Sonoma County Medical Association
Leona Judson, FNP; Kathryn D. Scott, DrPH; Panna Lossy, MD; and Mary Maddux-Gonzalez, MD, MPH
Purpose. This report presents characteristics of a Sonoma County community of Lua’, a Laotian cultural group. The Lua’ were discovered within the larger Laotian community during implementation of a project designed to improve primary care services for Southeast Asian patients at the Family Practice Center in Santa Rosa.
Methods. In 1999, interviews with 24 Lua’ were completed, as were medical chart reviews for 40 Lua’ patients.
Results. At the time of the survey, respondents had lived a median of 12 years in the United States, but they continued to have significant difficulties adapting to life in this country and coping with the trauma of their refugee experience. Low English literacy and high unemployment persist in this population. High rates of chronic pain, depression, and post-traumatic stress disorder were documented in the medical records.
Conclusions. Culturally appropriate interventions, developed with the assistance of the Lua’, are necessary for improving the quality of life for this unique cultural group.
War is one of the most powerful displacers of human beings, touching even our corner of the world here in Sonoma County. The Family Practice Center (FPC)—which employs physicians from Sutter Medical Center of Santa Rosa’s family practice residency—serves many people from Southeast Asian cultures. A large portion of them immigrated to the United States during the 1980s and 90s, fleeing the wars and reprisals in Vietnam, Laos, and Cambodia.
In the 1990s, the FPC made a concerted effort to improve cross-cultural training for family practice residents because of increased patient diversity. During this time, the Lua’ were recognized as a distinct group within the larger Laotian population served by the clinic. Sonoma County is believed to have one of the highest concentrations of Lua’ in the United States.
Little is known in this country about Lua’ culture, and the care and treatment of Lua’ patients has posed significant challenges for FPC resident physicians who were unfamiliar with their social history and medical needs. Accordingly, a research project was undertaken with support from the California Health Manpower Policy Commission Song Brown Fund. The results of that project are the main focus of this article.
Household survey: In 1999, 32 Lua’ households were identified through a review of the FPC’s patient census and knowledge of the Lua’ community. This sample was believed to include most Lua’ households within Sonoma County. Twenty-four Lua’ agreed to participate in the survey. A Lua’-speaking project assistant and a Laotian community health worker who is well-respected by the Lua’ community conducted the interviews together. They used a 71-item questionnaire to collect demographic and health-related data, along with information about respondents’ experiences as immigrants.
Medical Chart Review. The medical charts of 40 adult Lua’ patients who had received services at the FPC within the past three years were reviewed as well.
The results of these two surveys, presented in the next section, are rounded out with information taken from additional in-depth interviews with the Lua’.
The Laotian community in Sonoma County is made up primarily of ethnic (lowland) Laotians and the Lua’. The Lua’ lived on the mountain slopes at moderate altitudes in the northwestern portion of Sayaboury province in northern Laos, and in the northeastern portion of Nan province in northern Thailand. They do not have a written language, and neither Thai nor Lao is their primary language.1 They are multilingual, however. In addition to Lua’, all of the survey respondents speak Lao, and more than half speak Thai.
In their homeland, the Lua’ were primarily subsistence farmers. Their main crop was “sticky” rice, but they also sold farm animals and handmade crafts. Because of the significance of rice in their culture, their seasons are named after rice farming events, including clearing, burning, harvesting, planting, and weeding. When asked what they miss most about Laos, respondents stated that they missed the land, the richness of the forest and jungles, their homes and villages, family members, and being able to hunt for or grow their own food.
Sharing and working together are important values in the Lua’ culture. Both men and women perform various work tasks, although some tasks are more specific to gender, such as cooking for women and hunting for men. These values of sharing and cooperation are reflected in the close Lua’ family structure. Rank within the family is traditionally assigned by age and gender. The freedoms given to American children conflict with traditional Lua’ values, creating a source of stress for many Lua’ parents. Concerns about their children, including fear of gang involvement, were cited as a main worry.
To escape the war and Communist reprisals (e.g., forced participation in “reeducation” camps), the Lua’ walked across the border into Thai refugee camps, a journey of at least nine days. Many respondents said family members died during this journey, and they themselves were faced with starvation, illness, and the risk of attacks by soldiers.
The Lua’, self-sufficient prior to the war, were now dependent upon the Thai government. As they waited for a resolution to their situation, they confronted basic survival challenges in the camps, including poor sanitation, minimal health care, violence, depression, and boredom. Respondents reported living an average of 10 years in refugee camps.
The Lua’s stories are harrowing. One family fled Laos because the oldest brother was forced to go into a Communist reeducation camp. Their house was burned, and the army stole their animals. One of the children reported seeing bombings and killings on the journey to the refugee camp, where the father died. Four of the five children now live in Sonoma County, but they do not know if their oldest brother is still alive.
The elder couple of another Lua’ family met in a refugee camp. They are the elders for several Sonoma County families because the husband had a daughter by a former marriage. Both husband and wife are very depressed, and the wife is mute. The man fought for the CIA during the Vietnam War. His daughter is severely depressed and has been hospitalized several times for post-traumatic stress disorder. In addition to witnessing the death of two friends by bombs and the torture of her father and grandfather, this woman gave birth to twins while all alone in the refugee camp.
Following the birth of her fifth daughter in the United States, the woman began having “seizures,” during which she would fall violently to the ground. Only after extensive medical testing, including two MRIs and an endocrine workup for Sheehan’s syndrome, did clinicians realize she was having flashbacks. She would “hit the deck” during the flashbacks because she was reliving bombings she had experienced in Laos.
In their homeland, the Lua’ practiced ancestor and spirit worship, although most now identify themselves as Christian and practice Catholicism. Among the Lua’, illness and misfortune are generally thought to be the result of disharmony between people and spirits.1 Each person is said to have 32 souls that watch over the 32 organs of the body. These spirits constitute a person’s spiritual essence. Separation of any of these souls from the body leads to sickness.
The Lua’ also believe in spirit possession and spell casting. Spirits live everywhere—in trees, big rocks, or mountains. If a person doesn’t feed these spirits correctly, or if the spirits are angered, they can hurt your family or bring bad luck. In Laos, with few medical doctors available, spirit doctors tended to the sick. Some Lua’ elders in the Sonoma County Lua’ community are thought to understand what the spirits want, but nobody has been recognized locally as a Lua’ spirit doctor.
The Lua’ in Sonoma County have had difficulty organizing around a common social or political framework, unlike the lowland Laotian community, which has received more formal education than the Lua’. The lowlanders are predominantly Buddhist, and their temple in Santa Rosa serves as a focal point for the community’s social network. The leader of this community has made efforts to include the Lua’ in various social functions. Such efforts could go a long way toward reinforcing the cohesiveness of the Lua’ community and ameliorating the negative effects of their immigration experiences.
Basic characteristics of the household survey respondents are presented in Table 1. They reported a median age of 28 upon arrival in the United States, and most were born in a village. Nearly all stated that they came to Sonoma County because they had relatives or friends living here, or they had heard that Lua’ lived in the area.
Although respondents had lived in the United States for an average of 13 years, they continued to struggle educationally and financially. They reported an average of only four years of formal education, and less than 30 percent could read or write English. Nearly all reported a household income of less than $25,000 per year, and about three-fourths were unemployed or received Social Security benefits. Many stated that not having enough money was a significant worry for them.
The results indicated that transportation to health care is generally good, but nearly half the respondents ranked their health status as “poor.” Most had a doctor they visited regularly. Language barriers, however, probably discourage good follow-up to treatment. For example, when asked to read the statement “Take 2-3 times a day with food for pain,” respondents read a median of only two words correctly.
No respondent reported seeking care from a traditional healer. Nearly half grew their own vegetables, with 21 percent reporting that they grew their own herbs. Only one respondent reported using the herbs for medicinal purposes.
The medical chart review was based on the charts of 20 Lua’ men and 20 Lua’ women, who had an average age of 45 (range equaled 21 to 82 years). Chronic pain was a major health concern noted in both the household survey and the medical chart review. Fifty-nine percent of health problems mentioned by respondents dealt with pain; 44 percent of chief complaints in the medical records were about pain; and chronic pain was noted in 53 percent of the charts. Medications that address these conditions appeared with high frequency.
High rates of psychological distress were documented as well. Fifteen percent of the respondents suffered from post-traumatic stress disorder, 43 percent from depression, and 5 percent from anxiety. Prevalence rates for these disorders in the general U.S. population are 4, 7, and 16 percent, respectively.(2)
Hepatitis B and tuberculosis are both endemic in Southeast Asia. Only half the Lua’ medical charts, however, documented patients’ hepatitis B status, and just 43 percent documented tuberculosis status. Fifty-three percent of the latter group had positive PPD tuberculin. Routine health screening tests were also assessed: of patients 50 or older, a cholesterol test was documented for two of six Lua’ men, and a mammogram was documented for three of five Lua’ women.
This project provided an initial step toward understanding the culture, social background, and health concerns of the Lua’. The results indicate that the Lua’ have struggled to cope with the challenges surrounding their immigration to the United States. They appear to be poorly equipped to deal with mainstream Western culture, as reflected by their high unemployment rates and poor English skills.
The U.S. government must shoulder some of the blame for the Lua’s difficulties. The government supported the fighting in Laos yet subsequently provided less than adequate resources for refugees fleeing the chaos. Some refugees still have cards saying they worked for the U.S. Special Army in Laos. These refugees ask why the government does not help them now. Commenting on the resettlement of the Hmong—another cultural group that fled Laos for the same reasons as the Lua’—a former U.S. ambassador-at-large for refugee affairs said, “It was a kind of hell they landed into. Really, it couldn’t have been done much worse.”(3)
Psychological distress from the trauma of war, refugee experiences, and adapting to life in a foreign culture may be a primary source of the Lua’s complaints of pain. Most survey respondents, however, did not make direct reference to psychological distress as a health issue. This lack of reference likely reflects the Lua’s traditional worldview, which does not connect psychological distress with physical health. The Lua’s worldview and ancestral religious beliefs (animism) make the understanding and management of mental health, pain, and chronic disease difficult for both patient and provider. Low English literacy compounds this problem.
Since this project was completed, the California Endowment has funded diabetes education groups for Southeast Asian groups at the Family Practice Center. In addition, the Sonoma County Division of Mental Health provides Southeast Asian support groups. Both the diabetes and social-support groups have been well received by the community. Such strategies complement the Lua’s values of group and familial support.
Future steps to assist the Lua’ need to include culturally appropriate interventions developed with the assistance of the Lua’ themselves. For the present, health care providers can heed lessons learned by FPC staff. When caring for Lua’ patients:
Should problems arise, consult with bicultural Southeast Asian staff in Sonoma County. The following people have given their permission to be contacted:
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