of traditional Chinese health culture.

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[12] Health Care Decisions

The interpretation of the various health problems we have just examined, together with a person's knowledge of Chinese and Western medicines, play a role in the choice of an appropriate treatment. Most of the elderly Chinese I interviewed suffered from various chronic health problems, but many felt that Western medical practitioners offered few solutions to their problems. Others believed that self-acquired Chinese-made Western medications or Chinese herbal medications were more appropriate for treating these "small" problems. A large number of individuals believed that Western medical doctors only provided powerful drugs that were generally harmful. Some individuals simply felt that American-made drugs were too strong for them. "They are made for Americans, and American bodies are usually bigger than our Chinese bodies. For example, they usually can drink a lot of liquor, but not us," one informant explained. Some were also convinced that any medicines made from chemicals were not good. "They are too strong for older people and they have many side effects." One informant even stated that he did not have many problems before he began taking the powerful Western medications provided by his doctor to control his high blood pressure. "Now, I often cannot get to sleep and feel dizzy," he said. Another informant stated that ''Western drugs are very effective in treating the part of your body which has a problem, but they often damage other parts of your body. I do not use them at all unless I am completely out of other choices." One Chinese traditional doctor I interviewed told me: Western drugs are usually more effective than Chinese herbal drugs in treating most acute diseases in terms of time, but they usually are not as [125]

Aging and Health anwng the Chinese Elderly

effective as Chinese herb dmgs when it comes to chronic health problems. Well, the most common health problems among elderly are chronic. If an elderly person uses Western dmgs to treat his acute or chronic problems frequently, these dmgs would aggravate his health since his body is too weak to handle them. My questionnaire results indicated that 65 percent of Flushing's elderly Chinese agreed with the statement "Chinese herbal medicine is more effective than Western Medicine in treating chronic health problems," and 78 percent concurred that "Chinese herbal dmgs have fewer side effects than Western dmgs." In addition, 46 percent supported the statement "Chinesemade Western medications are more suitable for Chinese elderly than American-made," and 69 percent agreed that the "elderly should try to avoid taking Western medication if they can." On the other hand, practically all illnesses perceived by my informants as "big problems" were listed as "health problems that should be taken care of by Western medical doctors" (see Table 20). The majority of my informants agreed that Western medicine was effective in treating these problems because "they come to you real fast," "they need an operation," or "they are very infectious, and Western medicine has better ways to control them."

Table 20. Health problems to be treated by \Vestem doctors Problem Kidney disease Pneumonia Tuberculosis Bladder infection Cataracts Fractures Ear infections Coughing up blood Urinary tract infection Glaucoma Heart pain Heart disease Liver disease Pancreatitis Diabetes

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Respondents (N = 21) 21 21

21 21 20 19 19 19 19 19 18 18 17 17 16

Health Care Decisions Table 21. Problems to be treated by traditional Chinese doctors Respondents Problem Back pain Neck pain Shoulder pain Leg pain Senile arthritis Rheumatic arthritis Night sweats Rheumatoid arthritis Kidney insufficiency Tinnitus Body pain Deficiency of chi Chronic bronchitis Hyperplastic arthritis Flatulence

(N

=

21)

17 16 16 14 12 12 9

9

9 8 7 6 6

5 5

The fifteen most frequent health problems designated as "to be treated by Chinese traditional doctors" were all chronic, hot-cold imbalance, or musculoskeletal conditions (see Table 21). Only six of the fifteen had more than 50 percent concurrence, however. One factor that may contribute to this low agreement rate is that among the twenty-one elderly Chinese who participated in this exercise, twelve were from Taiwan, and like other elderly Chinese from that island, they held a skeptical attitude toward Chinese traditional medicine. Mr. Bai, a sixty-nine-year-old Taiwanese immigrant, stated: I never really believed in Chinese medicine. It is just too old. These doctors still use methods that are hundreds of years old to treat people .... I am not saying Chinese medicine is not useful. It is very useful for many things-for maintaining good health, but not to treat diseases .... Well, acupuncture is different. Good acupuncturists can treat certain diseases, but there is no good acupuncturist here. At least I have not seen one. Mother Shi is also from Taiwan. She told me that she believes strongly in Chinese medicine: Xiao Guo, I know you are from Mainland China, but please do not take what I say personally. Many people came from Mainland China and all [127]

Aging and Health among the Chinese Elderly

claim themselves as the best Chinese medicine doctors. You know, who would know, right? I had back pain a year ago, I went to see two of them. Neither of them helped much, and they were not cheap too. I know Chinese medicine is very good, and not every Chinese doctor here is selfmade. But how do you know which one is good or not? After you find out, you probably do not have any money left. So to be safe, I just use some Chinese herbal drugs. If I cannot handle the pain, I will take a painkiller. Although a large number of the Flushing elderly, including those from Mainland China, felt Chinese medicine is effective in treating most chronic diseases and symptoms, their experiences with traditional Chinese medicine since coming to the United States have not been satisfactory. This does not necessarily indicate to them that doctors of Chinese medicine in Flushing are less skilled than at home. Many individuals believed the lack of success in treatment was because they have had their health problems for so long that positive treatment now is unlikely. Mr. Ma, a seventy-three-year-old immigrant from Mainland China, stated, The doctor I saw was very skilled. After the first two sessions of acupuncture treatment, my fifteen-year tinnitus problem was significantly improved. However, several months later, it came back again. I went to see him, and he asked me to have a longer treatment with him, because I have had this problem for so many years. It always takes longer to get rid of the old problem. But I can not afford it. So I decided to just let it go. For more than twenty years Mother Cheng has had chronic bronchitis caused, in her opinion, by heavy smoking during her earlier years. "As I am getting older, the bronchitis is also getting serious." Acting on a friend's referral, five years ago she went to see a Chinese acupuncturist who is well known for treating bronchitis. He is a very honest person. The first thing he told me was that in my case it would be difficult to have an effective treatment because I have had this problem for too long. Secondly, he can not use a powerful treatment on me because I am not only an old person. I also have high blood pressure. So, since then I have been using home remedies to control the bronchitis. I know many people who got much better after his treatment. But they are all much younger than I am, and they did not have the problem as long as I have had. [128]

Health Care Decisions

Problems Treatable by Self-Care Table 22 lists the twenty-five most frequently mentioned ailments that could be taken care of at home. Among them, eleven problems are mental health related, and twelve are either hot-cold and indigestion associated or related to high blood pressure and body pain. Most of the twenty-five ailments are considered chronic health problems. The majority of elderly Chinese experienced or recognized symptoms such as "worrying," "loss of memory," "loss of sleep," and "loss of appetite," but did not consider them to be health problems. They thought that these ailments were "small problems," and believed they did not require medical attention. To the question, What kind of method would you use to deal with these problems if you experienced them? most people answered that there is nothing that can be done except to "be open minded," "be wise," or "not Table 22. Problems to be treated at home Problem Fatigue \'liony Loneliness No strength Loss of memory Loss of interest in everything Fear Loss of sleep Headache Anxious Loss of appetite Athlete's foot Nausea Feeling of exhaustion of the nervous system Rapid and irregular heartbeat Cough Dizziness Flatulence Deficiency of chi Bodypain Colds High blood pressure Constipation Toothache Hemorrhoids

Respondents (N = 21) 21 21 20 20 20 20 19 18 18 18 18 17 17 16 16 14 14 13 13 13 12 12 11 10 lO

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think too much" about them. For "fatigue," "no strength," and "feeling of exhaustion of the nervous system," however, many suggested that some ingested herbal or tonic items' should be used, since these problems are signs of body weakness. Mr. Pan, a sixty-nine-year-old immigrant from Taiwan, made this comment about high blood pressure, which he has had for more than five years: At my age, almost everyone has high blood pressure. That is lao nian bing (an age-caused problem). The only thing a doctor can do is to give you medication. The good medications are always so strong that they can control your blood pressure, but will usually harm other parts of your body systems since the older person's body is generally weak. So you will get worse if you take medication. The best thing you can do is to try not to eat too much fatty and salty food .... I am drinking a new kind of Chinese herbal tea; it is a very good tea. The other important thing is to control your temper.

Doctors of Chinese Medicine

There were over two hundred practitioners of Chinese medicine in Flushing. Despite the fact that none of them can accept private health insurance, Medicare, or Medicaid, a considerable number of elderly Chinese utilized their services. In fact 38 percent of the survey population of eighty-three reported that they saw doctors of Chinese medicine at least once in the past year, and half of these persons indicated they had visited such doctors five times or more. According to my interviews with various types of traditional Chinese medicine practitioners and my personal observations, the health problems that the elderly Chinese brought to these providers were predominantly chronic ones, including musculoskeletal problems, anemia, diabetes, heart diseases, and other functional problems. However, there were also considerable numbers who sought these practitioners for treatment of problems that doctors of vVestem medicine failed to treat or diagnose, and who, according to several doctors of Chinese medicine, came to see them after seeing Westem doctors. Dr. Zhang explained, 1 In Chinese health culture, tonic materials are herbs or other ingested materials that contain certain yin or yang energies or elements and that are used to improve one's bodily condition.

[130]

Health Care Decisions It is not surprising. Many people believe that the diagnosis method of Westem medicine is more effective than Chinese medicine's since they have good equipment. But they consider Chinese medicine to have better treatment methods than Western medicine. Especially for the elderly people, they are afraid of the side effects of Western medication, and they know Chinese medicine herbal treatment is holistic and effective in the long term, yet without side effects. That is why they came here for treatment.

In addition to the five health care facilities that advertised the "integrated" practice of Chinese and Western medicines, there were also solo practitioners of Chinese medicine in Flushing, especially those recently arrived from Mainland China, who provided "integrated" treatment. Because of its reputation for achieving great success in Mainland China, the practice of integrated medicine has attracted a large number of Chinese Americans, as well as non-Chinese patients. Several of these practitioners I interviewed indicated that they provided free consulting services and often had elderly patients come to obtain advice regarding which approach should be used to treat their problems. Dr. Liu said, "Since we all have some knowledge about Western medicine, we would suggest to them to see Western medicine doctors if we believed it was the best way. That is why so many people call us and come in to ask advice. They trust us." Several elderly Chinese I interviewed expressed the opinion that the explanations they received from doctors of Chinese medicine were very convincing. One elderly man who immigrated to the United States in the 1970s stated: The zhang yi (Chinese medicine doctor) I saw in Flushing is very different from those I had seen in Chinatown ten years ago. Over in Chinatovm, they all were too traditional. I could not understand their language, although they sounded familiar. That was why I have not visited any Chinese medicine doctors for ten years. The one I just saw a couple of weeks ago in Flushing is very knowledgeable about Western medicine. After I told him about my symptoms and illness history, he knew exactly what kind of Western medications I took. And he not only told me that the symptom I am having is because of the side effect from the Western drug I have been taking, but also he explained to me why. He is very convincing, and I have learned a lot about Chinese medicine since I saw him. According to several doctors of Chinese medicine, a large proportion of their elderly patients were immigrants from Mainland China. As Dr. Lo remarked, [131]

Aging and Health among the Chinese Elderly

It is because people from the mainland know more about Chinese medi-

cine. As you know, Chinese medicine in Mainland China has equal status with Western medicine. But in Taiwan it is different. I had quite a few elderly patients who came from Taiwan. They questioned me a lot, and they always seemed too suspicious about what I said to them. But not the mainland immigrants. I do not have to explain too much; they know what I mean. These Chinese medicine practitioners all agreed that elderly patients are not their main clientele. "Their major problem is the payment, since we do not accept any insurance," said Dr. Lo. Consequently they treat patients on a cash basis.

Faith in Western Medicine In general, for almost all dai mao bing (big problems), and especially for acute ones, the elderly Chinese were convinced of the effectiveness of Western medical treatment. This faith in Western medicine was firmly held. Even when patients were not satisfied witl1 a particular doctor's treatment, they would blame that doctor but retain confidence in \Vestern medicine. When such a situation occurred, the elderly patient would seek another doctor, and this led to the "doctor shopping" pattern so frequently encountered in Flushing. Even for those who did not have any health insurance, their first choice when they experienced an acute problem was to consult with \Vesterntrained doctors--either a unlicensed Chinese doctor or a physician at a public hospital. Some, however, might also go to the "integrated" doctors, since these individuals had some training in Western medicine.

Barriers to Health Care Both the survey results and key informant interviews confirmed that there were a number of individuals in Flushing who had no or only a few contacts with Western medical facilities. The reasons why many elderly Chinese were reluctant to seek health care are multifaceted. They include beliefs about aging and health problems, perceptions of health problems which lead to choosing particular health care methods, and previous encounters with health care providers. [132]

Health Care Decisions

Many Chinese elderly enjoyed a relatively high socioeconomic status and had access to well-established health care resources before they immigrated to the United States. Their home-country experiences of health-care seeking sometimes conflict v-rith the realities of health care in the United States. Many informants reported that they did not utilize health care resources here because they are too complicated and too expensive. This type of complaint was especially common among Mainland China immigrants. A sixtyfive-year-old former university professor in China put it this way: Money was never an issue when I went to see any doctor in China. It was because, as you know, everyone was covered by the university. Well, I knew it would be different when I carne here since there is a different health care system than in China, but the process of visiting a doctor is so complicated here. You probably know, in China doctors would immediately look at the part of your body that you had complained about, and then it would take no time for them to come up with a diagnosis. Of course, they sometime did use a machine to test you, but it would only be used when they could not come up with an idea of what was wrong with you in the initial diagnosis. Here, doctors just cannot do anything without a machine. Even for the simplest mao bing (health problem), they still use a machine to test you before they can tell you what is wrong. The contrast in health care systems led many elderly Chinese to think that Western medical doctors in the United States were less skilled than doctors in China because they relied on mechanically based diagnosis rather than on their clinical experience. One elderly person stated, In China, I would go to a health clinic even if I had some very minor problems. I didn't have to pay anything, and I would get excused from work too. But to see a doctor here is a killer. Even for a small problem, one test after another. They just want your money. It is not worth it. I would rather go out to get some Chinese medications to treat myself. The only thing a doctor can do here is to give you a prescription. So what is the difference .... What happens if I have a serious problem? Well, I certainly hope I don't. Ifi do, I only can say I do not have good yun qi (luck). Some individuals believed that the reason that American doctors asked patients to have tests was not only for the purpose of diagnosis but also for self-protection. Mother Wang commented: "Doctors in America are afraid of being sued, so they prescribe medications according to the result of ma[133]

Aging and Health anwng the Chinese Elderly

chine tests, even if they know these medications are not that useful. So, even if a patient's problem got worse because of that wrong prescription, they cannot sue the doctor." Mother Ge has not visited any doctor since she immigrated to America from Mainland China four years earlier. Her lack of health insurance was not the only reason; she also distrusted U.S. doctors. She explained: "I have a relative practicing medicine in San Francisco, so I know what they are doing. They often give out new medications to patients for experimental purposes. They get them from drug factories. If they use them on their patients, they can get many benefits from these factories. So a lot of times they just give them out even if they know there are better ones."

Western-Made Drugs Many elderly Chinese also believed that Chinese-made Western drugs and Chinese herbal drugs were better than Western-made drugs. It was not necessary, therefore, to consult a Western doctor, since they could obtain the medications they preferred without seeing a doctor. Many of these individuals consulted ''lith their doctors and friends in Taiwan and Mainland China by telephone and in writing to obtain advice and prescriptions for their health problems. Mother Fong, a sixty-four-year-old Taiwanese immigrant who visited Taiwan once a year, consulted with her doctor there by telephone every month. She explained: I do not trust doctors here, and I do not trust the prescriptions they give.

They are too businesslike; there is not much of a personal relationship. They do not like to listen to you, they like to do what the test result says. My doctor in Taiwan knows me very well. I do not have to explain much, and he will know exactly what is wrong, and what kind of treatment will be the best for me according to my overall health condition. People like Mother Fong, who could afford to call her doctor in Taiwan so often, were not in the majority. However, it was common for many individuals to consult their doctors outside the United States to obtain a second opinion after a diagnosis was made by a doctor in Flushing. A large number of individuals also expected to have some minor physical discomfort in old age. Complaining too much about these minor health problems to doctors was a sign of weakness. Mr. Pai commented: [134]

Health Care Decisions

We all have health problems. But the way we interpret these problems is different from the way the doctor does. Some people could not handle these xiao mao bing, or never had them before, so then they went to see a doctor. What happens'? If you complained too much, the doctor will give you all kinds of tests. These tests all are done by machines. Well, you only had xiao mao bing when you walked in the doctor's ofRce, because you want the doctor to give you some good medication to get rid of the pain, but it is not that simple. The result of these tests could make you feel as if you were seriously ill. Then you will be depressed because the doctor has said you need help. The doctor is a doctor; his job is to find out what is wrong. I know many people who never go to doctors, and they have many problems, but they still are doing very good. But I also know some people who always go to see doctors, even for a cold. Then they are so unhappy and tell everyone that they do not feel well.

Financial Barriers Ninety percent of the surveyed elderly population indicated that the high cost is one of the major harriers for them in utilizing health care facilities. Data obtained from key informants as well as from structured interviews suggest that certain groups, however, are particularly vulnerable to the high costs of health care. Many individuals, especially those who came from Mainland China, do not have any insurance coverage (see Table 23). The reasons for this are varied. Some individuals assumed that they did not qualifY for public health care assistance; others felt that if they applied for assistance it would harm their plans to bring other family members to the United States. Still others thought that they did not need to spend money on health insurance since Table 23. Insurance coverage Insurance type Medicare Medicaid Medicare & Medicaid Other No health insurance No data Total

Taiwan

Mainland

Total

18 5

4

11 1 4 3 42

1 8

22 13 12

8

9 24

20

3 83

0

41

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they had affordable alternatives if they needed health care. Finally, some elderly Chinese simply did not know how to apply for Medicaid or Medicare benefits. During the interviews, many individuals, especially those newly arrived from Mainland China, often compared U.S. health costs with their home country, where care is almost free. The expectation of substantial health care costs often resulted in a hesitation to seek services, even among individuals who had insurance coverage. During a chat in the senior center, I asked Mother Zhang why she did not go to see a doctor although when she was suffering from constant headaches. MOTHER ZHANG: GUO:

They charge too much for a little problem.

But you have the Medicare card, right?

Yes, but it still makes me very uncomfortable to see that they charge so much money. A year ago when I first obtained the Medicare card, I went to see a doctor for the flu. He hardly did anything but give some drugs. A month later, I received a statement from Medicare, it said that the doctor had charged over a thousand dollars for that visit. I was so mad .... I do not want to be seen as a bad citizen.

MOTHER ZHANG:

GUO:

What makes you say that?

The American government is kind enough to give us this benefit. Now that everyone is having economic problems in this country, how could I spend that much money for a little problem? Plus, the government must monitor how much money we have spent.

MOTHER ZHANG:

Many individuals felt that some health care costs were unnecessary, and that doctors charged for these services only to make profits. Mr: Tang commented: "Doctor and hospitals only want to make money from you, that is why every time when you go there they ask you to go through so many tests. It costs a lot of money. Although I do not have to pay from my own pocket, they are costs that could be saved." A concern over the high cost of many prescription drugs often deterred individuals who had Medicare coverage from seeing a doctor. Because "going to see doctor is mainly to get drugs," many of these individuals simply obtained drugs from black market or mail order sources, without consulting their physician.

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[13] Using the U.S. Health Care System

Elderly Chinese had well-formed ideas about the types of problems that could be solved by particular health care methods. Certain individuals would be likely to seek Western-style health care providers only when they believed that problems they had were dai mao bing (big problems), or that immediate medical attention was needed to treat acute symptoms. In these cases people would go either to Western-trained Chinese doctors or to hospitals. However, my interviews indicated that despite the fact that some elderly acknowledged their problems as dai mao bing, many did not go to a Westem medical provider until the problems became too big to endure. In other words, there seemed to be a gap between their knowledge of a particular health problem and their physical endurance of it. Only when their endurance reached its limit was a decision to seek health care likely to be made. My survey results illustrated this pattern. More than 60 percent of survey respondents indicated that going to see a doctor is their last resort. We now tum to the factors that caused many elderly Chinese to put off seeking health care when it appeared to be needed. The purpose of this discussion is not to make judgments on the performance of ·western-trained doctors in Flushing, but to demonstrate some of the problems that arise between some physicians and their elderly patients.

Westem-Trained Doctors

A large number of the physicians in Flushing are American trained. Most arrived from either Taiwan or Hong Kong in their younger years, but some [137]

Aging and Health arrwng the Chinese Elderly

are American-born Chinese. For some of these doctors, non-Asian patients make up a large percentage of their patients. Among this group, forty-five accept Medicare payments, but only three practitioners accept Medicaid patients. The majority of elderly Chinese in Flushing rely on these Western-trained Chinese doctors, especially those elderly who have Medicare or private health insurance. Moreover, during the twelve months preceding my survey of eighty-three elderly Chinese respondents, two-thirds had visited Westem-style doctors at least once. The attitudes of these elderly Chinese toward the Western-trained doctors were mixed. Some believed their doctors were very good, and they were happy with them. Others thought their doctors were very ordinary, and neither better nor worse than other doctors. A large number of individuals however, felt that there were very few good doctors in Flushing, and the skills of the doctors they encountered were not as good as they had expected. According to my survey of eighty-three elderly individuals, less than half thought that there were only a few good doctors in Flushing, and more than half felt the doctors they had seen were not as good as they had expected. In discussions with my informants, I found that many were noncommittal in their answers because they had never visited any doctors or did not want to complain, even if they did have problems. One informant said: Especially people who are my age, we do not like to complain--complaining is not a very good thing. Have you heard the saying, "Elderly Chinese only complain about 20 percent of what they are suffering?" If people think you are not bad, and someone else asks them about you, they will put in a good word for you, because that is the Confucian way of doing things. However, if someone asks me about you, and I know you are not that good, I would say to that person, "I do not know." But if you were a really bad person, then I would say, "He is not that good." You understand? That is the Chinese way. One clay three elderly Chinese women walked out of the elevator in the building where the Chinese senior center was located, and one said, "He is another Mongolian doctor." When I asked Mr. Fan about this, he asked, "You never heard this tenn?" He sounded very surprised. According to Mr. Fan, in Mongolia the few doctors who traveled widely to see patients were mostly self-taught. They treated not only people but also animals. They knew a bit of everything but were not good at anything. Somehow this ex[138]

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pression has become a commonly used phrase by Chinese in Flushing to refer to "ordinary" doctors. "But these doctors in Flushing are all medical school graduates," I said, "so how could they be that bad?" "There are many things you need to learn, let me tell you," Mr. Fan said. He continued: It does not literally mean they are lacking in medical knowledge. They

probably do know a lot since they all have degrees. But it is the way they treat you. If you are elderly, they know they have to treat you because otherwise the news is going to spread through the community, and then their faces would not look good. But they really do not want to treat you, because you are old.... Why? First is the money. They cannot make much money on us. Most people who go to see them have the laoren card [Medicare], so they cannot make much money. Well, if you are a first timer, then they have reasons to do all kinds of tests on you, and then they can make some money. But if you are an old patient, they cannot do that all the time unless you tell them something new, and then they can do the tests again. Second, most of us have chronic problems. We go there because these problems are bothe1ing us. They know it is difficult to cure these problems. So every time you call them, they have to make room for you. Then you are not happy because after you have seen them for many years nothing has improved. Also many elderly want to tell the doctor everything-what they ate, how their sleep was-because they want the doctor to understand why they are not feeling well. But some doctors do not have the patience to listen; for them time is money. They want to see other patients, not you. So what is happening is that as soon as you walk in, they will just talk to you for a few minutes, then say: "I am giving you a new medication. It is very good." Many elderly will feel hopeful because they are getting new medications. But a lot of people are not happy because we know what they try to do. That is why we call these doctors "Mongolian doctors." Many of the elderly Chinese I interviewed expressed similar views. Another term commonly used for these doctors is xiao er ke doctor. I first heard this term while accompartying an eighty-seven-year-old Chinese woman to her doctor's appointment in Flushing. Mother Chen came from Taiwan fourteen years ago. She has had diabetes for seven years artd has also been suffering from bronchitis, asthma, high blood pressure, and arthritis. In her own words, "I am a useless and hopeless old bing hao (one who is al[139]

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ways ill). No doctor likes to see me around. I cause headaches for them." She is also a person with a great sense of humor. In response to a compliment on her positive attitude, she said, "If not, I would have been in 'West Heaven' [a metaphor for death] a long time ago." Referring to the new doctor she just saw before the interview, she laughed and said, "They are all the same." Not understanding what she meant, I asked again, "Is the doctor good?" "Hai, just like Dr. Cai, he is another xiao er ke doctor." I puzzled over this term for a second. One of the meanings of xiao er ke is a miser who will not spend even one penny on others. But it can also mean "department of pediatrics." When used by people like Mother Chen, the term carries both meanings. First, those doctors who seem unwilling to listen, care little about their patients' problems, and rush patients out of their offices with "new medications" are dubbed a xiao er ke doctor. And second, many people think that little children have only little problems, and being a pediatrician therefore does not require a great amount of knowledge. Children, moreover, are easily satisfied if the xiao er ke doctor gives them sweettasting medications.

Good Doctors Although some doctors were dubbed Mongolian or xiao er ke doctors by some elderly Chinese, they were also thought of as "good doctors" by others. Few elderly Chinese in Flushing ever spoke about a "good doctor" by referring to his or her medical skills. When using this phrase the majority indicated that a good doctor was a "nice person" and was willing to prescribe the medications that elderly patients wanted to have. The "nice person" was a recurring theme when elderly Chinese discussed their doctors. Mother Chen talked about the xiao er ke doctor she and her husband had been seeing since they immigrated to the United States fourteen years earlier: "We like him. He is a nice man, kind, honest, and patient. It is not easy to find a skilled doctor here. They are busy making money with other kinds of people. They only take privately insured patients. We have no chance to see them, and tl1ey all have big heads. Would tl1ey see me? So tlw doctors we can see are all the same in skills. We feel lucky enough to have him." "But why did you see this new doctor today?" I asked. "I heard from the radio he is good at treating my problems. Although I didn't really believe it, I still thought I would try my luck," Mother Chen said. [140]

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"So why do you think he is also another xiao er ke doctor?" "He only asked me a few questions, and gave me the exact same prescription as I have been given by Dr. Cai [her old doctor] for five yearsmore 'cough syrup.' " Another key informant, Mr. Yang, said, Although we know that the health problems we have are impossible to get rid of, we do want to get some comfort from the doctor that our problems are not getting too far gone. vVe also know all doctors here are pretty much the same, so if a doctor wants to talk to you, shares his sympathy, tells you that you will be all right, that nothing will become serious, and he can give us the prescription we wanted, that is enough. That's all many people want. "So, what kind of medication do you want from your doctor?" I asked. "I know I 'Nill bring all the problems I have now [when I go] to see God. But just like many others, I do not want to suffer too much before that day arrives. So if the medication can make me feel better, that is enough.''

Doctors' Viewpoints Seven Western-trained Chinese physicians offered me their perspectives on the health and health care of the elderly Chinese in Flushing. Most of these doctors felt the elderly Chinese in this community were quite resourceful in dealing with their health problems, although some added that the wide range of available health care resources sometimes conflicted with their treatment protocols. It was surprising, then, to learn that some doctors thought that elderly Chinese lacked a prevention concept. My research clearly demonstrated that prevention was a central idea directing the daily activities of many elderly Chinese. According to Dr. Wu, a well-known physician in Manhattan, the general lack of a preventive concept among elderly Chinese was the reason that most elderly individuals did not seek health care until their problems became serious. "Few of them regularly go to their doctors to have their yearly physical check up, for example," Dr. Wu stated. It is true that a large number of elderly Chinese do not have an annual physical. My survey indicated that only a quarter of the population had an annual examination, and a third of the respondents reported that their last exam was at least five years earlier. The survey also indicated that the three [141]

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most common reasons why such numbers of elderly Chinese did not schedule annual checkups were "I know my health condition," "It is too expensive," and "It is not convenient to do it." Dr. H ui was a very popular doctor among the elderly Chinese in Flushing, and he was the only Western-trained doctor in this community who accepted elderly patients regardless of their insurance status. Almost every elderly Chinese knew of him, and a large number had been treated by him. Their opinion of his medical skills was mixed, but in general he was viewed as a "nice person" by this elderly population. "He will give you the medications for free if you do not have money," one person said. Although he specialized in cardiology and internal medicine, Dr. Hui saw patients \vith various health problems, and even treated his patients with acupuncture. According to Dr. Hui, the most common health problems among the elderly Chinese were high blood pressure, heart disease, arthritis, stomach and intestinal disease, diabetes, and hepatitis. A major problem in his view was that many elderly Chinese lacked knowledge of how to prevent such health problems. "For example, many people love pork," he said, "especially the fatty part. Many people cannot afford to buy other meats than pork, and they always like to buy the cheapest parts. They also like to cook the foods with various strong tasting ingredients. Some of these will cause high blood pressure if they are frequently consumed." Dr. Hui also listed lack of exercise, the pressures of being in an unfamiliar social environment, and intergenerational family problems as factors affecting the prevalence of high blood pressure and other health problems among Flushing's elderly Chinese.

Doctor Shopping The practice of doctor shopping by elderly patients frustrates many physicians in Flushing. Many elderly Chinese do not have a regular doctor and frequently visit different doctors. Even among these who have one regular physician, it is common to see another doctor at the same time, including practitioners of Chinese medicine, without telling their own doctor. "It creates a big headache for me," said Dr. Zhang. "I never know what kind of medications they have been taking. I know many of them are not satisfied with their doctors because they think that their problems have not gotten better as quickly as they wanted. But to see different doctors at the same time only makes the situation worse. We never know the real history of their [142]

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problems." Dr. Zhang also said that he constantly gets new patients. Although he knows that these patients have previously seen other doctors before coming to him, "they do not tell me what kind of doctors they saw before." One day an elderly Chinese woman asked me to accompany her to a university health clinic. There were no Chinese-speaking doctors in that clinic, and I served as translator. Since it was first time Mother Gao had been to this clinic, an American physician asked her to provide her previous doctor's name and address. She asked me to tell the American physician that she preferred not to give out the name of her doctor. Later I asked her why, and she said, "Dr. Cheng is a very nice man. I did not tell him about tllis. I do not want to hurt his feelings."

The Image of the American Health Care System Although they understand that the American health care regime is highly sophisticated, the image of this system held by many elderly Chinese is that it is extremely complicated. As one key informant described it, the "American health care system is like another puzzle that exists in a puzzling society." Another complained: "There are too many policies and regulations, not to mention doctors and hospitals; even the government agencies have different versions of interpretations on the coverage of the Medicaid card. It is just too complicated to know what I can do and what I cannot. That is why so many people will not go to see a doctor even if they cannot handle their problem." My research uncovered some of the most frequently asked questions: What are Medicaid and Medicare? What are the differences between them? What do the Medicare billing notices mean? Why do so many doctors not take the lao ren card (Medicare)? What are the differences between a private hospital and a public hospital? How and in what situations should one make an appointment with a doctor? Particularly for new arrivals still unfamiliar with the American health care system, there is much confusion about publicly funded health services. For example, seven of the twenty-five structured interview participants did not know what kind of health care benefits they were entitled to. But they had been told by friends that the cost of health care in the United States was very high. Among earlier-arrived immigrants who either had Medicare coverage or private insurance, however, there was less concern about using the American system. [143]

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Hospitals There are two private hospitals in the central area of Flushing. These hospitals are equipped with advanced medical facilities and provide a wide range of services. Although they were in convenient locations and many elderly Chinese had heard of them, few had actually used them. The majority of elderly Chinese, particularly those who did not have health insurance and who had only Medicaid coverage, would travel to two city hospitals in lower Manhattan where financial assistance and some bilingual staff were available. In Flushing there were only three doctors willing to treat Medicaid patients. Because the two city hospitals provided services to low-income individuals of many ethnic backgrounds, they were known in the Flushing Chinese community as "the poor people's hospital" or "the United Nations hospital.'" During weekdays, these two hospitals were always filled with patients in the waiting areas. Because of a shortage of physicians, a wait of several hours or more was not uncommon, even for people with an appointment. "People bring their lunch there; I do too," one elderly Chinese said told me. Most people would only go to one of the city hospitals when they had depleted other alternatives to managing their health problems. The reasons for this included the inconvenience of traveling from Flushing to lower Manhattan, the prospect of a long wait, and the quality of services in these two hospitals.

Making an Appointment Both these hospitals required a patient to make an appointment at least two weeks in advance. However, if the patient wanted to see a specialist, it was not uncommon to wait three or four weeks. For the elderly immigrants from Mainland China, making an appointment a few weeks ahead was a difficult concept to understand. In Mainland China, people normally go to the hospital whenever they need to. Mr. Liu, a sixty-four-year-old Mainland China immigrant, spoke with emotion: "It is really a joke. Who knows they will be sick four weeks ahead? The only time when I need to see a doctor is because I am ill. Three weeks, by that time it has gotten better by itself." He continued: I had a fever five months ago. After three days, it was still pretty high. I felt all right, but my wife was worried because my health has not been that [144]

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good since we came to America.... Since I do not have any insurance, I had to go to a hospital. I heard that you have to make an appointment first. But how? I did not know. By the time I found out from my friend, another two days passed. Finally I called my son and asked him to make an appointment for me .... My son moved to New Jersey a year ago with his family because he found a new job. Then my son told me I have to wait for three weeks. So I did not go. I know a friend who knows something about medicine, he came over, and said [my illness] was not a big problem. I took some Chinese-made medication, and slept a lot. Two days later, I was all recovered. Later, many people told me, in my situation I should go to the emergency room, it does not require an appointment. But it is very expensive and you have to wait too.

Paperwork and Tests For those who got to the hospital and waited, the process was still not easy. Mr. Yan, a former university professor, shared his story: A couple of years ago I caught a flu, and I used some of the Chinese flu drugs I had, but they did not work So I decided to go to the hospital. After I had waited for almost half a day in the waiting area, an American doctor finally asked me to his office. I know a little bit of English so I told him what was wrong with me. He did not seem to care much about what I said. lie asked a nurse over. She brought in a couple of forms and asked me to fill them out. It took me twenty minutes to finish them. When he learned that I am sixty-five years old, he asked to do some examinations and tests from foot to head. I tried to explain to him that I only had a bad flu. But he would not listen to me and insisted that I must do the test before he could treat me. After several tests, the nurse told me I had to come back some other time to do other tests since their schedule is booked. The whole process of these tests lasted a couple of months. I did not expect so simple a problem to cause so complicated a process. No wonder America needs health care reform. Mr. Li had suffered from a serious stomach pain for several weeks before becoming bedridden. He had been diagnosed with a chronic stomach problem ten years earlier when he was still in Mainland China, "but it was all recovered five years ago before I came here," he said. But after a one-month period of self-care, Mr. Li's stomach did not seem to get better. He decided to take a friend's advice to go to one of the city hospitals. "I was there all day, [145]

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but the total time I had with the doctor was only ten minutes. The rest of the time I was busy filling out the forms and doing all kinds of tests which were unrelated to the reason I went there." Then, after a few visits, a doctor told him that he must go to another hospital for a more extensive examination, as the particular equipment was not available at the first location. Two weeks later Mr. Li went to the second hospital. The staff there asked him to provide a financial support statement before they could perform the examination. As he was unable to provide this statement, the hospital asked him to come back ten days later for an interview with a social worker to discuss the possibility of applying for Medicaid. Unfortunately, he missed the scheduled appointment because his translator could not accompany him that day. He then managed to have someone write a letter to the hospital requesting a new appointment, and asking if the hospital could find a bilingual person to translate for him. Three weeks later he received a reply from the hospital. They informed him that they had scheduled a new interview for him, and a bilingual staff member would be available. but he would have to wait for another two weeks. "The process took a couple of months before I could do that test," said Mr. Li. "If the problem had been really serious, I would be dead before they could start to find out why. Good thing the problem was not that serious, and I did not rely on them." During the two-month waiting period, Mr. Li continued self-treatment with Chinese herbal and Chinese-made Western medications. By the time he received the final clearance note from the hospital, "I was all better already."

Language and Cultural Barriers

Several New York City hospitals, especially the two lower Manhattan hospitals, have recmited bilingual staff and physicians in recent years to meet the needs of patients who do not speak English. During interviews with staff members of these hospitals, I was told that language, especially for Chinese patients, should not be a problem since there were a number of staff and physicians who speak "Chinese." However, what I learned from interviews with elderly Chinese revealed that the problem is in the type of dialect that is spoken. The majority of the Chinese staff in these hospitals were either ABCs (American-born Chinese) or immigrants from southern China who arrived in the United States when they were very young. Among them there were [146]

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very few who have any medical e;..'Perience in China. According to one sixtythree-year-old Chinese man who had many contacts \vith these staff and doctors during the past five years, the only difference between them and other Western doctors is that "they could speak 'Chinese.'" What he meant, beyond any difference in dialects, is that there was a lack of understanding in vocabulary and common expressions since most of these health care providers acquired their Chinese in the United States. Another seventy-oneyear-old female informant said, "Sometimes it is worse to run into this type of doctor. They thought they understood me, but I knew that they did not because I did not understand what they said." Mr. Lang is a sixty-seven-year-old man who immigrated to this country from Mainland China in late 1980s. Recently Mr. Lang visited one of the Manhattan hospitals several times for "stomach pain." My interview 'Nith him revealed a common reality of many elderly Chinese when encountering a health care provider.

GUO:

The last time you were there, did you see a Chinese-speaking doc-

tor? MR. LANG: GUO:

No, the doctor I saw is not Chinese. He looks like an Indian.

Did you go by yourself or with somebody else?

It is not good to ask someone for help here, because everyone is busy working.

MR. LANG:

Did you worry about the language problem before you went there by yourself? MR. LANG: Of course, but what could I do? I would not go if I had other choices. GUO:

But I hear that in these hospitals you can ask for a Chinese-speaking doctor. Why didn't you ask for one?

GUO:

Of course I did. But they told me that if I wanted to see a Chinese doctor, I had to make an appointment at least three to four weeks al1ead of time. But I was in great pain at that time. I could not wait for another two weeks. So I went there anyway.

MR. LANG:

GUO:

How did you communicate with that doctor, then?

After he realized I do not speak much English, he went to the waiting area and hollered to the people: 'Who can speak Chinese and English?" Nobody responded. Five minutes later, a ChineseAmerican nurse came in with him.

MR. LANG:

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Did it work well? LANG: No, it did not.

GUO: MR.

GUO:

How come?

She came in with a very reluctant face. She asked me what I wanted to tell the doctor. I said lots of things, but she only translated into a few words. It was the same situation every time I was there. It just makes me feel very uncomfortable to say anything. I did not want to explain anything either.... Would you feel comfortable when you see their unhappy faces and the way they tell you what the doctors said? They made me feel that I am a waste of their time ... and [that] what I said was all nonsense. They always seem in a big hurry. Probably it is true, I heard that translation is not their job. They do not get paid for doing that.

MR. LANG:

GUO:

But she did speak Chinese?

You can say that is Chinese, but it is a broken Mandarin with strong Cantonese accent. It was very hard for me to understand what she said. She also did not understand most of what I said.

MR. LANG:

Interviews with several individuals who had experiences with "Chinesespeaking" doctors in these hospitals illustrated that they still considered language a barrier to care. Even when doctors could speak to their patients, a gap in cultural meaning usually existed between Chinese-speaking American doctors and immigrant Chinese patients.

Quality of Service Among fifteen individuals interviewed who had been to the two lower Manhattan City hospitals for treatment, three said that they had no complaint about the services. One of them is Mr. Zhang, a sixty-seven-year-old former chief engineer in Mainland China. When I asked him about his first and last visits to that hospital, he showed a little embarrassment and said he did not have a story to tell. After hearing what other people who had been there experienced, he said: "What should we expect from that type of hospital? We all know we go there because we do not have a better choice. We should appreciate that at least we have a place to go. This hospital is cheaper, and we want to save money. We made our own choice, so do not complain." [148]

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When she heard what her husband had said, Mr. Zhang's wife expressed a different attitude: Yes, it is true that we go there because it is cheaper, and we do not want to spend hundreds of dollars just for one antibiotic shot. But all hospitals should have one principle regardless of what class of people they servethat is humanism. I have only been there twice, but what I received from the doctors was a far way from humanism. I do not mind much about waiting. But I cannot stand the way they looked at you, as if you are a worthless person. The doctor I saw was the worst doctor I have seen anywhere. Even the barefoot doctors [in China] are better; at least they treated me with sympathy. That doctor did not even bother to look at me much. Two questions and everything was over before I had a chance to explain anything. That has nothing to do with the type of hospital. The problem is the doctor. Mr. Zhang responded. "Do not say that. Who wants to work for that type of hospital? No money, and lots of patients. The doctors who are willing to work there are sacrificing their benefits. After all day long with no break in their working hours, who has any energy? We should not complain too much." Miss Li, a nursing school graduate, flew to Flushing from Mainland China in 1991 to take care of her severely ill parents who had immigrated to the United States eight years before. Shortly after her father was diagnosed three years ago with Babinski's syndrome (a combination of cardiovascular and neurological disorders due to tertiary syphilis), her seventy-two-year-old mother experienced high blood pressure and other symptoms, including weakness and fatigue. Her two sisters decided to take their mother to one of the public hospitals, but an uncle who had been living in the United States for more than twenty years rejected this idea. "He knows all about the American public hospital situation," Miss Li said. Her two sisters still insisted on taking their already weakened mother to the hospital emergency room. They arrived in the morning, and did not leave until seven at night. The next morning, Mother Li could neither speak nor move, and they took her to the hospital again. With a sense of disappointment, Miss Li told me the story about her mother. During the Cultural Revolution my mother had developed high blood pressure. But a doctor found out that the type of blood pressure she had [149]

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was different than most other people's. It was caused by the nervous system. So the doctor only prescribed a kind of medication for nervous sedation. She became better after that, especially after the Cultural Revolution, and before she came to America she never had high blood pressure again. But her blood pressure went up ever since she came to America. My father's health condition definitely put a lot of pressure on her. When she was in that hospital, after being sent to various departments for tests, she was completely exhausted when the doctor gave her some high blood pressure depressor. She and both my sisters thought that the doctor must have known everything about our mother since they did ail-day tests on her.... After it happened, my sisters called me [in China]. I asked several doctors, they all said it was caused by the depressor.... My sisters made a big mistake by taking my mother to that hospital. I went to that hospital many times to see my mother after I came here. During those three months I witnessed many things about that hospital, from nursing care skills to the treatment process. I was a nurse, and had worked in a small hospital [in Mainland China] for ten years. Not only are the nurses' clinical hands-on skills so bad here, their attitudes are also far worse than in China. Because it is a public hospital, and most patients there are poor and cannot speak English, they treated them with icy faces .... The doctors also try new drugs on their patients. I heard so many people complain about these things. What I want to tell you is this: once you walked into that hospital, you would have a problem if you did not have one before you walked in; the problem would be bigger if you only had a small one; and you would die if you had a big one. Many individuals throughout my field research shared the attitude Miss Li had toward public hospitals.

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[14] Conclusion

The overall picture of health-seeking behavior among the elderly Chinese in Flushing is complex. The factors that affect their access to health care facilities are multiple, and they differ according to the individual. Although many persons have faith in Western medicine and acknowledge that certain problems can best be treated by Western-trained health providers, they do not always act on these beliefs, but instead wait until they can no longer handle problems themselves. Many individuals have mixed strategies for seeking health care, such as doctor shopping, utilizing integrated practitioners before making a health care decision, seeking treatment from a Chinese medicine practitioner after obtaining a diagnosis from a Western-trained doctor, and stopping doctor visits after obtaining a diagnosis and then seeking further help from other sources. The chief factors that generate these patterns can be summarized by the following points: l. New immigrants are often misinformed and misled by characterizations

of the American health care system, and they are apprehensive about pursuing health care service. At the same time, the very real complexity and problems existing within the American health care system confront everyone and enhance existing fears. 2. Individuals experience high costs, a language barrier, the requirement of making an appointment several weeks in advance, the substantial amount of paper work, and long waits in hospitals. In addition, health care services are difRcult to obtain for elderly Chinese who do not have health insurance. 3. The complicated machine tests used in modem American health care create a biased attitude toward Western practitioners among many Chi[151]

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nese elderly. They believe these Western-trained doctors are less sldlled than doctors in China because they rely heavily on machine-based diagnosis rather than clinical experience. 4. Many Chinese elderly in Flushing believe that Chinese herbal medicine and Chinese-made Western medications are superior to American-made medications. Since the major purpose of seeing a doctor is to obtain a prescription, it is not necessary to visit doctors if you can obtain the medications you need without a prescription by mail order or from relatives and friends in Taiwan or China. 5. The various types of Chinese medicine practitioners, especially those who practice integrated medicine, provide an important alternative for those dissatisfied with Western medicine. Even though none of these practitioners accept health insurance, many elderly Chinese, especially those from Mainland China, utilize them. Many also go to doctors of Chinese medicine for treatment after first obtaining a diagnosis from a Westem-trained physician. 6. Important differences in aspects related to health seeldng behavior characterize immigrants from Mainland China and Taiwan, even though most hold the same general beliefs concerning the relative merits of Chinese and Western medicines. The differences between the Taiwanese and Mainland Chinese elderly in their health-seeldng practices represent a complex mixture of economic and ideational factors. The Taiwanese have, on average, been in North America for longer and arrived with greater financial assets. The second most important factor is the fact that Taiwanese elderly are from a capitalist society in which they were familiar with Western-style private health care providers and health insurance. The Mainlanders, on the other hand, are from a communist society in which their relatively secure social status was not linked to "capitalistic wealth." Consequently they did not come to America with a lot of money to invest; nor did they have strong entrepreneurial sldlls. And the socialist health care system in Mainland China has been centralized by the government. There are neither private health care providers nor private health insurance carriers. In sum, elderly individuals from Taiwan are more prepared for the American health system than those from the mainland. Only four of the forty-two Taiwanese survey respondents had no form of health insurance; but many more Mainlanders, especially recent immigrants, fell into the uninsured category. Consequently, the Taiwanese elderly have a greater frequency of visits to hospitals and Western medical doctors than do the Mainlanders. It is partic[152]

Conclusion

ularly striking that half of the forty-one Mainlanders reported no visits to Western medical doctors in the past year, while only seven of the Taiwanese elders did. As a result of their greater degree of contact with such health services, the Taiwanese elderly do not resort as much to home remedies and self-care for their minor problems. On the other hand, despite the fact that the Taiwanese elderly have greater material resources and access to both public health insurance (Medicare or Medicaid) and private health plans, the differences between the two groups is not simply a matter of money. Some of these differences are best understood in terms of the historical (and political) events that separated these two groups. However, it would be a mistake to consider the differences totally due to traditional cultural beliefs. The different ideas about the causes and treatments of illness, and the resulting behaviors in relation to the American system, are only partly "pure culture," since economic and situational factors affect them as well.

Search for a Remedy: An Eclectic Approach

As vvith other elderly persons, the Chinese elderly's search for a cure for every illness is ultimately doomed to failure. As the Chinese elderly themselves put it, "The machine is getting worn out. More and more of the parts are beginning to fail." All remedies offer only a temporary reprieve. Still, people do not give up the search for improved health. They spend much time, effort, and money trying to keep the body in good repair. But despite their concern about keeping healthy, eating properly, and maintaining a balance of yin and yang, people continue to do things they want to, even when they know it is "not healthy." Many people realize that frequent consumption of pork, especially the fatty parts, is harmful to their health. Nonetheless, they continue to consume this kind of food, even those who have high blood pressure. We also see a paradox in the Chinese elderly's attitude toward drugs and medicines. On the one hand, they place strong reliance on medications; on the other hand, they worry about the powerful effects ofWestem medicines. They understand that those medicines appear to be effective. As one informant explained, "a good drug will cure everything at once, so I do not have to take many other drugs." Yet they also fear the side effects. This wariness toward Western medicines may be quite reasonable. A recent study indicates that adverse drug reactions (ADRs) may be responsible [153]

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for more than a hundred thousand deaths in the United States each year, making it one of the leading causes of death (Lazarou, Pomeranz, and Corey 1998). Many Western-trained geriatricians are uncomfortable with the tendency to overmedicate in our health care system, and are calling for caution when providing elderly patients with powerful medications (McGeer and McGeer 1997; Tourigny-Rivard 1997; Zayas and Grossberg 1998). There is a concern particularly that elderly persons using medications for chronic conditions may encounter serious interactive effects if they add another medication for an acute illness. Many Chinese believe strongly in traditional ideas about health, illness, and treatment. But they feel no conflict over seeking Western diagnoses. It appears that these two Chinese and Western models of health care are incorporated into a larger "supermodel," a semi-integrated medical pluralism that tries to make sense ofboth sets of ideas. This "integration" is sometimes hard to envision because the technical aspects of Western medicine are so starkly present-the electronic medical equipment and the complex technicallanguage-in contrast to the philosophical and low-tech Chinese tradition. But, in fact, the differences are complementary. The successes ofWestern medicine in acute and serious illness fade off where the preventive orientation of traditional Chinese medicine and its "home-style" medications become effective for chronic illness and health maintenance. These general points illustrate the eclectic approach of Flushing's elderly Chinese in recognizing and dealing with their health problems. Most accept the coexistence of ideas and treatment regimens from both the Western and Chinese medical traditions. Most, in fact, employ more than one health care method at the same time. Even people with strong faith in Chinese traditional medicine will use Western medical services if given the opportunity. At the same time, they rely heavily on self-care. For those who seek professional help, their main concern is to find relief from the symptoms that interfere with normal daily activity. When people are seeking help for serious, life-threatening health problems, they consider many alternatives. Even in the case of minor problems, they often utilize a mixture of Western and Chinese resources. They do not resist something simply because it is "culturally different." Much of their resistance to Western medicine is due to high costs, complexities of access, language problems, and other pragmatic reasons. Thus, the adaptation of Flushing's Chinese elderly to their total health care situation has many positive features, even if their access to Western medical facilities leaves much to be desired. [154]

Conclusion

Still, people do vary in their states of health. Those who have experienced much illness throughout their lives have different expectations and behaviors from relatively healthy people. In addition, people have different "first experiences" with health care in New York City. Some individuals are lucky in their first encounters and develop positive links to the American health care system. Others remain distant from these new, unfamiliar health care sources, and seek help from a variety of nonmainstream practitioners.

Decision-Making Models Researchers have formulated various models of medical pluralism and health care decision-making processes (Fabrega 1974; Louie 1975; Weaver 1970; Young and Garro 1982). Approaches that use systematic models to explain health care decision making have value in preliminary assessments of health-seeking behaviors (Cove and Pelto 1994; Pelto and Pelto 1997), but the data from Flushing illustrate the complexity of health care decision making within this elderly Chinese immigrant population. The variety of health care resources and the eclectic health care seeking behavior found here suggest that formal models are sometimes too rigid. I have not attempted to offer a new model in this study. but rather I wish to emphasize the diversity of health behaviors that I discovered. Underlying this diversity are a few general principles that elderly Chinese hold in making sense of health problems and utilizing various health care methods. Most elderly Chinese perceive their health ailments as "big" or "small" problems; if a problem is big and becomes serious, most will rely on Western medicine. On the other hand, illnesses and complaints that are regarded as small are relegated to home remedies. Chronic illnesses are also often treated by herbal and home remedies and acute illness by "stronger" Western medicines. Thus, a coherent strategy drawing on the rich variety of health care resources appears to be emerging among this population. This study has also illustrated intracultural diversity within New York's Chinese population. The findings point to differences between elderly Chinese immigrants from Taiwan and the mainland, and also to contrasts between newer Chinese immigrants and the older, established Chinese population. Moreover, the Chinese immigrants of Flushing represent the rapidly growing and changing Chinese population in North America. Across the United States, many communities like Flushing are receiving new immigrants from Taiwan and Mainland China, as well as from Chinese commu[155]

Aging and Health anwng the Chinese Elderly

nities in Southeast Asia. Although there are differences within these new immigrant populations with respect to health behavior and adaptation, we should expect similar patterns to those in Flushing to be emerging elsewhere in the United States. The example of the elderly Chinese in Flushing illustrates the potential for human creativity and adaptation in the domain of health. All minority cultural groups in the United States experience disadvantages in seeking access to health care, notwithstanding their financial means. Language barriers, different cultural assumptions about health and illness, and cultural stereotypes and discrimination by mainstream health care providers all play a role. Facing these realities, people will utilize the various resources available to them in the search for physical well-being and peace of mind.

[156]

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Index

Academy of Traditional Chinese Medicine, 63 Acculturation health and, 46 stress of, 104-5 See also Cultural differences Acquired immunodeficiency syndrome, 80 Acupuncture, 12,41, 74,114,127 ancient schools for, 57 for anesthesia, 64 applications for, 64, 79 for bronchitis, 128 for heart disease, 81 Adverse drug reactions, 131, 153--54. See also Drugs African Americans Chinese immigrants and, 16 in Flushing, N.Y., 26 Aging "biomedicalization" of, 46 diet and, 88--89 elderly views of, 87--94 in Flushing, N.Y., 29 health and, 46--47 hypertension with, 130 mental illness and, 99--102 physical ailments of, 87-88, 102-5, 108 sleep patterns with, 88, 89 structured interviews and, 39 See also Chinese elderly AIDS, 80 Alcoholism, 47 Allopathic medicine. See Western medicine Alternative medicine advantages of, 11, 61, 74

effectiveness of, 127-28 fees for, 11 in Flushing, N.Y., 73-74 home remedies as, 40--41, 94, 113-24 integrated, 74, 80-82, 131, 152 referrals to, 127, 130--32 scientific method and, 14 types of, 74, 79, 114

See also specific types Amateur healers, 74 Anal fishtlas, 64 Anemia, 117, 120 Anesthesia, acupuncture for, 64 Animal remedies diet and, 119-21, 120 restrictions on, I 0--ll Anxiety. See Stress Appetite loss causes of, 99 dietary remedies for, 120 ment.J health and, 111 prevalence of, 98 self-care for, 129 treatment of, 117 Appointment making, 144--45 Arabic medicine, 58 Arteriosclerosis, 11, 108, 109 Arthritis, 95-96 causes of, 104 dietary remedies for, 120 among immigrants, 13 prevalence of, 98, 142 severity of, 110 treatment of, 117, 127

[165]

Index Arthritis (cont.) t)pes of, 110 See also Musculoskeletal problems Arthur, Chester A., 16-17 Aspirin, 116 Asthma, 110, 120. See also Respiratory illness Athlete's foot, 107, 129 Babinski's syndrome, 149 Bachelor s~ciety, 17, 20 Back pain, 98 causes of, 103-4 treatment of, 127 See also Musculoskeletal problems Banks, Chinese, 26 Bao ji wan, 116 Barefoot doctors, 66-67 Bedbugs, 66 Belt, health, 10 Beriberi,61 Binney, Elizabeth, 46-47 Blood disorders, 116, 117, 120 Blood pressure. See Hypertension Blood vessels, hardening of, ll, 108, 109 Blue-collar workers, 16 in Flushing, N.Y., 29 structured interviews and, 39 Body as machine, 89-91 mental health and, 96-97 Bone injuries, 64 gou shang ke for, 79 severity of, 110 treatment of, 126 See also Muscnloskeletal problems Brain drain, Taiwanese, 19-20 Bronchitis, 110, 120 acupuncture for, 128 treatment of, 127 See also Respiratory illness Buddhism aging in, 93-94 in Flushing, N.Y., 28, 34, 36 mental health in, 28, 34, 36 Bureaucratic problems, 36, 145-46 Bums, 64 Bu xue yao (drug), 64 California, Chinese in, 15-16, 20, 47 Cancer as deadly disease, 106 herbal medicine for, 64

[166]

throat, 64 traditional medicine for, 79 Cataracts, 64, 95 treatment of, 126 Charms, 50, 57 Chen, Hsiang-shui, 19-20 Chiang Kai-shek, 21 Chi disorders, 102 causes of, 103 mental health and, 111 as minor problem, 107, 108 prevalence of, 98 traditional medicine for, 79 treatment of, 117, 127, 129 China doctors in, 58, 67, 130-32 foreign influence on medicine in, 58, 60 Guomindang vs. Communist, 21, 59-DO, 91-92, 102 health care costs in, 75, 133 health care in Communist, 61-68, 149-50 health promotion in Communist, 65-68 hospitals of, 62-64 infant mortality in, 61 integrated medicine in, 74, 131 life expectancy in, 61 medical research in, 63-65 modem medicine in, 59-68 . traditional medicine in, 54-58, 60-63 Western medicine in, 58, 60-63 Western-trained doctors in, 137-42 See also Taiwan Chinatown, 18-21 in Boston, 53 in Manhattan, 27 in San Francisco, 47 Chinatown No More, 19 Chinese Americans business association of, 25-26 in California, 15-16 diversity of, 15-23, 52-53 health decisions by, 50-52, 125-36, 151, 155-56 population of, 15, 17, 26 prejudices against, 16-19 in World War II, 17, 21 Chinese elderly, 20-22, 28-30 demographics of, 26, 29, 39 health concepts of, 22, 95-97, 123 homebound, 37-38 hospitals and, 72, 114 interview of, 39--41 mental health of, 45, 47, 99-102, 108

Index questionnaire for, 41-42 from Taiwan, 29 views on aging, 87-94, 108 See also Aging Chinese Exclusion Acts, 1&-17 Chinese immigrants bachelor society of, 17, 20 in Chinatowns, 18-20 demographics of, 29, 39 dialects of, 20 early, 1.5-17 in Flushing, N.Y., 2&-27 health of, 13, 45-4 7 laws against, 1&-17 "paper sons" of, 20 recent, 17-18,22 Chinese medicine. See specific types Chinese Must Go, 16 Chinese Senior Center, 30--32, 34 Cholera, 61 Chou dynasty, 55 Christian churches, 28, 34, 38 Cirrhosis, 79 Climacteric syndrome, 79 Cole, Thomas, 4&-47 Communication problems cultural differences and, 11 as health care barrier, 14&-48 Confucius, 55, 113 Consolidated Chinese Benevolent Association, 19 Constipation,96,98, 102 causes of, 103 as minor problem, 107, 108 treatment of, 117, 120, 129 Contac, 116 Coping. See Stress Coronary disease. See Heart disease Cost of health care, 135-36 cultural differences about, 13, 92 herbal medicines and, 18 insurance for, 13, 74-75, 132, 135-36 U.S. vs. China in, 75, 133 Cough, 98, 102 blood with, 108, 120, 126 causes of, 103 dietary remedies for, 120 as minor problem, 107 treatment of, 116, 117, 129 See also Respiratory illness Cowgill, Donald, 46 Cultural differences as barrier, 14&-48

communication and, 11, 14&-48 health care costs and, 13, 93, 133 health concepts and, 48-49 home remedies and, 114 homogeneity and, 52-53 information economy and, 52-5:3 in mental health, 111-12 pain response and, 49 symptoms and, 11, 49 Cupping, 50. See also Folk medicine Dancing studios, 34, 94 Dang gui, 116, 117 Decision making, health care, 50-52, 125-36, 151--52 models for, 155--56 Demographics. See Population Depression, 47, 111 causes of, 99 as minor problem, 107, 108 prevalence of, 98 symptoms of, 97-98 treatment of, 9&-97 See also Mental health Diabetes, 13 as major problem, 108, 126 prevalence of, 98, 142 treatment of, 120, 126 Diagnosis, 54, 152 of intermediate problems, 109-11 of major problems, 108-9, 126 of minor problems, 10&-8, 114 Western methods of, 131, 133-34, 145-46 Diarrhea, 98, 102 causes of, 103 treatment of, 117 Diet aging and, 88-89 deficiencies in, 61 folk medicine and, 50, 114, 119-21 healthy, 76, 77 h)pertension and, 94 mental health and, 111 yin/yang and, 56, 113 See also Home remedies Digestion problems, 102 causes of, 103 health and, 95 among immigrants, 13 prevalence of, 98, 142 self-care for, 129 severity of, 107, 110 treatm~nt of, 117, 120, 127

[167]

Index Ding, Si-Fan, 7-9 Diversitv, 15-23, 52-53. See also Cultural differences Dizziness, treatment of, 120, 129 Doctors amateur, 74 barefoot, 66-67 Chinese, 58, 67, 130-32 choice of, 12, 121, 126, 127, 142 as expense, 13, 135-36 in Flushing, N.Y., 72-73 "good," 140-41 job of, 135 "Mongolian," 138-39 perceived need for, 96 shopping for, 142-43, 151-52 trust in, 134 viewpoints of, 141-42 Western-trained, Chinese, 137-42 xiao er ke, 139-40 Doctrine Five Elements, .5.5-57 Two Principles, .55-.57 Dragon Ginseng Herb Co., 9-11 Drinking water, 66 Drugs adverse reactions to, 131, 153-54 black-market, 136 Chinese names for, 115 faith in, 134 herbal medicine vs., 134-35 horne remedies and, 11.5 patient research with, 134 without prescriptions, 11, 75-76 Western, 125-26, 134-35 See also Herbal medicine Dysentery, 64, 117 Ear and hearing problems, 93 infection of, 126 ringing in, 11, 117, 127 Earth elements, 56 Eclectic health care, 152-55. See also Integrated medicine Ecology, human, 45 Economv, information, 52-53 Educati~n in Flushing, N.Y., 29 structured interviews and, 39 Eight Diagrams, 55 Elderly. See Chinese elderly

[168]

Encephalitis, 61 Equilibrium, 56 Estes, Carroll, 46-4 7 Exercise. See specific types Explanatory model, Kleinman's, 50-51 Family problems, 101 mental illness and, 112 Fatigue mental health and, 111 as minor problem, 107, 108 self-care for, 129 treatment of, 117, 120 Fennel, 116, 117 Fertility treatment, 79 Fever severity of, 110 treatment of, 116, 120 typhoid, 61 Filariasis, 61 Fire elements, 56 Five Elements Doctrine, 55-57 Five Virtues, 113 Flushing, N.Y., 24~'32 access to health care in, 74-76, 151-52 Asian immigrants in, 24-25 Chinese dialects of, 27 Chinese elderly in, 28-30 Chinese firms in, 25 Chinese immigrants in, 26-27 demographics of. 26, 29, 39 doctors in, 72-7.'3 enterprise in, 26 ethnicity of, 26 health care in, 71-84 herb stores in, 118 histmy of, 24 hospitals of, 71-72, 144 introduction to, 3N7 nursing homes in, 82-84 office rents in, 25 population change in, 26 religions of, 28 as second Chinatown, 27 social organizations of, 27-28 traditional health care in, 73-74, 79 Western health care in, 71-73, 80 Flushing Chinese Business Association, 25-26 Fly control, 66 Folk medicine definition of, 49

Index diet and, 50, 114, 119-21 practices of, 50 See also Alternative medicine Foot problems, 73, 107 self-care for, 129 See also Musculoskeletal problems Fractures. See Bone injuries Fu Hsi, 54 Gallstones, 64, 108 treatment of, 109 See also Digestion problems Can mao chongji, 116 Gelman, Richard, 25n Gender Flushing demographics and, 29 stmctured interviews and, 39 Ginseng, ll.5, 116, 117 Glaucoma, 126 Gou qi zi, 116, 117 Gou shang ke, 79 Grimm, Henry, 16 Cui yuan, 116, 117 Guomindang Party in China, 21, .59-60, 91-92, 102 in Taiwan, 68 "Guo Yu" dialect, 27 Gynecologic problems, 79, 117 Hand manipulation. See Tui na Hayes, Rutherford, 16 Headaches, 98, 102 causes of, 103 dietary remedies for, 120 as minor problem, 107 self-care for, 129 treatment of, 117 Health balance and, 97-98 beliefs about, .52 body/mind, 89--91, 96-97 as c~ltural concept, 48--49 definition of, 48 elderly views of, 22, 9.5-97, 123 religious views of, 113 self-reliance and, 97 See also Illness Health care access to, 74-76,132-36,1.51-.52 advertisements for, 78-79 American system of, 137-.50 appointments for, 144-4.5

of Chinese Nationalists, .59-61 in Communist China, 61-68, 123 eclectic approach to, 152-.5.5 explanatory model of, 51~52 in Flushing, NY, 71-84 immigrants and, 45-47 language barrier with, 146-48 paperwork for, 145-46 pluralistic, 50-52, 1.55 publications on, 76-79 quality of, 148-.50 mral, 65-67 systems theory and, 52 in Taiwan, 68-70 traditional, 73-74 types of, 71 See also Cost of health care; Decision making; Western medicine Health promotion, 13 in Communist China, 6.5-68 public health and, 62 self~care for, 113 Hearing problems, 93. See also Ear Hearing voices, 102 Heart disease, 74 acupuncture for, 81 causes of, 104 among immigrants, 13, 64 as major problem, 108, 126 prevalence of, 98, 142 self-care for, 120, 129 treatment of, 117, 126 Heizhima, 116,117 Hemorrhoids, 102 causes of, 103 dietary remedies for, 120 as minor problem, 107-8 prevalence of, 98 treatment of, 79, 107-8, 129 Hepatitis prevalence of, 13, 142 treatment of, 79 See also Liver disease Herbal medicine, 41, 114 access to, 7.5-76 animal remedies vs., 10-11 for cancer, 64 case study on, 121-22 common, 117 cost of, 118 home remedies and, 40-41, 50, 94, 11.5-19

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Index Herbal medicine (cont.) indications for, 79, 127 public health and, 63 research in, 63-65 Sheng Nung and, 54-55 sources of, 118-19 Western medicine vs., 126, 127, 134~3.5, 152 Hernia, 117 Herskovits, Elizabeth, 112 Hispanics. See Latinos HIV disease, 80 Homebound elderly, 37-38. See also Chinese elderly Home remedies, 40-41, 113--24 cultural differences with, 114 names for, 115 "secret," 94 sources of, 118-19 types of, 116-18 See also Alternative medicine Home visiting services, 84 Hong Kong, 17 Hong Kong foot, 107, 129 Hongzhou, China, 10 Hookworm, 61 lfospitals Chinese, 62--64 Chinese immigrants and, 71-72, 144 See also Health care Huang Ti, 55 Human ecology model, 4S Hygiene campaigns, 6.5--66. See also Health promotion Hypertension, 96 as age-related illness, 130 case studies on, 121-22, 149-.50 causes of, 104 diet and, 94 kidney disease and, 109 prevalence of, 98, 142 traditional medicine for, 79 treatment of, 120, 129

I Ching, 5S Illness behavior and, 48-49, S2 causes of, 97-98 classifications of, 48-49 as cultural concept, 48 definition of, 48 of intermediate severity, 109-11 major, 9S, 108-9, 126

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mental illness as, 99-100 minor, 9S, 106-8, 107, 113-14 religious views of, 113 symptoms of, 98 types of, 102~ See also Health Immigrants. See Chinese immigrants Indian medicine, S8 Indigestion. See Digestion problems Infants Chinese mortality rate for, 61 respiratory diseases of, 64 Influenza, 98, 102 causes of, 103 dietary remedies for, 120 treatment of, 116, 129 See also Respiratory illness Information economy, 5~3 In-home services, 84 Insurance, health, 13, 74-7S, 132,135-36 Integrated medicine, 74, 80--