People of Russian, Polish, and Thai Heritages

Chapter 24 People of Russian Heritage Karen J. Aroian, Galina Khatutsky, and Alexandra Dashevskaya Overview,

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Inhabited Localities, and Topography Overview Russia, also known as the Russian Federation, was the largest part of the former Soviet Union before the Soviet Union collapsed in 1991. Presently, Russia is the largest country in the world, nearly twice the size of the United States. It covers 11 time zones. The climate ranges from temperate and humid to arctic. Ethnically, 80 percent of those living in Russia are Russian, 3.8 percent are Tartars, 2 percent are Ukrainian, and 14.4 percent are other smaller groups. Between 15 and 20 percent of Russians are Russian Orthodox, 10 to 15 percent are Muslim, and 2 percent belong to other Christian groups. Only about 500,000 Russians are Jews. In 2005, Russian Orthodoxy became the official religion and enjoys a privileged position with the current government (Library of Congress, 2010). However, a large number of Russians are either nonreligious or nonpracticing, which is the result of over 7 decades of religious suppression under communist rule. The population of Russia is about 139 million and is declining, with 1.6 deaths for each birth (CIA World Factbook, 2010). This high death rate is related to high-risk behaviors such as smoking, alcoholism, heart disease, traffic accidents, and low education about sexually transmitted infections. The average life expectancy is 59 and 73 years for Russian men and women, respectively. A low fertility rate (1.4 per women of reproductive age) adds to this population decline (CIA World Factbook, 2010; Library of Congress, 2010; Marquez, 2005). The two largest cities—Moscow, which is Russia’s capital, and St. Petersburg—have 10 million and 4.5 million people, respectively. Although major cities are heavily populated, 27 percent of Russians live in very rural areas (CIA World Factbook, 2010; Library of Congress, 2010). In 1917, the imperial Czar was overthrown and Vladimir Lenin took power, replacing imperial rule with communism. The overthrow, referred to as the Bolshevik revolution, was due to the discontent that 426 ensued after the horrific defeat of the Russian armies during World War I. Josef Stalin took power after Lenin, further strengthening and unifying communist rule and infusing it with brutality. During this time, the Soviet Union was comprised of 15 ethnically and culturally diverse republics, the largest of which was the Republic of Russia. On August 24, 1991, the Soviet Union collapsed and Russia became an independent country. Each of the other republics of the former Soviet Union also developed into independent nations. This collapse led to Russia adopting a new constitution in 1993 and three branches of government: the executive, the legislative, and the judiciary. The 1990s were a period of intense democratic reform and the development of a market economy. However, many important democratic reforms made in the 1990s have been overturned. Political bribery and corruption are rampant today. Russia’s poverty rate is 13.1 percent, with a 6.7 percent inflation rate (CIA World Factbook, 2010). The number of adults who are unemployed (7.6 percent) or underemployed is high (CIA World Factbook, 2010). Crime rates are also high. Police have low pay, low status, and are highly corrupt. Economically, Russia has some of the most abundant natural resources, including rich deposits of oil, natural gas, coal, timber, and minerals such as diamonds, nickel, aluminum, and platinum. Over 20 percent of the world’s forests are in Russia (Library of Congress, 2010). However, water, land, and air pollution is high (Energy Information Administration [EIA], 2010; Library of Congress, 2010). Heritage and Residence According to the Russian 2002 census, the largest ethnic group was Russian, accounting for 80 percent of the total population. Ethnic minority groups with significant numbers (about 1 million in each group) include Tartar, Ukrainian, Bashkir, Chuvash, Chechen, and Armenian. These minority groups are the result of their homelands being former republics People of Russian Heritage of the Soviet Union. During the period of Soviet rule (1917 to 1991), Soviet citizens moved, leaving their own culture and birthplace to work and live in another republic. Since the fall of the Soviet empire, non-Russians in Russia have been migrating back to their homelands, in part because of growing intolerance in Russia against its ethnic minorities (Library of Congress, 2010). International migration includes the United States, Israel, Canada, and Australia as major destinations (Vishnevsky & Zayonchkovskaya, 1994). In fact, in the 1990s, immigrants from the former Soviet Union were one of the fastest-growing ethnic groups in the United States, with a 254 percent increase in the Russian-speaking population (U.S. Department of Homeland Security, 2005a). Another source of population growth came from adopting Russian children (U.S. Department of Homeland Security, 2005b). According to the U.S. Census Bureau, (2000), over 2.6 million Russians live in the United States. However, in the last decade, the immigration from Russia to the United States is slowing. From 2001 to 2009, about 14,277 Russian immigrants came to the United States (U.S. Department of Homeland Security, 2010). Almost 90 percent of Russian immigrants in the United States live in urban areas such as New York City and the Tri-State area (24 percent), Boston, Philadelphia, Baltimore, Miami, Atlanta, Cleveland, Chicago, Detroit, Denver, Houston, Los Angeles, San Diego, San Francisco, Seattle, and Portland, Oregon (Allied Media Corp., n.d.). Florida has also become an increasingly popular destination for Russian immigrants who are close to retirement age (U.S. Department of Homeland Security, 2005c). In Canada, Russian-speaking immigrants primarily live in Toronto, Vancouver, and Montreal (Aroian, 2003). Classifying Russian immigration is complicated by several facts. First, until the Soviet Union collapsed, people from Russia and other former republics of the Soviet Union were often referred to and classified as one group regardless of where they were from. Second, the definitions vary widely; some are based on the country of origin, some on primary language, and some on the ethnic or religious affiliation. Third, the immigrants from the former Soviet Union are presently classified as from independent republics, such as Armenia, Russia, and Azerbaijan. Thus, when the term Russian immigrant is used in the literature, it may refer broadly to Russian-speaking immigrants of multiple nationalities from the former Soviet Union (one group under Soviet rule with Russian as the official language uniting them) or to people specifically from Russia. Given the complicated history of Russian immigration to the United States, this chapter should be read with an important qualifier in mind. Most of what is 427 written pertains to immigrants who emigrated in the latter part of the 20th century. These immigrants were reared under communism. Later arrivals, those who came after the Soviet Union collapsed, left a very different homeland. These immigrants were more apt to be familiar with the English language and a market economy. In addition, as is the case for most immigrant groups, immigrants become more acculturated over time. This is particularly true for immigrants who are younger and go to school and/or work in the new country. Although most of this chapter pertains to a given wave of migration, generational and cohort differences as well as acculturation trends will be noted when applicable. Reasons for Migration and Associated Economic Factors Migration to the United States from Russia or the former Soviet Union occurred in four waves (Hobbs, 2002). The first wave of Christian Orthodox Russians fleeing religious and political persecution was between 1900 and 1914 (Hobbs, 2002). The second wave began in 1914 and primarily included middle- or upper-class Russians fleeing the Bolshevik revolution and the onset of communism. After the Bolshevik revolution of 1917, thousands of expropriated wealthy Russians and middle-class professionals and army officers fled their homeland. About 20,000 Russian refugees, enslaved workers, or war prisoners from Germany entered the United States from 1947 to 1952 (Hobbs, 2002). As the first and second waves of Russian immigration to the United States, Jews from Ukraine and other bordering countries were also migrating to escape the pogroms (Abramson, 1991). The third wave began in the 1970s, when the United States granted refugee status to religious and ethnic minorities because of their persecution by the Soviet government (Aroian, 2003). This wave was comprised primarily of Soviet Jews, but it also included Soviet Armenians, Pentecostals, and Evangelicals (Aroian, 2003). The fourth wave of immigration started in 1991 with the dissolution of the Soviet Union, which resulted in much more freedom to immigrate. One motivation for this fourth wave of immigration included harsh economic conditions. When communism transitioned to a free-market system, economic conditions were particularly difficult for researchers, scientists, and physicians. Salaries were fixed and well below poverty levels, causing a desperate migration in hopes of improved quality of life. Motivation for the fourth wave also included family reunification, political turmoil, and greater overtly expressed Russian nationalism and anti-Semitism (Bistrevsky, 2005). Presently, emigration from Russia has slowed considerably. Only about 3 percent of the Russian population emigrated in 2010 (CIA World Factbook, 2010). 428 Aggregate Data for Cultural-Specific Groups Educational Status and Occupations The average age for U.S. Russian immigrants is 42 years, and nearly one-fourth of the total U.S. Russian immigrant population is 65 years of age or older. Almost two-thirds (64 percent) of these immigrants are married, with 1.6 children per couple. Of adults over age 25, 1 million have at least a bachelor’s degree, and over 18 percent have graduate degrees. The average adult Russian in the United States works in a professional area, is well educated, and has a better-than-average income (Media Corp, n.d.). However, it is important to note that more recently arrived Russian-speaking immigrants tend to be less well educated and more likely to pursue technical and service occupations (Minnesota Department of Employment and Economic Development [MDEED], 2006). Of note is that Russia has a 99.4 percent literacy rate, which is one of the highest literacy rates in the world. Men and women are equally literate. Russianspeaking immigrants highly value education. In the former Soviet system, education was strongly promoted for both genders, and prestige was tied to occupational status, which in turn was determined by education (Aroian, 2003). Given these values, it is not uncommon in the United States for extended Russian immigrant families to work additional hours and pool their financial resources to provide a good education for their children. However, the value on education is in transition. By the mid-1990s, making money by being an entrepreneur became another venue for self-respect and prestige in Russia (Library of Congress, 2010). The current focus on commercialization will likely influence the cultural values of immigrants from future waves of immigration. Teaching/learning systems in Russia are rigid compared with U.S. standards. Until recently, learning English was not a priority. As a result, Russian immigrants, especially older people and those who came to the United States before English became part of the standard curriculum, are likely to have difficulty with the English language. Recently, English has grown more popular in Russia owing to the Internet and other forms of media, including Western films, music, and advertising. Thus, younger, more recent immigrants are likely to have some English ability. Some Russian immigrants in the United States receive public assistance such as Medicaid, Supplemental Security Income, subsidized housing, or food stamps. This assistance offsets low income because of disability, age, and inability to find work commensurate with premigration work experience. Most Russians immigrants receiving public assistance, including older immigrants, have a college education (Hobbs, 2002). Many Russian immigrants, particularly those who came in the latter third of the 20th century, were highly trained professionals, employed in fields such as engineering, math, medicine, biotechnology, computer science, and education. Unfortunately, fulltime and well-paying positions in these fields were unavailable to many of these professionals due to language, licensing, and credentialing barriers in the United States. Language barriers and unfamiliar legal regulations were also salient for Russian-speaking immigrants who attempted to start their own small businesses (Hobbs, 2002). Thus, occupational status demotion was a common component of the initial immigrant experience for Russian immigrants (Aroian & Norris, 2003). Most Russian immigrants were able to overcome this initial occupational status demotion, but this was not the case for Russians who emigrated at an older age. Communication Dominant Language and Dialects Russian is a living language that is rich and expressive. It is one of the world’s major languages, the most pervasive of all Slavic languages, and the primary language for over 150 million people. It is also one of the six official languages of the United Nations. As the official language of the former Soviet Union, it unified the 15 Soviet republics and Soviet-controlled satellite nations. Although each republic and Sovietcontrolled satellite nation had its own language and culture, schoolchildren under Soviet rule were required to take many years of Russian-language courses. According to the U.S. Census Bureau (2007), 850,000 persons over age 5 spoke Russian at home. Of these, only 43 percent could speak English very well, 29 percent could speak English well, 21 percent could not speak English well, and 6 percent could not speak English at all. Even with limited English proficiency, many Russian-speaking immigrants can read and write English better than speak it. Most Russian immigrants, with the exception of older ones, eventually become proficient in English. However, large urban centers with a concentrated number of Russian speakers have their own newspapers and television and radio programming. These are self-maintained communities with numerous Russianlanguage services, including health care. Immigrants in these communities usually get by despite having very limited English proficiency, speaking both Russian and their own native languages (e.g., Ukrainian, Georgian). This is especially true for older Russians immigrants who intentionally live in Russian-language communities even when their adult children move to outlying areas. Living in a Russian-speaking enclave allows older Russian immigrants to purchase food and supplies from Russian retailers and socialize with their Russian-speaking peers. Such communities provide little incentive to learn English. People of Russian Heritage Written Russian uses the Cyrillic alphabet, which is derived from but not the same as the Greek alphabet. Russian is considered phonetic and includes five vowels and numerous consonants that are considered hard or soft. Interestingly, Russian does not include articles (e.g., “the”) and is often called a house green language (“the” and “is” are omitted). Cultural Communication Patterns Russians enjoy intellectual conversations that focus on political, economic, cultural, and social issues. Word of mouth and advice among Russian speakers are strong influencing factors for making decisions regarding health care and major purchases (Aroian, Khatutsky, Tran, & Balsam, 2001). Russians seek emotional support from spouses, relatives, and friends, and report not trusting religious advisors, teachers, social service workers, or community leaders. However, they report a willingness to talk with physicians and other health-care providers, especially when these workers are able to speak Russian (Hobbs, 2002). Russians tend to speak loudly (MDEED, 2006). They have great insight into their own and others’ feelings and often communicate on an emotional level. Russians make eye contact, nod their head in a gesture of affirmation or approval, and are respectful in their verbal and nonverbal behaviors toward older people and persons of perceived rank or authority (“Culture Tips,” 2000; MDEED, 2006). Russian men shake hands firmly, and this symbol of agreement is considered more binding than paper documents. The doorway of a Russian home is considered the spirit center of the house, and it is a bad omen to shake hands over the threshold. Shoes are often removed prior to entering the home (MDEED, 2006). Behavior in public is formal and respectful. Russians do not appreciate casual gestures such as standing with hands inserted into pockets, arms crossed over the chest or behind the head, slouching posture, and putting feet up on a desk. These behaviors are particularly insulting if they occur when they are being interviewed for a job. Shaking a fist shows anger or disagreement, and pointing with the index finger is considered rude (Hobbs, 2002; MDEED, 2006). Russians often require less personal space than European Americans. Russians freely touch friends and family members. Greeting close friends by kissing each cheek is common. Russians are social diplomats and will “bend” the truth for the sake of politeness or to soften bad news (Birch, 2006). Russians have a sense of duty, self-sacrifice, and genuine caring toward others (“Culture Tips,” 2000). They perceive themselves as spontaneous and emotional, able to be extremely empathetic toward the suffering of others. They are emotionally strong and have a long and distinguished history of enduring great 429 hardship and adversity. Thus, Russians may present a pervasive attitude of endurance with comments such as “We have overcome many troubles and we can overcome these troubles because we are strong; we are Russians.” They look to others for the same level of respect and recognition of social order as they give. Temporal Relationships Russians who have immigrated to the United States tend to be both present and future oriented. This is not the case, however, among nonimmigrants. Russians living in Russia live in the present, as demonstrated by a comment the chapter authors and book editor heard frequently: “Because we have no future.” Russian immigrants are punctual and value this attribute. For appointments, Russians will arrive either early or right on time. However, being punctual is less important for social occasions. Social occasions typically last late into the night, so late arrivals are not disruptive. Format for Names Russians use titles such as Mr., Mrs., Dr., professor, aunt, and grandfather to show the appropriate respect (“Culture Tips,” 2000; Hobbs, 2002). Even when friendships are established, they often ask to be addressed by their first name plus their patronymic. The patronymic is the first name of their father with either a feminine or a masculine ending, depending on the person’s gender. An example of a preferred name format might be Oleg Vasilievich (Oleg, son of Vasily). Family Roles and Organization Head of Household and Gender Roles In Russia, younger adults and youth depend on the wisdom of their parents and grandparents whenever important decisions need to be made. In the United States, these roles are often reversed because of an English-language barrier whereby older Russianspeaking immigrants often have to depend on their children and grandchildren to guide decision making (Aroian, Khatutsky, & Dashevskaya, 2006). Role reversal may be particularly difficult for older Russians if they are not living in the United States by choice. Unlike many other immigrant groups, Russian immigrants arrived in the United States in multigenerational family units. This emigration pattern occurred, in part, because the Soviet regime did not allow families to emigrate unless they took older family members with them (Aroian et al., 2006). Although women are an important part of the workforce in Russia, the roles of mother and homemaker are also valued. Russian women pursue education and careers, but they often juggle multiple roles, fulfilling cultural expectations for home and child-care responsibilities (Aroian, 2003; Aroian, Norris, & Chiang, 2003; Remennick, 1999). 430 Aggregate Data for Cultural-Specific Groups It is important to note that Russians will be reluctant to sign consent forms and other documents without first consulting their family members (Keefe, 2006). Family members will often attend health-care appointments in order to provide cognitive as well as affective support (Aroian, 2003). Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Russian children are taught to obey their parents and older people, as well as to achieve high grades in school and complete a university education. Children are expected to care for family members who are ill and in need of care (“Culture Tips,” 2000). Older people are expected to raise their grandchildren, especially if both parents are employed. Sexual topics such as contraception and sex education are not considered appropriate topics for public discussion. Sexual activity outside of marriage is not sanctioned even though the age of sexual consent in Russia is 16. If teen girls get pregnant, abortion is the primary intervention (Aroian, 2003). Older Russian immigrants tend to be more modest, disliking public displays of affection (Aroian, 2003). Family Goals and Priorities Collectivism has been part of Russian society for centuries. Russians view family, group, and communal needs as more important than individual needs. Extended family and friends are highly important. Relationships are very close. Russians depend on and trust family, neighbors, friends, and colleagues. Love and support from family and friends are expected and forthcoming during crises. Spouses consult each other (“Culture Tips,” 2000). Russians contrast their personal relationships with Americans’ tendency to reserve close, intimate ties for immediate family members and are struck by Americans’ individualism and independence. Russian young people are expected to do household chores. Household chores are gender-specific, with girls doing tasks such as cooking and cleaning and boys doing more physical labor. Grocery shopping is an exception; it is a task for both boys and girls. Although education and a good job are considered important for Russian women, finding a good husband is even more important. Being an “old maid” is socially frowned upon (Aroian, 2003). Domestic violence is a rising concern in Russia. Because of long-standing distrust of authority figures, Russian immigrants may not report domestic violence. Russian women will only rarely admit to and report being raped. This cultural tendency may also be operative after immigration. Domestic violence is often tied to alcohol abuse. Alternative Lifestyles Divorce rates in Russia are high, and small families are typical because of economic hardships. Russian immigrants also have high divorce rates, perhaps because of the stress of immigration. For example, Russian immigrant women grow more independent as they acculturate, and differential rates of acculturation can cause family problems (Aroian, Spitzer, & Bell, 1996). On the other hand, Russian women may wait to reach their new country before ending an unhappy marriage. Religion seldom plays a role in the lives of most Russian immigrants, most likely because of the antireligion dogma of communism. (Exceptions include Russian Pentecostals and other religious fundamentalist groups in Russia.) Therefore, divorce does not negatively affect social status. Divorced men in Russia are rarely awarded child custody, and although they pay child support, they do not often remain active in their children’s lives (Aroian, 2003). This tendency may also be noted with Russian immigrants. Russian women with fertility problems are not considered desirable spouses (Aroian, 2003). Although Russian women are expected to marry by age 25 and have children, they are also expected to continue to pursue education and career paths. This is possible because grandmothers become primary caregivers for young children. Men are seldom expected to fulfill child-care responsibilities. The Russian penal code was revised in 1997, and homosexuality is no longer a crime. In July 1997, the first gay and lesbian pride festival occurred in Moscow. Even so, alternative lifestyle choices are still stigmatized by a large part of the population. Overtly expressed antigay graffiti is still commonly seen in Russia (“News About Gay Russia,” n.d.). Given the lack of acceptance about same-sex relationships, gay and lesbian Russians in the United States are likely to remain closeted, even with health-care providers, unless significant trust is developed. Similarly, same-sex behavior is not typically disclosed to family members or friends. Workforce Issues Culture in the Workplace When communicating in the workplace, Russians embrace the value of positive social communication. Politeness is a key component of positive social communication, as well as saying nice things to connote acceptance, offer support and empathy, and just to avoid negative discourse. When negotiating compromise in the workplace, Russians invest time and effort to provide information that supports their decisions and requests. Russians expect to be specifically asked for this kind of information (Bergelson, 2003). This communication style is in contrast with the more direct communication Russians employ with friends. Direct communication with friends is considered to be a sign of sincerity. Russian-speaking health professionals in the United States serve a large group of older Russian People of Russian Heritage immigrants who do not speak English or do not speak it well. If the health-care professionals were trained in the former Soviet Union, they are used to an authoritarian work environment. The training for nurses in the former Soviet Union has been likened to that of American licensed practical nurses (LPNs) (Alaniz, 2001). These nurses are not used to critical thinking and are used to hierarchical relationships with physicians, which conflicts with expectations in the United States for nurses to be part of a healthcare team (Alaniz, 2001). A positive characteristic of health professionals trained in the former Soviet Union is that they reflect the Russian emphasis on holism and holistic health care. Issues Related to Autonomy In the United States, nurses and physicians work as a team. Yet each member maintains independence. In Russia, the physician makes the decisions and does the problem solving. Thus, the nursing profession gets limited status and respect from Russians (Alaniz, 2001). One Russian immigrant explained, “What do we expect from a nurse? We don’t expect anything; we only expect something from a doctor. A nurse is just someone who obeys” (Smith, 1996). Russian immigrants in other professions may also be used to hierarchical work relationships based on authority. Biocultural Ecology Skin Color and Other Biological Variations Ethnic Russians are Caucasian. Stature and skin color for ethnic Russians are similar to other North American groups, with the exception of high rates of obesity among Russians and Russian immigrants. Diseases and Health Conditions Common health disorders seen in Russian immigrants include hypertension, coronary disease, gastrointestinal disorders, and diabetes. Common disabilities include the results of diabetes (e.g., sensory impairment) and other chronic health disorders, such as hypertension, psychosocial disorders, arthritis, lung disease, and cancer (Keefe, 2006; MDEED, 2006; Shpilko, 2006). There is also some evidence of a higher than average rate of colorectal polyps (Vadlamani et al., 2001). A number of studies suggest that health status is poorer among Russian immigrants than it is for other immigrant and nonimmigrant groups. For example, Russian Jews who immigrated to Israel between 1989 and 1992 reported an average of 3.5 chronic diseases—a much higher rate than that reported among immigrants from other countries (Rennert, Luz, Tamir, & Peterburg, 2002). These findings are similar to findings from a comparative study of lowincome Russian immigrant and nonimmigrant older persons in the United States (Aroian & Vander Wal, 2007). In this study, Russian immigrants had more 431 health problems than their nonimmigrant counterparts even though the nonimmigrant group was significantly older than the Russian immigrant group. Older Russian immigrants are also prone to depression, particularly when they live alone and do not speak English well (Aroian et al., 2001; Shpilko, 2006; Tran, Khatutsky, Aroian, Balsam, & Conway, 2000). In Russia, older people often live with their adult children and have family responsibilities, such as caring for grandchildren. In the United States, because of language barriers, older people are more apt to live in elder housing with other Russian-speaking older immigrants rather than with their children and grandchildren. Other groups of Russian immigrants at risk for psychological distress include those with less education and greater immigration demands, such as difficulty with English (Aroian, Norris, Patsdaughter, & Tran, 1998; Miller & Chandler, 2002; Miller, Sorokin, Wang, Feetham, Choi, & Wilbur 2006). Russian immigrants who feel alienated in the United States or do not possess resilient personalities also experience more psychological distress (Miller et al., 2006). In a longitudinal study of depression trajectories over time, Russian immigrants who remained depressed past the initial resettlement period were less likely to have family in the area or to have the highest immigration demands at both time points (Aroian & Norris, 2003). There is also some indication that Russian immigrant children are at risk. Goodman, Slobodskaya, and Knyazev (2005) found that emotional and behavioral disorders were nearly 70 percent higher in Russian immigrant children compared to other children in Great Britain. The most predictive factors in this study were the child’s school performance, the mother’s mental health, having a close relative with alcohol addiction, and witnessing domestic violence. A number of anecdotal reports and empirical studies suggest that Russians somaticize psychological disorders (Belozersky, 1990; Brod & Heurtin Roberts, 1992; Levav, Kohn, Flaherty, Lerner, & Aisenberg, 1990). For example, Russians may present with vague complaints of skeletal or gastrointestinal problems when they are suffering from depression. This tendency to somaticize has been attributed to the stigma of mental illness in Russia, Soviet ideology that recast psychiatric disorders as neurological, and prior psychiatric abuses by the Soviet regime. However, it is important to note that Aroian and Norris (1999) found that somatization was more common among Russian immigrants who were not highly educated and those who were older. Variations in Drug Metabolism According to Gaikovitch (2003), who investigated variability in genetic polymorphism and drug metabolism, the allele distribution of important metabolizing enzymes in Russians is not significantly different 432 Aggregate Data for Cultural-Specific Groups from that of other Caucasians. In other words, there are no genetic differences to suggest that medications are rendered more water-soluble and more readily excreted in urine in Russians. Thus, drug side effects and efficacy in Russians are likely similar to other European populations. The metabolism of alcohol may be the exception. According to Gabriel (2005), Russians may have inherited a genetic characteristic from Mongolian invaders that prevents processing ethanol derived from fruit or potatoes. Gabriel believes that this genetic trait makes Russians more susceptible to alcoholism, especially when the alcoholic beverage is cognac or vodka. High-Risk Behaviors Nutritional issues are a major contributing factor toward the number of chronic diseases experienced by Russians. According to some studies, over half of Russian adults have high blood cholesterol, obesity, or hypertension (Marquez, 2005; Mehler, Scott, Pines, Gifford, Bigerstaff, & Hiatt; 2001). Nearly half of the sample in one study (Mehler et al., 2001) had two or more cardiovascular risk factors. All of these chronic illnesses are related to Russians’ nutritional habits, specifically high-salt, carbohydrate, and fat intake (Keefe, 2006). Hard liquor, mostly vodka and cognac, are served routinely at family gatherings and celebrations, and heavy alcohol consumption is a part of daily life in Russia. Russian statisticians estimate that over 30 percent of deaths in Russia are directly related to alcohol (Nemtsov, 2005; Nicholson, Bobak, Murphy, Rose, & Marmot, 2005). Russian authorities appear indifferent to these statistics, as they have no official plan to address the problem of alcoholism. Alcoholism is far less prevalent among Russian religious groups and women (Aroian, 2003). This fact most likely accounts for lower rates of alcoholism among Russian immigrants relative to the population in Russia. A disproportionate number of those who emigrated from Russia are Jews or Christian fundamentalists, and these groups are known to have lower rates of alcoholism. Smoking is prevalent in Russia. Russia is one of the few countries that currently do little or nothing to curb tobacco use. Nearly 63 percent of Russian men and 15 percent of Russian women smoke, and this number increases by about 2 percent per year. Although 60 percent of current smokers want to quit, no state-supported programs exist to help them do so (Parfitt, 2006). This may explain, in part, why the male life expectancy in Russia is just above 59.8 years (CIA World Factbook, 2011). Like alcoholism, smoking is less prevalent in Russia’s ethnic minorities. Russian immigrants, who are comprised of a disproportionate number of Russian ethnic minorities, do not demonstrate the same level of smoking behaviors as their native-born counterparts. However, more recent Russian immigrants are likely to engage in these behaviors at higher rates than earlier Russian immigrants because current migration from Russia includes fewer ethnic and religious minorities (Hasin et al., 2002). Based on high rates of injection drug use in Russia, there is some evidence that Russian immigrants are at risk. A preliminary study conducted in New York City on this topic found that Russian immigrants have unique drug abuse patterns and behaviors, including rapid transition to injection drug use (Isralowitz, Straussner, & Rosenblum, 2006). This study also found that Russian immigrants are suspicious of traditional drug treatment approaches. Russians are reluctant to immunize, and this reluctance may also be considered a high-risk behavior. In Russia, immunizations are available but are of poor quality. Reports of hepatitis- and HIV-positive– contaminated immunization needles have created fear and distrust. Thus, Russian immigrant parents may not immunize their children unless they receive sufficient assurances that immunizations are safe. Another high-risk behavior is the medication behavior of many Russian immigrants. These behaviors include sharing leftover prescriptions with family and friends, not informing health-care providers that they are using herbal remedies, and polypharmacy from augmenting prescriptions with Russian pharmaceuticals (Aroian, 2003). Russian grocery stores in Russian immigrant communities or people traveling to and from Russia are both ample sources of Russian pharmaceuticals and herbs. Adverse health consequences from polypharmacy are a well-known problem, and some common herbal remedies interact dangerously with prescribed medications. According to one study, high-risk sexual behavior is increasing among Russia immigrant adolescent girls, with greater risk among girls who are more acculturated to American culture (Jeltova, Fish, & Revenson, 2005). The association between risky behavior in adolescents and acculturation is not unique to Russian immigrants or girls. Mostly likely the association between acculturation and greater risky behavior results from the erosion of traditional family practices as youths acculturate to the United States. Nutrition Meaning of Food Many Russians grew up with serious food shortages. Thus, food carries a lot of meaning. When entertaining, Russians can use food as a demonstration of their love and respect for their visitors, spending days purchasing and preparing food for their guests. Presently, this practice appears to be limited by time constraints and increased acculturation to the United States. People of Russian Heritage Common Foods and Food Rituals Older Russian immigrants have little interest in American food. As previously stated, traditional Russian diets contain high levels of saturated and hydrogenated vegetable fats, salt, and carbohydrates (Keefe, 2006). Typically, Russian immigrants eat three meals a day, with their largest meal in the middle of the day. Russians enjoy snacks and tea, water, and fruit juices without ice. Russian grocery stores and restaurants were quite popular in Russian immigrant communities, but these venues are losing business as Russian immigrants, particularly younger ones, are acculturating to American diets. Dietary Practices for Health Promotion When Russians are ill, they prefer soup and broths, bland foods, chicken, potatoes, fruit and vegetables, and yogurt. Tea with honey and milk is considered medicinal (Hobbs, 2002). Nutritional Deficiencies and Food Limitations Russian Jews, if observing kosher dietary restrictions, do not eat pork or shellfish or combine milk and meat products (Hobbs, 2002). REFLECTIVE EXERCISE 24.1 Inna Scheider is an 87-year-old woman residing in a longterm-care facility. She has multiple chronic diseases, including advanced congestive heart failure (CHF) and is very frail. Inna had balance problems and had multiple falls in the past year, which resulted in numerous hospitalizations. In addition, she has moderate dementia. Currently, Inna exhibits some behavioral problems and does not follow directions. Inna does not speak English and can communicate with her health-care providers only through an interpreter or when her sons are present. One of the certified nursing assistants (CNAs) in the facility is Russian-speaking and often stops by to help calm her down when her family is not present. Inna has two sons who live in the area and visit often. Both are very devoted to their mother and are very involved in her care. In the past, when Inna lived at home with her children, she was a great cook and spent a significant amount of time preparing family meals. Making multicourse meals was a very important daily family ritual. In the United States, Inna developed a great fondness for local Russian grocery stores that sell foods that were not available during severe food shortages in the Soviet Union. After several months in the long-term-care facility, Inna developed weakness and dizziness. Her physician suspects that she had internal gastrointestinal bleeding. Her physician was also concerned about risk of aspiration. As a result, Inna was put on a soft food diet and receives some of her food with added thickeners. However, the facility staff noticed that her sons repeatedly brought Inna ready-prepared Russian food 433 from a local Russian grocery store. One son was observed trying to feed her pieces of hard salami, herring with black bread, and a diced beet salad. Inna was choking from her difficulty swallowing some of the items. When confronted by the staff, the son responded that this was the food that Inna loved and it would make her feel better. 1. What cultural trait in food attitudes is exhibited by Inna’s sons? 2. What educational efforts are needed by the health-care team to educate the family about Inna’s condition and the need for a special diet? 3. How can Inna’s care plan be integrated to balance her health-care needs with the need to validate her tastes and preferences? Pregnancy and Childbearing Practices Fertility Practices and Views Toward Pregnancy Marriage and childbearing are acceptable starting at age 20. Childbearing and child rearing are highly valued. Infertility is perceived by Russians as a health problem, disappointment, and even punishment for some feminine wrongdoing (Aroian, 2003). Russian women are responsible for contraception and often make contraception decisions without consulting their male partners. These decisions often relate to access, cost, safety, and partner issues. Contraception for Russian women is allowed without sanctions or taboos. Even so, many Russian immigrants are afraid of birth control pills and refuse to take them. Possible reasons for this reluctance are the poor quality and high dosage of oral contraceptives in Russia. To compound this problem, condoms in Russia were poorly made, and many jokes have evolved about the routine breakage of Russian-made condoms. Furthermore, Russian men believe that condoms hinder sexual pleasure and many refuse to wear them. Most Russian men also refuse vasectomies (Aroian, 2003). Abortion was and is one of the most common forms of birth control in Russia. Russia has one of the world’s highest abortion rate, with the average woman having three or more abortions in her lifetime. In 1990, there were 1972 abortions per 1000 live births. In 2002, this number dropped to 1276 abortions per 1000 live births (World Health Organization [WHO], 2005). Self-induced abortions are not uncommon. Frequent abortions contribute to the high rate of infertility in Russian women. Infertility issues may lead to marital discord and divorce. Beliefs about menstruation are based on biomedical principles. Nonetheless, young Russian women are discouraged from strenuous exercise, including swimming, while menstruating (Aroian, 2003). This practice 434 Aggregate Data for Cultural-Specific Groups may have evolved from the former unavailability of tampons in Russia. Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family Pregnant Russian women do not engage in heavy lifting and often commit to bed rest if it is prescribed. Russian women who are pregnant receive more respect. When born, boys are dressed in blue and girls in pink. Breastfeeding is encouraged, and nursing women are told to drink tea with milk and eat nuts to improve their milk supply (Aroian, 2003). Owing to religious beliefs, Russian Jews circumcise their male infants. Ethnic Russians do not circumcise their newborn boys. Death Rituals Death Rituals and Expectations Flowers are used to beautify caskets and funeral services. Caskets are typically closed, and stones are put on graves instead of flowers. Food and beverages are usually served during wakes and funerals. Friends and family come to pay their respects for 7 days postmortem, but the expected total period of official mourning is 1 full year. A full year is considered the minimal appropriate time for a surviving spouse to wait before remarrying. Close relatives of the deceased dress in black. Russians do not hesitate to cry and sob at funerals, but overt wailing is often confined to the home of the deceased (Aroian, 2003). A family will hold vigil day and night if their loved one is dying. All relatives and friends are expected to visit a dying patient and often sit with the person for hours. Depending on religious affiliation, the placing of hands on the ill person’s forehead may occur as a ritual gesture of blessing. Religious symbols may also be placed at the ill person’s bedside, and a spiritual advisor may be present when death is impending. Russian Orthodox families pay vigil to terminally ill and deceased persons, praying for mercy on their souls and their entry into heaven (Yehieli, Lutz, & Grey 2005). Spiritual leaders from the Russian Orthodox religion institute a special prayer vigil, called panikhida, over the deceased, a vigil that includes chants, prayers, singing of hymns, and gospel readings (Yehieli et al., 2005). Regardless of religious affiliation, once a person dies, his or her mouth and eyes are closed, and mirrors are covered with black fabric (University of Washington Medical Center, 2005). If the patient and family are Russian Orthodox, cremation is unlikely (University of Washington Medical Center, 2005). Cremation is forbidden in the Jewish tradition. However, some Russian immigrants may choose cremation so the deceased’s ashes can be shipped back to “Mother” Russia (Yehieli et al., 2005). Russian Jews bury the dead within 24 hours except during holidays, on Saturdays, or if awaiting the arrival of additional friends and family (University of Washington Medical Center, 2005). Responses to Death and Grief Russians are reluctant to disclose terminal illness or poor prognosis to patients and believe that talking about death is a bad omen (Aroian et al., 2006; Birch, 2006; MDEED, 2006; Norman, 1996). Family members feel responsible for protecting their loved one from the psychological turmoil that could result from disclosing a poor prognosis. They tend to feign cheeriness in the presence of a dying person rather than openly grieve in front of a sick or dying loved one. This behavior stems from the belief that the stress of bad news increases morbidity and perhaps even causes death (Norman, 1996). Two additional explanations for not disclosing a poor prognosis are that the dying person would lose hope and succumb to the illness and the prognosis could be wrong. Therefore, it is important to carefully and diplomatically talk with the family first, prior to disclosure of bad news to the patient (MDEED, 2006). Consistent with the value on collectivism, Russians believe that a problem for one family member is a problem for the entire family. However, discussions about end of life are better addressed by identifying a spokesperson from the family. When discussing end-of-life decisions, it is also important to note that morphine or other potent analgesics may be perceived as hopelessness or abandoning the patient (University of Washington Medical Center, 2005). Compared with Americans, being in control of decisions at the end of life is less important for Russian immigrants. Therefore, requests for living wills or durable powers of attorney, as well as consents for withholding or withdrawing treatment, are usually declined by Russian patients and family members (University of Washington Medical Center, 2005). One reason for this is that Russians have great faith in U.S. medical care and therefore expect that everything possible will be done to restore health, even when their expectations are at odds with a grave prognosis (Aroian et al., 2006). However, evidence suggests that culturally sensitive educational efforts can be productive in increasing family decisions for palliative care of Russian older adults (Dashevskaya, 2004). Spirituality Religious Practices and Use of Prayer Preferred religious practices for Russian immigrants vary. Many Russians have no religious affiliation, which is likely the consequence of antireligious dogma of the former Soviet Union. Prior to the overthrow of Czarist Russia, ethnic Russians were predominantly Russian Orthodox. However, during the Soviet era, People of Russian Heritage REFLECTIVE EXERCISE 24.2 During the admission to the long-term-care facility, the healthcare team approached Inna and her sons to complete healthcare proxy forms and make some end-of-life decisions. During the admission interview, it became clear that Inna’s sons do not fully understand the extent of their mother’s physical and cognitive impairment and would like the health-care team to pursue a very aggressive approach in treating her. Inna did not participate in the discussion fully and deferred all decision making to her sons. As a result, Inna’s treatment plan included “full code” instructions to health-care providers. One day while visiting, one of the sons observed a team treating Inna during an acute CHF episode. He was distraught by how much his mother suffered from the brutality of the medical intervention. Afterward, he asked the health-care team to change “full code” instructions to Do Not Resuscitate (DNR) but declined Do Not Hospitalize (DNH) instructions, stating that he did not have the heart to institute this instruction. 1. What attitudes and cultural trends were demonstrated by Inna’s sons during her admission to the long-term facility? 2. How should the facility admission team have approached the discussion regarding Inna’s end-of-life wishes? 3. How should the discussion about DNR and DNH have been framed to demonstrate respect for Inna’s sons’ values and traditions? 4. What type of educational materials would be helpful for Inna’s sons to help them consider how to address quality of life and end-of- life goals in her treatment plan? religious practices of all types were condemned, and people caught practicing their religion risked being punished severely. With the resurgence of Russian nationalism, the Russian Orthodox Church has resumed a major role in the life and politics of the Russian people. As evidence of this renewed emphasis, Russian Orthodox Churches are being restored. Religious practices among ethnic/religious minorities in present-day Russia also vary. Russian Jews may or may not be religious, but Pentecostals tend to be devout. Meaning of Life and Individual Sources of Strength Although self-professed atheism has had a dramatic decline since 1991, religion is still not prominent in many Russians’ lives. Russians, including Russian immigrants, often lead secular lives and tend to gain spiritual strength, stability, and meaning through their associations with family and friends. Spiritual Beliefs and Health-Care Practices Seriously ill patients and family members who are religious consider prayer an essential and powerful tool 435 toward health and healing (University of Washington Medical Center, 2005). Members of the Russian Orthodox faith believe in the heavenly position of saints as well as religious miracles. Health-Care Beliefs and Practices Russians define health as the absence of disease. Although they embrace biomedical explanations for disease, their approach to health is holistic. They endorse the notion that stress, including family and economic stress, is a causative factor in disease. Additional causative factors include getting chilled and not having fresh air, sunlight, and nutritious food. Given their holistic perspective, they expect their health-care providers to holistically diagnose the etiology of health problems. A common complaint is that Western medicine places too much emphasis on medications and laboratory results and not enough on clinical diagnosis and holistic care. Russians consider health an important resource and are active in maintaining their health (Aroian et al., 2001). Russian immigrants generally keep health-care appointments and adhere to prescribed treatments (Aroian, 2003). On the other hand, the general belief is that more professional input is superior to relying on a single health provider. Thus, Russians often combine prescribed treatments from many providers, and providers are often unaware of multiple treatment plans. In addition, Russians often supplement prescribed treatments with homeopathic and herbal remedies. Mental illnesses are highly stigmatized in Russia. As a result, Russian immigrants may not provide truthful answers to questions regarding a family or personal history of mental illness (University of Michigan Health System, 2007). Russians often self-diagnose, seeking out and reading Russian-language health articles related to their disorders. One important method of receiving healthcare information is through mass media and the Internet. Rulist.com is a search engine that provides a kind of Russian yellow pages with information on health and wellness. Russian immigrants may also subscribe to the Russian Health Magazine, a magazine geared toward increasing the medical awareness of Russian-speaking people in the United States. It is also noteworthy that a significant portion of Russian immigrant men and women who emigrated in the latter part of the 20th century were physicians. Although some of the older people from this group never practiced medicine in the United States, they provide informal health information to Russian immigrants. Russian immigrants have a very different view of obesity than the dominant U.S. culture. Generally, they are more accepting of excess weight and obesity, perhaps because excess weight and obesity are common due to a high caloric diet and low levels of exercise. For 436 Aggregate Data for Cultural-Specific Groups example, Stevens and colleagues (1997) compared attitudes and behaviors related to body size and other parameters among black, white, and Russian adolescents. Russian adolescent girls were less likely than black and white adolescent girls to identify obese and overweight status as a concern. Health-Seeking Beliefs and Behaviors Clinical and anecdotal reports describe Russians as demanding patients who overuse health care. It is true that Russians are not passive in voicing their healthcare needs (Aroian, 2003). However, empirical data about their health care use illustrate that their use is not always disproportionate to their health needs (Aroian & Vander Wall 2007). It is also important to consider that the Russian immigrant community in the United States is diverse, with much variation in many of the characteristics that affect health-care use, such as education, language ability, age, and insurance coverage. For example, Ivanov and Buck (2002) found that younger Russian immigrant women only used health care for emergencies, reportedly because of lack of time and third party insurance. In contrast, the older Russian immigrant women in their sample had much heavier use, presumably because they were retired and covered by Medicaid. There is also geographic variation in the number of Russian-speaking health-care providers and transportation barriers for accessing health care. Geographical differences may account for why Wei and Spigner (1994) found that Russian immigrants had lower rates of clinic use than Southeast Asian refugees in Portland, Oregon, whereas Aroian and colleagues (2001) found very high healthcare use among Russians in Boston, Massachusetts. Portland had comparatively fewer language barriers for Southeast Asians than for Russians, whereas Boston had almost no language barrier for Russians. Russianspeaking physicians in Boston also purposefully set up practices close to dense Russian-speaking communities so as to minimize transportation barriers. There are mixed findings about how satisfied Russian immigrants are with their health-care providers. In one study, Russian immigrants expressed dissatisfaction with family physicians, perceiving them as lacking professionalism (Ivanov & Buck, 2002). They were dissatisfied with the general appearance of health-care providers and how difficult it is to distinguish between the nurse and the janitor. In contrast, another study that compared Russian immigrants with nonimmigrants found no differences in satisfaction with providers, but did find that Russians were less satisfied with appointment availability and physical access (Aroian & Vander Wall, 2007). Dissatisfaction with appointment availability and physical access may be related to the fact that Russians were used to having health care readily available in Russia through walkin clinics located in convenient settings where people live and work. Russians were also used to physicians making home visits in Russia when people are too ill or frail to travel for health care (Aroian et al., 2001). Russians perceive male physicians as more skilled and competent and as having more status than female physicians (Ivanov & Buck, 2002). Nonetheless, they are used to having female physicians. Women in Russia have been practicing medicine in large numbers for decades. Responsibility for Health Care Russians believe that individuals are responsible for their health and that disabilities and negative health events result when individuals do not take care of themselves (Aroian et al., 2001; Aroian & Vander Wal, 2007). Most Russians take an active role in their health and health care. They use alternative and homeopathic remedies and commit to self-care. Even though Russians acknowledge personal responsibility for their health, they are used to authoritarian health encounters. They expect health-care providers to be directive, telling them exactly what to do to get or stay well (Aroian et al., 2006; Ivanov & Buck, 2002). They are unlikely to schedule preventive screening unless a health-care provider directs them to do so (Ivanov & Buck, 2002). Folk and Traditional Practices Homeopathic and traditional medicines have been used for centuries in Russia and continue to be used widely, often simultaneously with those of Western medical science. Russians, especially older individuals, use herbal teas, tinctures, mud baths, massage, saunas, and other alternative medicines and healing practices (Yehieli et al., 2005). Additional home remedies include rubbing oils and ointments, enemas, saunas and whirlpools, mineral water (for soaking as well as drinking), herbal teas, hot and cold soups, liquors, and mud plasters (Bistrevsky, 2005). “Cupping,” a technique whereby the inside of a glass cup is heated and placed on a person’s back, shoulder, or chest, is used for respiratory problems such as bronchitis and asthma. In Russia, physicians and nurses go to patients’ homes to perform cupping. Barriers to Health Care Awareness and Attitudes Russians expect their health-care providers to look and act professional. Russian immigrants also expect health-care providers to be nonjudgmental about herbal and homeopathic treatments. Russians are very involved with the care of their family members, which can conflict with providers who approach care by only involving the patient, either as a means of promoting autonomy or protecting the patient’s privacy. Owing to social and political sanctions against psychiatric People of Russian Heritage illness in Russia, Russian immigrants may also be reluctant to disclose mental health issues and a family history of mental disorders. Therefore, providers need to approach the subject carefully and with full assurances of confidentiality. Russians are unaccustomed to the concept of managed care. They want direct access to multiple, sophisticated tests and procedures and to health-care specialists of their choice. They believe the additional step of needing a referral by a primary care provider is not only expensive and wasteful but also detrimental to their health because it reduces timeliness to care. Recent Russian immigrants may also be unfamiliar with concepts such as defensive health care and medical malpractice. Affordability Russians are egalitarian and believe in an equal distribution of health-care benefits (Culture Tips, 2000). In the former Soviet Union, health care was free. Therefore, concepts like private pay, co-pay, and insurance premiums are difficult for many Russian immigrants to understand. They may need help to understand U.S. health-care systems, including Medicaid and Medicare programs. However, the Russian health system underwent significant transformation after the fall of communism. Therefore, recent immigrants are more familiar with the notion of paid health care and the need to have health insurance coverage. In the United States, about 85 percent of Russian immigrants carry some kind of health insurance REFLECTIVE EXERCISE 24.3 When Inna was admitted to the long-term-care facility, the admission staff obtained a list of her prescribed medications from her primary care provider. During one of the visits by Inna’s other son, the staff observed that he was giving Inna pills to take with her meal. In the facility, Inna receives several medications, and they are administered in a crushed form due to her soft food diet and difficulty swallowing. The staff was worried and informed Inna’s physician that her son was giving her additional medications. When the physician called Inna’s son, the son explained that the pills were “natural,” were recommended by his alternative health-care provider, and were likely to help his mother. He takes the same pills to boost his energy level. However, he does not know what the pills contain. 1. What cultural responses to health and illness are demonstrated by Inna’s son? 2. What was the missing element in the admission process in terms of Inna’s medication history? 3. What discussion should have taken place when Inna’s care team discussed her medication regimen and her treatment plan with her family? 437 coverage, including employer-based private insurance or government plans such as Medicaid, Medicare, or both (Ethnic Population, 2003). Due to low income, a lot of older immigrants are dual eligible: enrolled in Medicare as their primary insurance and also enrolled in Medicaid to help pay for co-payments and deductibles. In cases of chronic illness and frailty, dual enrollment provides coverage for home and communitybased services and nursing home care. Even with coverage, cost can be a major barrier to health care. Copayments can compete with money needed for food and other household essentials (Ivanov & Buck, 2002). Language Proficiency There are generational differences in language proficiency. Older immigrants have a lesser command of English than younger immigrants who went to school in the United States and/or are working for American employers. Therefore, younger family members often act as interpreters for the elderly. However, Russian immigrants who are not proficient in English strongly prefer Russian-speaking health-care providers and will actively look for them. Depending on geographical area, there are a large number of Russian-speaking health providers and health services in the United States. For example, some nursing homes have “Russian units” staffed by Russianspeaking nurses. It is also noteworthy that Russian medical and dental associations have been established in the United States and are a testimony to the language- and culture-specific health-care resources that are available to Russian immigrants who speak only Russian. The Russian American Medical Association (RAMA) was founded in 2002 and has a peer-reviewed journal and a Web site with information relevant to all Russian-speaking health-care providers (RAMA, 2007). As previously mentioned, there is also a good amount of Russian-language health literature available for Russian lay audiences (e.g., the Russian Health Magazine and Web sites like Rulist.com). There is also a Web site called RussianDoctor.com, which allows Russian immigrants to locate Russian-speaking dentists and physicians by specialty and location (city/state). Accessibility For every 1000 people in Russia, there are 4.25 physicians compared with 2.56 physicians in the United States (WHO, 2006). Although the United States has more nurses and more nurses in expanded practice roles than Russia, Russian immigrants perceive that health care is far less accessible than what they were used to (Aroian & Vander Wall, 2007; Benisovich & King, 2003). Russian immigrants complain about needing to wait many weeks or months before getting a health-care appointment. As mentioned above, Russians were used to much greater accessibility in the former Soviet Union, including conveniently located walk-in clinics and home 438 Aggregate Data for Cultural-Specific Groups visits by physicians. Transportation is another barrier, even in geographical settings where Russian-speaking health-care providers have intentionally set up practices in Russian-speaking neighborhoods. In addition, in the Soviet Union, people were hospitalized for minor illnesses. Therefore, Russian immigrants may be less used to traveling back and forth for outpatient visits and multiple appointments in different locations. Cultural Responses to Health and Illness Russian immigrants often have unrealistic expectations of U.S. health-care providers (Aroian et al., 2001). They expect that a rich country like the United States should be able to cure disease easily, regardless of disease state. When one physician is unable to meet expectations, the patient will likely seek the services of others. Treatments prescribed by one health-care provider may not be disclosed to another, which raises concerns about negative health effects from polypharmacy (Aroian, 2003). In addition, Russians are accustomed to health-care providers placing a greater emphasis on treatment than prevention. Long in-patient hospitalizations were the norm in Russia. Thus, Russian immigrants are dismayed by short hospital stays in the United States (Aroian et al., 2001). Blood Transfusion and Organ Donation Owing to contaminated blood supplies in Russia and the former Soviet Union, health-care providers may have difficulty convincing Russian immigrants to consent to giving or receiving human blood products. Health-Care Providers Traditional Versus Biomedical Care In Russia, health care was more holistic, with biomedical providers prescribing homeopathic treatments as supplements to biomedical approaches. As previously mentioned, Russian immigrants are disappointed by the lack of holism in American health care. Status of Health-Care Providers Physicians are considered to be the most knowledgeable of all health-care providers and “in charge” of health care. 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Retrieved from www. uscis.gov/graphics/shared/statistics/yearbook/LPRO5.htm U.S. Department of Homeland Security. (2005c). Supplemental Table 2: Legal permanent resident flow by leading core-based statistical areas (CBSAs) of residence and region and country of birth: Fiscal year 2005. Retrieved from www.uscis.gov/ graphics/shared/statistics/yearbook/LPRO5.htm U.S. Department of Homeland Security. (2010). Yearbook of Immigration Statistics: 2009. Retrieved from http://www.uscis. gov/graphics/shared/statistics/yearbook/LPRO5.htm University of Michigan Health System. (2007). Cultural competency. Patient Education. Ann Arbor. Retrieved from http://www.uofmhealth.org/health-library University of Washington Medical Center. (2005, April). Communicating with your Russian patient. Culture clues: Staff Development Workgroup, Patient and Family Education Committee. Seattle. Vadlamani, A., Maher, J.F., Shaete, M., Smirnoff, A., Cameron, D.G., Winkelmann, J.C., & Goldberg, S.J. (2001). Colorectal cancer in Russian-speaking Jewish émigrés: Communitybased screening. American Journal of Gastroenterology, 96(9), 2755–2760. Vishnevsky, A., & Zayonchkovskaya, Z. (1994). Emigration from the former Soviet Union: The fourth wave. In H. Fassman & R. Munz (Eds.), European migration in the late twentieth century: Historical patterns, actual trends, & social implications 440 Aggregate Data for Cultural-Specific Groups (pp. 239–285). Aldershot, UK: Edward Elgar Publishing Limited. Wei C., & Spigner, C. (1994). Health status and clinic utilization among refugees from Southeast Asia and the Former Soviet Union. Journal of Health Education, 25(3), 266–273. World Health Organization (WHO). (2005, January 14). Country profile. WHO Regional Office for Europe. Retrieved from http://www.who.int/countries/rus/en/ World Health Organization (WHO). (2006). Health workers: A global profile. The world health report 2006: Working together for health. Annex table 4, pp. 197–199. Retrieved from http://www.who.int/whr/2006/en/ Yehieli, M., Lutz, G., & Grey, M. (Eds.). (2005, November). Russians and other immigrants from the former Soviet Union. Health disparity factsheets. Cedar Falls, IA: Center for Health Disparities, University of Northern Iowa. For case studies, review questions, and additional information, go to http://davisplus.fadavis.com Chapter 22 People of Polish Heritage Larry Purnell The author would like to thank Henry M. Plawecki, Lawrence H. Plawecki, Judith A. Plawecki, and Martin H. Plawecki for their contributions to this chapter in the 3rd edition. Overview, Inhabited Localities, and Topography Overview Almost 9.9 million people in the United States (U.S. Census Bureau, 2011) and over 8 million people in Canada identify their ancestry as Polish (Statistics Canada, 2010). Poland—officially the Republic of Poland—occupies 120,727 square miles (312,683 square kilometers), which is slightly smaller than the state of New Mexico (CIA World Factbook, 2011). The capital of Poland is Warsaw. Located in Central Europe, Poland, with a population of about 38,111,000, is the eighth largest country in Europe. The life expectancy in Poland 72.1 years for men and 80.25 years for women (CIA World Factbook, 2011). Poland shares its western border with Germany, and to the south, it is bordered by Slovakia and the Czech Republic. Ukraine, Belarus, Lithuania, and Russia all share eastern and northeastern borders with Poland. The Baltic Sea borders the majority of the northernmost part of the country. Poland is an ancient nation that was conceived near the middle of the 10th century. Its golden age occurred in the 16th century. During the following century, the strengthening of the gentry and internal disorders weakened the nation. In a series of agreements between 1772 and 1795, Russia, Prussia, and Austria partitioned Poland among themselves. Poland regained its independence in 1918, only to be overrun by Germany and the Soviet Union in World War II. It became a Soviet satellite state following the war, but its government was comparatively tolerant and progressive. Labor turmoil in 1980 led to the formation of the first independent free trade union in Eastern Europe, Solidarnosc (Solidarity) that over time became a political force and by 1990 had swept parliamentary elections and the presidency. A “shock therapy” program during the early 1990s enabled the country to transform its economy into one of the most robust in Central Europe, but Poland still faces the lingering challenges of high unemployment, underdeveloped and dilapidated infrastructure, and a poor rural underclass. Poland joined NATO in 1999 and the European Union in 2004. With its transformation to a democratic, market-oriented country largely completed, Poland is an increasingly active member of Euro-Atlantic organizations (CIA World Factbook, 2011). In 1947, elections officially brought the Communist Party to power. The Stalinist model was implemented until 1956. After Stalin’s death, Polish Communism vacillated between repression and liberalization until about 1970. Poland’s resistance to Communist rule began in 1970 with the emergence of Lech Walesa, the leader of a strike in the Gdansk shipyards. Walesa headed Solidarity , which was created because of the Communists’ violent repression of the workmen of Radom in 1976 and a second strike at the Gdansk shipyards in 1980, the result of the government’s raising food prices (Gdansk, 2008). The 1978 election of a Polish cardinal, Karol Wojtyla, as Pope John Paul II led to unprecedented social and political changes in Poland. The 1980 emergence of Solidarity and the election of a Polish pope rekindled a religious rebirth in the Poles, an increased sense of self, social identity, and the realization of their collective strength. Solidarity became a major social movement and phenomenon unheard of within the Soviet bloc’s political system. Despite negotiations, confrontations, and, ultimately, repressive military operations by the ruling Polish Communist Party, the Solidarity movement survived as its influential unofficial opposition. Ultimately, the Polish Communist Party recognized that the people’s massive opposition reduced their ability to govern. In 1988, formal negotiations between the Polish Communist Party leaders and the unofficial opposition, called the “Round Table talks,” resulted in partially free Parliamentary elections. Solidarity won a landslide victory in the 391 392 Aggregate Data for Cultural-Specific Groups June 1989 elections. In July 1989, the newly elected Parliament changed the country’s name and constitution, establishing the Third Republic of Poland and a democratic system of government (von Geldern & Siegelbaum, 2003). Polish immigrants and their descendants who immigrated to America for many generations have maintained their ethnic heritage by promoting their culture, attending Catholic churches, attending parades and festivals, maintaining ethnic food traditions, speaking the Polish language, and promoting interest in their home country through media events as well as economic and political channels. For newer immigrant Poles, maintaining ethnic heritage means learning English and obtaining a good job (Erdmans, 1998). Newer immigrants are less concerned with raising consciousness over Polish American issues than they are with financially helping families who remain in Poland and raising concerns over the political and economic climate in their homeland. Heritage and Residence The first contribution of the Poles to the development of American democracy occurred during the American Revolutionary War. Two prominent Poles who assisted the colonists in their fight for independence were Count Kazimierz (Casimir) Pulaski and Tadeusz Kosciusko. General Pulaski, a valiant cavalryman, led soldiers by courage and example. His many heroic actions on behalf of the colonists lead to naming him the “Father of the American Cavalry” (Polish American Center, 1997). Many American towns, counties, parks, and other memorials bear the names of these Polish heroes. The Poles’ dedication to the welfare of the United States was summarized by the motto of the first Polish American political club, the Kosciuszko Club, established in 1871, which states, “A good Pole is a good American citizen” (Jarczak, n.d.). Immigrants, regardless of their country of origin, leave their homeland for a variety of reasons that include avoiding ethnic, religious, and political persecution; seeking a better lifestyle; and providing a means of support for family and relatives who remained in the homeland. Like any other group who perceives themselves as unaccepted, displaced, and different, the Polish immigrants established a geographically and socially segregated area called a Polonia, the medieval name for Poland. Polonia allowed members of the immigrant group to experience social comfort, speak their native language, and openly practice the customs of their homeland. The initial migration of about 2000 Polish immigrants occurred between 1800 and 1860. This group consisted of intellectuals and nobles who were motivated by political insurrections. The first substantive Polish settlement in America was founded in 1854 by Father Leopold Moczygemba and 100 Polish immigrant families in Panna Maria, Texas (Panna Maria, 2006). Even though most Poles preferred living in agrarian communities, they gravitated to cities where work for laborers was plentiful. Between the early 1800s and the beginning of World War II, over 5 million Polish immigrants came to the United States. Many of these immigrants perceived America only as a temporary home. This first major immigrant group was called za chlebem, or “forbread” immigrants. These immigrants came to earn money and then return to Poland. Polish immigration to America continues today. A new generation of immigrants recently freed from foreign domination have recently been coming to the United States seeking better lives (Library of Congress, 2004). At the peak of Polish migration, Chicago was considered the most well-developed Polish community in the United States (Pacyga, 2004). The first Polish immigrants to Chicago were primarily nobles who fled Poland after the Polish-Russian war of 1830 to 1831. They came with plans of establishing a Polonia in Illinois (Pacyga, 2004). Chicago’s Polish community grew rapidly after 1850. Peter Kiolbassa, who served as a captain in the Sixth Colored Cavalry during the Civil War, emerged as a local leader. Kiolbassa organized the first Polish Society of St. Stanislaus Kostka in 1864. This organization prepared the community for the development of the city’s first Polish Roman Catholic parish. Located along the north branch of the Chicago River, the residents of Polonia initially attended a German parish church. Facing hostility from some of the Germans, who discouraged their priest from ministering to the Polish religious needs, the Polish community established its own Roman Catholic parish, St. Stanislaus Kostka. The parish was central to the creation of Polonia, because the establishment of ethnic Catholic parishes provided the community with a stable institutional base and served as a status symbol for the new immigrant colony. The Polish community’s development allowed them to actively participate in the labor movement, which, along with their involvement with fraternal groups, led to the development of neighborhood organizations. By 1980, Hispanics and African Americans had largely replaced Poles in the inner-city core neighborhoods. Polish Chicagoans left the old neighborhoods and moved to the suburbs. Chicago’s Polonia played a crucial role in the political, religious, educational, business, institutional, and cultural life of Chicago. Polonia was also the name given to Polish communities found in northeastern and midwestern cities after 1945 (Best, 2004). Members of these communities kept Polish nationalism alive by speaking their native language, preserving customs, and attending the local Catholic church run by Polish clergy and the Felician Sisters. Because Poland was partitioned until 1919, Poles coming to America during the 1800s and early People of Polish Heritage 1900s were unable to report Poland as their emigrating country, but they tenaciously worked to ensure the survival of the Polish culture. Over time, the 120-year partition of Poland and its absence from the world map significantly reduced the number of immigrants who could identify Poland as their emigrating country. Therefore, the partition ultimately led to an undercount of the actual number of Americans with Polish ancestry. For many older Poles, the neighborhood is their community. Polonias, especially in urban ethnic communities, provide a sense of belonging, reduce alienation, and enhance people’s ability to solve problems and maintain the motivation to address modern-day frustrations. Plawecki (2000) states, “The assumption of voluntary Americanization continues to exist in spite of the behaviors of past generations who resisted the assimilation process and have, in fact, reestablished their pre-immigration cultures in multiple voluntarily segregated ethnic enclaves/communities” (p. 7). Consequently, the segregated group develops communication styles, cultural beliefs, and interactive behaviors that are socially accepted within their community but are different from those expected by the general populace (Plawecki, 1992). Poles are a heterogeneous group. As such, they were slow to assimilate into multicultural America. Much of the variation within this ethnic group is due to variant cultural characteristics (see Chapter 1). Polish Americans were well represented in the WWII war effort of the United States. Significant numbers of Polish Americans, both native and immigrant, joined the U.S. military. Even after displaying that sense of duty, honor, and patriotism, Polish Americans often experienced discrimination during and after the war. Poles were passed over for jobs because they had difficulties speaking English and their names were difficult to pronounce or spell. As a reaction to this discrimination, name changes became common for upwardly mobile Polish Americans. The shortening and changing of names were intended to decrease discrimination and promote greater acceptability in the job market as well as increase social acceptance. Many Polish Americans still experience discrimination and ridicule through ethnic Polish jokes, which are similar in scope to those about Irish, Italian, Mexican Americans, and other ethnic groups. Reasons for Migration and Associated Economic Factors Polish immigration to the United States occurred in three major waves. The first wave of immigrants, arriving in the early 1800s through 1914, came to America primarily for economic, political, and religious reasons. Many immigrants were illiterates, peasants, or unskilled laborers (Grocholska, 1999). They took 393 low-paying jobs and lived in crowded dwellings just to make a meager living. The second major wave of immigration occurred after World War II. During the war, Poland lost over 6 million of its 35 million people (Brogan, 1990). The nearly complete destruction of Poland prompted the post-WWII wave of Polish immigrants to come to America. This group primarily included political prisoners, dissidents, and intellectuals from refugee camps all over Europe. These immigrants, who were both educated and had a basic knowledge of English, assimilated more easily into American culture than those from the first wave. They consciously separated from Polonia and aligned themselves with other middle-class and professional groups in America. The upwardly mobile and middle-class aspirations of this group differed from the working-class orientation of the first- and second-generation descendants of the first wave (Grocholska, 1999). The current third wave of immigrants, often called the Solidarity immigrants, began arriving in 1978 (Grocholska, 1999). These Solidarity immigrants reflect the ideologies of the first two waves—that is, they want to work and to speak freely about political and intellectual issues. Two types of third-wave immigrants came to America. The first came to work without any initial interest in permanently relocating. They entered this country on a visitor’s visa and left their families in Poland. These immigrants frequently lived in low-income housing, shared rooms with other immigrants, and worked hard to send money to their families in Poland. Networking with other Poles was their primary source of job contacts. They quickly took any job available, particularly as laborers, domestics, and unskilled farm workers. Because many of these immigrants were sending money to their families in Poland, they often overstayed their visitor visas. The second type of third-wave Polish immigrants chose to come to America for political and economic reasons. This group typically consists of well-educated professionals and small-business owners. They consciously decided to leave Poland forever and bring their families with them. This group epitomizes the Polish characteristics of hard work, determination, and frugality. Although many in this group are underemployed, they actively use English and integrate into their new country, recognizing that this may be a necessary first step to assimilation. Many second- and third-wave immigrants avoid Polish communities because they believe that American ethnic Polonias are different from those in Poland. The concerns and issues of political representation and discrimination of established immigrants living in America are irrelevant to this wave of immigrant Poles. In addition, many older Polonias are located in diverse, changing, inner-city neighborhoods, and the upwardly mobile 394 Aggregate Data for Cultural-Specific Groups Polish Americans, like other successful groups, have begun to leave the cities for the suburbs. Educational Status and Occupations Educational priorities and their desire to assimilate into American culture vary widely among Polish immigrants. The educational status, socioeconomic levels, and cultural philosophy often depend on the time frame when the family emigrated from Poland. Until the 1950s and 1960s, many Polish families were slow to recognize the value of education for their children. Before WWII, most Polish children went to Catholic schools, where they learned about their culture, its language, and Catholicism. After WWII, parents felt an acute responsibility to have their children learn English. Subsequently, the Polish language was eliminated from the curriculum of many schools, and its use was restricted to the home. The second wave of Polish immigrants placed a high value on education and culture. Educated, cultured Poles were expected to read widely and speak several languages. Cultured Poles have great pride and respect for Poland’s most famous people, such as composer Frederic Chopin, two-time Nobel laureate scientist Marie Curie, novelist Joseph Conrad, astronomer Nicolaus Copernicus, and Karol Wojtyla, better known as Pope John Paul II. Poles are known for epic works in prose and poetry. Major themes in Polish literature are nationality, freedom, exile, and oppression. After World War II, many Polish Catholics were blue-collar workers who perceived hard work as honorable. Many feared that education and its resultant mobility were a threat to their family, religious, and community life. For women, education was seen as even less necessary because of the value placed upon their staying at home and raising their children. Television helped change the character of ethnic communities forever as it brought the outside world into both the community and the home. The descendants of immigrants who did go to college valued obedience and self-control, respected authority, and exhibited determination (Bukowczyk, 1987). Communication Dominant Language and Dialects The Polish language was influenced by the countries surrounding Poland and by the Latin of 11th- and 12th-century kings. Depending on the regional and cultural background of the speaker, Polish may sound German, Russian, or French. The Polish language has a lyrical quality that is pleasant to the ear, even if one has difficulty understanding the words. Poles are an animated group, and facial expressions generally convey the tone of the conversation. The dominant language of people living in Poland is Polish, although there are some regional dialects and differences. Generally, most Polish-speaking people can communicate with one another. Recently, a resurgence of interest in learning to speak the Polish language has occurred among Polish Americans. Both adults and children are learning Polish in churchaffiliated language schools, cultural centers, and colleges. Polish radio stations help keep an ongoing interest in the language, music, and culture. Cultural Communication Patterns Poles use touch as a form of personal expression of caring. Touch is common among family members and friends, but Poles may be quite formal with strangers and health-care providers. Handshaking is considered polite. In fact, failing to shake hands with everyone present may be considered rude. Most Poles feel comfortable with close personal space, but distances increase when interacting with strangers. First-generation Poles and other people from Eastern European countries commonly kiss “Polish style”—that is, once on each cheek and then once again. For Poles, kissing the hand is considered appropriate if the woman extends it. Two women may walk together arm in arm, or two men may greet each other with an embrace, a hug, and a kiss on both cheeks. To Poles, love is expressed through covert actions and displayed easily in the form of tenderness to children. However, loving phrases are uncommon among adult Polish Americans. Poles praise others’ deeds and good works, but they may be reluctant to acknowledge how they feel about one another. These behavioral variations may have persevered through generations of assimilated Poles. Acknowledging the hostess is important when Poles visit one another’s homes; bringing flowers or candy is always in good taste. Normally, guests are discouraged from assisting the hostess in the kitchen or with cleanup after meals. After the event, thank-you letters and greeting cards should be sent to demonstrate an appreciation for the host’s hospitality. Many Polish Americans consider the use of spoken second-person familiarity rude. Polish people speak in the third person. For example, they might ask, “Would Martin like some coffee?” rather than “Would you like some coffee?” Although the first expression might sound awkward, the latter expression may be considered impolite and too informal, especially if the person being asked is older. Many Polish names are difficult to pronounce. Even though a name may be mispronounced, a high value is placed on the attempt to pronounce it correctly. When interacting with others, Poles consider age, gender, and title. For example, when a group is walking through a door, an unspoken hierarchy requires the person of lower standing to hold the door for a woman or those of a higher title. To many Americans, this behavior may seem excessive, but for Poles, it People of Polish Heritage shows respect and courtesy. Polish Americans also use direct eye contact when interacting with others. Many Americans may feel uncomfortable with this sustained eye contact and feel it is quite close to staring, but to Poles, it is considered ordinary. Most Poles enjoy a robust convers…
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