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Wednesday, April 24, 2013

International Mobility and Health

Benjamin Pelletier has another very good post up on his site Gestion des Risques Interculturels.  It is called La santé des expatriés à l’épreuve des risques interculturels (Expatriates' Health Put At Risk by Intercultural Issues.)  In it Pelletier conducts a fascinating interview with Dr. Franck Scola who is a psychiatrist and a certified intercultural mediator.

Dr. Scola has identified certain behaviours on the part of expatriates that put them and their health at risk.  Very interesting and there were a few I hadn't thought of:
  • un écho affectif majoré par la survenue de la maladie ou de l’accident loin de chez soi, (an emotional state that leads to an illness or accident far from home)
  • des consultations tardives face à des symptômes, soit abusivement imputés au mal du pays, soit explorés sans prise en compte du facteur migratoire, (delay in consulting a medical professional even in the face of symptoms that are often mistakenly attributed to homesickness and often examined without taking into account migration as a factor)
  • un excès de confiance dans des conseils médicaux émanant des réseaux d’expatriés et parfois inutiles, retardant plus ou moins les soins, voire même dangereux car erronés, (too much faith placed in medical advice coming from the expatriate network, which can more or less delay care and can be very dangerous if it is erroneous)
  • une négligence vis-à-vis des attitudes préventives, (negligence in preventive behaviour)
  • une confiance partielle envers les équipes médicales des pays d’accueil, et parfois l’attente d’un séjour dans son pays d’origine pour consulter, espaçant la fréquence du suivi. (Only partial confidence in the medical teams in the host country and often waiting for a trip home in order to consult a medical professional which further delays treatment).
I would add to this list a refusal to acculturate or to do so in a very limited way.  Where a migrant is not comfortable with the local language and may be too embarrassed to ask for help (or may not even know anyone who can) he or she may put off seeing a doctor.  There can also be serious misunderstandings about the doctor/patient relationship and who does what.  A very good example of this is my experience in the U.S. where my gynecologists always sent reminders for annual exams and followed up if I did not respond.  That has not been my experience in France and it does not appear to be a standard service offered to patients.  I had to train myself to mark my own agenda.

The "partial confidence" that expats may feel about the host country medical system is exacerbated by pressure from family and friends in the home country to come back to get it checked out or to be treated.  I knew expats in Japan whose families really wanted them home because they had no idea about Japanese medical care and were simply acting on the feeling that French care would be better or less expensive.  I was personally advised by an American acquaintance to return to the U.S. when I was diagnosed because that person genuinely believed I would get much better care and have a higher chance of survival in the U.S.  It is very difficult to tell people who love you and are worried about you that you prefer to be treated where you are.  And, frankly, if things do not go well there is a high likelihood that these people will question the wisdom of your decision.  All this adds another layer of stress.

I have also encountered a certain suspicion on the part of the natives toward people who are obviously foreigners using national healthcare systems.  When you arrive at a clinic and someone makes a sly comment about Brits or Americans coming over to France for the express purpose of abusing the healthcare system, it tends to set one back on one's heels.  You can get a sense that the person (who is supposed to be there to provide care) resents you and it does not encourage you to avail yourself of their services again anytime soon.

These are not minor problems because what is at stake is health.  Every migration story is different but what they all have in common is a leap into the unknown which means there is risk.  Dr. Scola's observations are dead on and he uses his experience and training to work people to mitigate them.  

I definitely could have used someone like him when I first arrived here in France.  I believe that the only reason I am alive today and able to write this post are my intercultural skills and some very hard work integrating.  When I felt the lump in my breast I called the medical center and got an appointment with my doctor, someone that I have developed a close and trusting relationship with and who knows me and my family.  He ordered a scan, the radiologist detected the cancer and in a few short days I was at the cancer clinic for a biopsy and a consultation for a course of treatment. It went flawlessly - I was taken in hand quickly, efficiently, and compassionately.  Being able to communicate in French with my doctor and my oncologist was a necessary but not sufficient condition for being able to actively participate in my treatment. There were also expectations to manage, a working together framework to develop, and the understanding that not all of our communication was explicit and clearly stated and learning when it was necessary to ask for clarification.  All this stretched my language skills and cultural knowledge to their absolute limit.

If this had happened to me in the first few years of living here or if I had not learned the culture and language sufficiently well to be comfortable and at ease, I believe that I would be dead or dying in a hospice right now.  In the early years I did many if not all the things Dr. Scola identified as risky behaviour. 

Today I feel that  I am a very lucky woman because I was diagnosed after nearly 20 years in this country but I would suggest that you not rely on luck.  Stuff happens and living abroad does not exempt you from life's odd twists.  I do not know how to stress enough that "later" (when you've learned the language or have recovered from the stress of moving) may be too late.  Read Pelletier's post and, if you see yourself in it,  start making some phone calls.  The house can wait and the job can live without you for an afternoon.  Hire a translator or ask someone for help if you're not comfortable doing it by yourself.  Be open to learning about your new environment.  Be a sponge, be "teachable."  This is definitely a situation where a lack of intercultural skills can kill you.  

And remember that if you don't have good health then the exciting job, the house, the thousand and one responsibilities and that long "to do" list become completely irrelevant very quickly. 

Believe me, I know.

(And for another very good article, Mr. Pelletier has a 2011 post on Pratiques interculturelles en milieu hospitalier which I wish I had read before I actually did end up in the hospital...)


Tim said...

Isn't there this place too.

I knew someone who lived in Neuilly Sur Seine. Big money place.

Victoria FERAUGE said...

@Tim, Oh yes, the American Hospital is very well known.

Honestly I've never been there - just never lived anywhere near it and it has a rep for being very expensive.

I just checked and it is a hospital non-conventionne which means that social security won't cover everything (some but not all).

Anonymous said...

Good post. And you are well educated, informed, and speak French well (although you likely learned a vocabulary that we all hope we never have to learn). The situation for immigrants with lower education background and language skills is that much harder. Some studies in Canada as well on health and new Canadians that show similar patterns.

One challenge, particularly in North America, is that the healthier diets of original homelands get corrupted by poor nutrition habits here, resulting in obesity, heart disease etc rates rising.

Victoria FERAUGE said...

Thanks, Andrew, and you added some important points to the discussion.

Socioeconomic status does matter a lot. There are classes available for people who want to learn French but they are not always accessible to people who work very long hours and can't get time of work. The cost is also a factor. While I was waiting for my work permit I took classes at the Alliance Francaise in Paris and they gave me a good start. Not everyone has that opportunity.

And thanks for mentioning how a change in the diet impacts health. I was reading Jared Diamond's book , The World Until Yesterday, and he talks about how Western diets in another context have terrible outcomes.

I've found Pollan's rule of thumb, "Don't eat anything that your great-grandmother wouldn't recognize as food" to be a good answer to this. Not just for migrants but for the native population whose habits have degraded over the past few generations.