| Vietnamese | |
| Cultural Profile |
Pamela LaBorde, MD, with special thanks to Binh
Duong, Program Manager, Division of Refugee Assistance at the
Department of Social and Health Services, Olympia, WA, and many
Vietnamese community members.
July 1996
Vietnam occupies the Eastern coast of the Southeast Asian peninsula. It is bordered by the South China Sea on the west and south, China to the north, and Laos and Cambodia to the west. The terrain of Vietnam is varied, with mountainous regions, thick forested areas, and lowlands leading down from the rugged mountains to coastal plains and river deltas. Major Vietnamese cities include Hanoi in the north, Da Nang in the mid coastal region, and Ho Chi Minh City (formerly known as Saigon) to the south.
Vietnamese culture is very complex, in part due to the participation of many groups in Vietnamese history. The earliest known inhabitants of the Indochinese peninsula were Austronesian tribes that migrated north from the islands of the South Pacific. The Khmer (people of Cambodia) are thought to have migrated east from India, the Laotians came from the highlands of China's Yunan province, and the Vietnamese came south from the lower Yhangtze valley. The newer arrivals settled in the rich delta areas and coastal regions, forcing the Austronesian peoples into the mountains. Their descendants formed the diverse mountainous tribes. Many of these exist today.
The first Vietnamese believed they were the descendants of a dragon and an angel. They brought their economy based in rice farming with them from China. Rice production requires complex irrigation and collective farming, which led to the development of a strong sense of community in Vietnamese villages. Their first recorded history begins in 208 B.C. when Trieu Da, a defiant Chinese general, established his own empire of Nam Viet, which included northern Vietnam. Later, in the 1st century B.C., the Han dynasty expanded and incorporated Nam Viet into the Chinese empire as the province of Giao Chi. This was the beginning of a long Chinese occupation and domination. Despite more than a millennium of Chinese occupation, the Vietnamese retained a strong and separate identity. There were numerous revolts against the Chinese (two of the most legendary in 40A.D and 248 A.D. were led by women), but none found lasting success until the tenth century Emperor Dinh Bo Linh called this new state Dai Co Viet (the Kingdom of the Watchful Hawk) and won Chinese recognition of independence with regular payments of tribute.
In the fourteenth and fifteenth centuries, the Vietnamese themselves became expansionists and they conquered Champa, an Indianized kingdom in central Vietnam. This campaign depleted the Vietnamese kingdom's resources, and they again fell to the Chinese, this time to the harsh rule of the Ming dynasty. Again the Vietnamese revolted and won independence under Le Loi, a Vietnamese cultural hero. This independence lasted for the next four hundred years. The initial years of this period saw the establishment of unusually liberal legal codes that protected ordinary people from mandarins and allowed women to own property.
A lack of political cohesiveness between the north and south is not a recent development. The Mekong delta, which had been under Cambodian control, was seized in the sixteenth century by a Vietnamese clan who was constantly fighting a clan to the north. This conflict divided Vietnam at about the seventeenth parallel (the same division between North and South Vietnam in the twentieth century) and lasted for the next two hundred years.
The Portuguese were the first Europeans to sail to Vietnam in the mid-sixteenth century. Lather the Dutch and English established small trading centers. The Catholic church, first through the Portuguese and later through the French, won many converts among the Vietnamese, despite many emperors' efforts to eradicate the religion.
Significant French influence in Vietnam started in the seventeenth century. In 1627 a French missionary adapted the Vietnamese language to the Roman alphabet to create a writing style called quoc ngu. By the mid nineteenth century, the French had gained control of Vietnam. Throughout French occupation there were pockets of Vietnamese resistance, but the efforts were not unified.
Under French rule, Vietnamese were second-class citizens. Even the highest ranking Vietnamese made less than the lowest ranking Frenchman. Many people were displaced from their lives as rice farmers and forced to work under horrible conditions in rubber plantations and coal mines. Though a Confucian system of education was well established, this was replaced by a French system where students had to read and write French or quoc ngu (even though about 80% of the population was literate with Chinese ideographs). It was during this time that resistance to French occupation solidified, and a young man named Ho Chi Minh formed his nationalistic ideals.
In 1941, Ho Chi Minh formed the Vietminh in northern Vietnam to fight both the French and Japanese for control of Vietnam. During this period, the French backed emperor, Bao Dai, recanted allegiance from France to Japan and proclaimed independence. Loyalties were rapidly shifting, and Japan soon transferred support from Bao Dai to the Vietminh. Bao Dai abdicated his throne. When Japan surrendered to the Allies following the second world war, Ho's Vietminh declared independence. This independence was brief as the British soon landed in Saigon and returned authority to the French. With the Japanese retreat, the Chinese had invaded the North, but withdrew in 1946. While France was planning to reoccupy the North, Ho proclaimed a separate government for Vietnam, violating a previous agreement with France. Fighting broke out in Hanoi. Ho then retreated to create a rural northern base.
Bao Dai, with the support of France, returned to Vietnam, but by 1954 the French withdrew following defeat by the Vietminh. In an attempt to end the conflict, the 1954 Geneva accord divided Vietnam along the seventeenth parallel into North and South. Bao Dai's government in the south denounced this division. Ngo Dinh Diem, prime minister under Bao Dai, recruited US monetary aid. Soon, the US was training the South Vietnamese army. In 1955, Ho began accepting Soviet aid in the north, heightening the US interest in the South. During this time, Diem held a referendum to defeat Bao Dai and declared himself president of the Republic of Vietnam (the South). In 1964, the Tonkin Gulf resolution was passed by the US Congress, leading to increased US participation.
As the fighting continued, the Vietcong (a Vietminh backed communist group) attacked the South with guerrilla warfare. Among the chaos, many isolated groups arose in opposition to both the Vietcong and Diem. Eventually Diem was murdered by his own staff. The US continued to support the South Vietnamese succession of leaders including Gen. Duong Van Minh, who staged the coup against Diem. The final leader of the south was Nguyen Van Thieu. With no permanent end in sight, US troops retreated after the signing of a cease-fire agreement in 1973. Fighting soon resumed, and in April 1975 Thieu fled to Taiwan. Communist forces took Saigon days later.
The Vietnamese people who worked with the US government or who sympathized with the South feared for their lives once Thieu lost power. In 1975, 130,000 Vietnamese fled to the US with the collapse of the Thieu regime. They escaped with the help of the US, and were mostly young, well educated, English speaking, urban dwellers. 55% were Catholic, and many were able to bring their families intact. Most were kept at relocation centers on US military bases until sponsors were found to help them resettle. This is referred to as the first wave of immigrants.
The second wave of refugees was a more diverse group. It included people with differing ethnicity's, nationalities, religions, and languages. As a group, these people were less educated, less literate (in Vietnamese and English), less familiar with western ways and thoughts, and more rural than those in the first wave. Due to the Vietnamese invasion of Cambodia, military offenses against the hill people of Laos, and the continued anti-Sinitic policy of the new Vietnamese government, 455,000 refugees from SE Asia settled in the US between 1979 and 1983. With relations between China and Vietnam deteriorating, and with the ethnic Chinese remaining in Vietnam being persecuted, at least 500,000 fled from 1977 to 1979. During the second wave, escape attempts were long and arduous, only half those attempting escape are thought to have survived. Hoards of people attempted escape by boat. Travel by boat was filled with peril, many died due to disease, mishaps on overcrowded boats, or at the hands of pirates. Those in Northern Vietnam boated to Hong Kong or to nearby Chinese provinces. From these destinations, many came to the US. Others stayed in Hong Kong, where Vietnamese are currently being held in camps with repatriation to Vietnam planned when Hong Kong returns to Chinese control. Those escaping Vietnam from the South boated to Thailand, Indonesia and the Philippines. Some spent years in internment camps in these countries prior to entering the US. Of those who survived, many suffered malnutrition, disease, and horrible treatment at the hands of camp guards.
A third wave of refugees arrived from 1985 to 1991 and continues to arrive in small numbers. This group included both Vietnamese and ethnic Chinese people who were brought to the US through family reunification programs. Additionally, in 1988 and 1989, the US government negotiated the release of political detainees held in "re- education" camps. Many people in this wave spent years in camps under devastating conditions.
Rural people of the second wave are less likely to speak languages other than Vietnamese. Some have difficulties learning to read and write a second language because as farmers, many were not literate in their native Vietnamese. If they had learned to read and write, they seldom used these skills. Local Vietnamese-American Associations and others have established ESL programs in the Seattle community.
Vietnamese has three basic dialects, all are generally understood by most Vietnamese speakers. It is a tonal language with six basic tones. It is very different from English; verbs do not change forms, articles are not used, nouns do not have plural endings, there are no prefixes, no suffixes, no definitives and no distinction among pronouns. Its complex vocabulary reflects basic cultural values, for example, there are two forms of the verb "to eat", used for people of higher or lower status.
Many refugees of the first wave are bilingual. Older urban people may speak some French, and those who had government jobs in South Vietnam speak some English, or are even fluent.
Many customs are rooted in both the Confucian respect for education, family and elders, and the Taoist desire to avoid conflict. Vietnamese tend to be very polite and guarded. Sparing one's feelings is considered more important than factual truth. Many alter these practices in the US, especially when dealing with non-Asian people.
Traditionally, Vietnamese people list their family name first, then their middle name, with their first (given) name listed as last. Family members use different given names (first names aren't passed down), and the name reflects some meaning. Most names can be used for either gender. Many in the US have adopted western customs of naming.
Vietnamese culture is concerned more with status (obtained with age and education) than with wealth.
"Thua" (meaning please) is added in front of the first name to show respect. To show respect, Vietnamese will bow their heads to a superior or elder. When talking, one should not look steadily at a respected person's eyes.
To address people formally, use Mr. or Ms. or a title plus the first name. There are several titles of respect in Vietnamese, but they aren't used in English.
Women do not shake hands with each other or with men.
Many may greet by bowing slightly to each other, they may join hands. Usually, higher ranking people are greeted first (the family head).
To avoid confrontation or disrespect, many will not vocalize disagreement. Instead of relaying negative communication, people may not answer a question.
It is disrespectful to touch another person's head. Only an elder can touch the head of a child.
Praising someone profusely is often regarded as flattery, and sometimes even mockery. Most people are very modest and deflect praise.
Insults to elders or ancestors are very serious and often lead to severed social ties.
Many will smile easily and often, regardless of the underlying emotion, so a smile cannot automatically be interpreted as happiness or agreement.
Vietnamese often laugh in situations that other cultures may find inappropriate. This laughter is not ridicule or beratement.
Breaking a promise can be a serious violation of social expectation. It is very difficult to re-establish a lost confidence.
When inviting a friend on an outing, the bill is paid for by the person offering the invitation.
Vietnamese may not take appointment times literally, and will often arrive late so as not to appear overly enthusiastic.
When giving gifts, often the giver discounts the item, even though it may be of great value. The recipient of a gift is expected to display significant gratitude that sometimes lasts a lifetime. Some may be reluctant to accept a gift because of the burden of gratitude. Vietnamese may refuse a gift on the first offer, even if they intend to accept it, so as not to appear greedy.
Speaking in a loud tone with excessive gestures is considered rude, especially when done by women.
Summoning a person with a hand or finger in the upright position is reserved only for animals or inferior people. Between two equal people it is a provocation. To summon a person, the entire hand with the fingers facing down is the only appropriate hand signal.
Influenced by Buddhist theology and Confucian philosophy, Vietnamese believed that fate in marriage, as well as wealth and position, were preordained, though choice could play some role in activating a positive or negative fate. Traditionally, children lived with their parents until marriage, then the couple moved to the husband's father's household. The extended family arranged marriage, but individuals were usually consulted on the choice of their mate. The typical engagement lasted six months, with little contact between the bride and groom prior to the marriage. Traditionally the marriage was at one of the couples' homes. Men usually married between 20 and 30 years, and women at 18 to 25 years. Women kept their maiden names legally but used their husband's name formally.
As western influence increased in Vietnam during this century, parents began to take more of an advisory role in the choice of their child's mate, and arranged marriages are starting to decline. In the US, most young Vietnamese date in the same way as American youth. Though rarely given absolute choice, family still bears heavy influence over the decision to marry. There are a variety of different wedding practices, most common in Seattle are Buddhist and Christian ceremonies. Divorce is uncommon, even in the US, and is considered shameful, especially for the woman. Many Vietnamese community leaders in the US are concerned about the growing divorce rate. In Vietnam, a man is responsible for his spouse until death.
In Seattle, most still wish to marry within the Vietnamese community. It appears more acceptable for a Vietnamese man to date a non-Vietnamese woman. Vietnamese women are seen by more traditional community members as "bought" when dating white or African-American men.
Based on Confucian tenets, men have higher status than women, and sons are valued more highly than daughters. Traditionally, an ideal man should develop through four steps. First, he must learn how to cultivate himself and next, to govern his family. If he does this successfully, he can rule the country, and pacify the world. To do this he must be merciful and kind, adhere to the rites and ceremonies of family and social hierarchy, help the needy, be strong and determined, and be trustworthy and loyal.
A traditional Vietnamese woman is governed by three basic tenets from Confucianism. First she must submit to her father, next obey her husband, and then if widowed, obey her eldest son. She is considered "virtuous" if she is an effective homemaker, a good cook, and has the appearance of modesty coupled with feminine grace. Ideally, she is soft spoken, and above reproach for her moral conduct. In reality, in Vietnam and in the US, mothers are not docile. The mother is considered the home minister (noi tuong) and is responsible for family harmony, the family budget, and family schedules. She also makes decisions with the father.
Tasks were divided along gender lines in Vietnam; fathers typically worked outside the home. With the war, many men were absent from the home and women took on more independence out of necessity. This trend has continued with migration to the US. Many of the jobs available in the US were of lower status and fit the expectations of refugee women, but not of refugee men. Refugee men have been forced to take work with less status than they could have done in Vietnam. This has created a situation where many families are dependent on the income of the mother, causing readjustment of family roles and expectations. Due to the effect of migration and Western influence, traditional gender roles are changing, and Seattle families display varying degrees of traditionalism.
The traditional Vietnamese family is patriarchal, patrilineal, and patrilocal, often with two to four generations under one roof. There is the immediate family (nha) and the extended family (ho). In Vietnam, the immediate family is the nuclear family plus the husband's parents and the grown sons' spouses and children. The extended family is the immediate family plus family members of the same name and relatives residing in close proximity.
Family members are expected to work and behave for the good of the group. Families may publicly denounce a member who is ill behaved, they may also pronounce family achievements. Each member has a designated kinship term, and these are used when addressing one another. The father has ultimate responsibility and acts as an authority leader while delegating tasks and involving others in decision making. The father also leads the family in ancestor worship. In Vietnam, the father often worked outside the home, while the mother cared for the children and managed the household. Grandparents helped with childcare, and children helped with various chores. Younger siblings are to respect and obey older siblings, and aunts and uncles are treated as parents.
In the US, household structures vary greatly. One study of refugees in Oklahoma City showed 57% of households were only nuclear families, 12% included extended family (grandparents, etc.), 13% were people living alone. Another study elsewhere showed more households included extended family than nuclear families. The population of Vietnamese in the US is young; the median age for males and females is in the low twenties. Also, Vietnamese-American families appear to be the only group of Asian-Americans with a significant number of families headed by women (14.2%). Many of these women are war widows, were separated in flight from Vietnam, or have husbands still in Vietnam.
The elderly parents are taken care of until they die.
Most women in Seattle seek conventional prenatal care when pregnant. Traditionally, it is shameful and dishonorable to the family if pregnancy occurs in an unmarried woman. Therefore, women who are pregnant outside of marriage may deny signs of pregnancy or try to hide the pregnancy from family members. Abortion is not openly discussed, but women in Seattle may seek medical abortion or use a Chinese herbal formula.
In Vietnam, husbands would never be present at their child's delivery. For Vietnamese in the US, this varies and some men do attend deliveries. When a child is born it is considered one year old.
Women whose medical beliefs are based on Chinese medicine often refuse to bathe, drink juices or water, or wash their heads in the post partum period so as not to upset the hot/cold balance of their body. The thought is that blood, which is hot, is lost through delivery, so the body is at risk of becoming too cold or of getting too much air.
Nothing written for EthnoMed at this time
Most Vietnamese women breastfeed their infants for the first 6-12 months (both in the US and in Vietnam). This can be difficult when they work outside the home and such women may stop breastfeeding sooner than they would in Vietnam. Children are often delayed in weaning from the nursing bottle to the cup until 2 years of age. This may result in an iron deficient diet.
"Children sit where their parent's place them." This traditional Vietnamese expression characterizes the Confucian based parent-child relationship. Though parents in Seattle have adopted various degrees of western parenting styles, they take their responsibility to teach their children very seriously. The first priority is to teach filial obedience and respect, the second is to provide as much educational success as possible. In many homes, homework must be completed when arriving home from school, and television is only allowed on the weekends. If the parents don't feel the teacher is providing enough homework, they may make homework assignments themselves, or write questions for the child to answer.
In Vietnam, corporal punishment was the norm. In the US, parents are aware that this is not commonly accepted and they have had to change methods of discipline. Some parents state their children are harder to control here than they would have been in Vietnam and are frustrated that their children seem to lack respect for their elders.
Refugee families have had to deal with many issues in adapting to their new home. In Vietnam, elders were the leaders in families, had the strongest influence in decision making, and were respected and sought after for advice. Younger family members were to be obedient and respectful. Also, elders held property rights of the family, and could retire once their children could support the family.
When these elders were transported to the US, they lost their property and much of their material goods. Many elders who want to work outside the home are unable to because of their lack of training for available work, their age, and lack of English skills. They can become very socially and culturally isolated while their younger family members become more Americanized. This can create a fundamental role reversal: the elders no longer have power, money or land, and become financially dependent on their children. Because they are culturally isolated, they are no longer sought after for advice. This creates much tension in families where elders feel ignored and disrespected, while their children become more culturally proficient and adapt ways their elders do not approve of.
Vietnamese Boys is currently one of the largest Seattle gangs (probably more than 50 members). They commit burglary and auto thefts and usually use their own "fences" within the Asian community. They are thought to participate in heroin trafficking, though use of heroin by gang members is not common and is thought of as "weak". Many gang members have tattoos signifying affiliation. They are very secretive, and it can be difficult to elicit any information about gang activity. Even concerned parents may be very hesitant to discuss gang involvement of their children. One interviewee stated that "you can hire the gang members to do bad things".
Many Vietnamese are lactose intolerant as adults so do not consume much milk. The traditional diet is mostly rice, fish, and vegetables, plus pork or chicken when available. In the US, most older people still prefer a traditional diet, though more meat is available than was in Vietnam. Many parents complained during interviews that their children eat poorly, preferring western fast foods with few fruits and vegetables. The vegetables available here are similar to those in Vietnam, but the fruits are very different. In Seattle's international district, there are several Vietnamese markets that carry more traditional foods.
See related Nutrition and Fasting in Vietnamese Culture
Traditionally, women do not smoke in public, and public drunkenness is a disgrace. Alcohol use seems to be increasing among adolescents according to several people interviewed. Rates of smoking are very high among Vietnamese men in the US (41.7% in Vientamese men in Washington state in 1989 - MMWR 41:1992;pp 854-856.)
In Vietnam there are many religions and this diversity extends to the US. Confucianism underlies many Vietnamese traditions shared by people of various religions.
This was the predominant religion in Vietnam, practiced by an estimated 90% of the population prior to the war. In Seattle, the majority of Vietnamese are Buddhist. There are two main forms in Vietnam. The southern Hinayana believe only monks and nuns can achieve enlightenment, while the northern Mahayana believe laymen can attain enlightenment as well.
More a code of behavior than a religion, it emphasizes filial piety and obligation, altruism and the belief that man creates his own destiny. Music, respect for authority (including teachers), and social rites are very important.
Founded by a Chinese philosopher, Lao-tzu, this religion teaches that the goal of becoming an Ultimate and Unconditioned being can be achieved through thrift, humility and compassion. Taoists may worship many gods, and value simplicity, patience, and contentment. They avoid confrontation and strive for harmony both between men and between man and nature. Some Taoist groups also worship deities or other religions. They have an organized clergy and temples. Though many Vietnamese do not practice this religion, Taoism has strongly influenced Vietnamese culture.
Introduced in late sixteenth century by Portuguese, Spanish and French, Catholics in Vietnam have intermittently suffered persecution. Before the collapse of South Vietnam, an estimated 2 million people (of a population of 17 million) practiced Catholicism. This is the religion of many first wave refugees.
Many Vietnamese practice animism (worship of spirits and natural forces), ancestor worship, astrology, and are very superstitious. Older refugees in the US continue these practices and beliefs, while many younger people in the community do not. Cao Dai and Hoa Hoa are both sects with little influence.
Tet is the Vietnamese New Year, celebrated on the first day of the first month on the lunar calendar, usually between January 19 and February 20. It symbolized new beginnings, with various rituals added by different religions. In Vietnam, Tet was a time to pay debts, forgive others, improve self, and make friends out of adversaries. The celebration lasted three days, beginning at home. The first day was to be with family and pay respect to one's ancestors. The second day was in honor of teachers, and the third day was to visit friends. Most families saved throughout the year for Tet, houses were cleaned, decorated, and even repainted. Large expense was put into the celebration to ensure that the new beginning was a positive one. Buddhists in rural areas would erect bamboo poles and drape amulets from them to repel evil spirits.
The celebration of Tet has continued in the US. Older Vietnamese think of Tet very traditionally, while many younger Vietnamese think of Tet as a time for food, friends and parties.
Death
Rituals in Vietnamese Society
A personal story by Dieu Hien Hoang.
Vietnamese Buddhist
- Medical Examiner Encounter
A perspective about death taken from conversations with community
members.
Added August 2003: Traditional Vietnamese Medicine: Historical Perspective and Current Usage
These practices vary greatly between ethnic groups. The mountain dwelling Mien and H'mong groups intertwine medicine and religion. Sickness is believed to come from the wrath of the gods. The physician is a priest who negotiates with the gods to remove the sickness. These priests are considered superhuman, and if they fail to alieve the illness it is not their failure, but the will of the gods. Conversion to Christianity and urban living has lessened the use of shamans (even before flight to the US), but the belief in external causes of sickness remains. Often, these groups resist invasive techniques, and see a physician who does not intrude on the body as the best healer. Women from these groups often refuse anesthesia for childbirth.
The lowland peasant groups and urbanites from Vietnam employ a medicinal system based on Chinese medicine. This system is based on the premise that living things are composed of four basic elements, air, fire, water and earth with the associated characteristics of cold, hot, wet and dry. This hot/cold belief system is common to many Vietnamese, regardless of their educational status or occupation (rural vs. urban). Many see traditional herbal remedies, tonics, massage, and avoidance of excess as the pathway to good health.
Dermabrasive procedures based on hot/cold physiology are often used to treat cough, myalgia, headache, nausea, backache, motion sickness, and other maladies. Cutaneous hematomas are made over the face, neck, anterior and posterior trunk (sparing the genitals) to release excessive air. These are made in many different ways; by pinching and pulling on the skin, by rubbing oiled skin with the edge of a coin or spoon (cao gio), or by cupping. Cupping (Giac hoi or hut hoi) is done by heating the air in a cup with a flame, then placing the cup onto the skin. As the air cools, it contracts and pulls on the skin, leaving an ecchymotic area.
Moxibustion is a technique used mostly by Mien cultures. Small circular superficial burns on the torso, head, and neck are made by igniting combustible material placed on the skin or with sticks of burning incense. This is often combined with acupuncture.
Acupuncture is used widely (in Vietnam and the US) for musculoskeletal ailments such as arthritis pain, and for stroke, visual problems, and other ailments.
Typical associations made by Vietnamese:Traditionally, mental illness is a shameful thing among most Vietnamese cultures. Because of this shame, mental illness is often feared or denied, and those who are ill are hidden away by their families until the family can no longer care for them. In Vietnam, the mentally ill may be taken to hospitals and abandoned. The hill people think of mental illness as bad karma that has accumulated because of misdeeds done in past lives. Due to the stigma of mental illness, many refugees tend to somatizice and will avoid referrals to mental health clinics. Mental health practitioners in Vietnam often use placebo medication to gain the trust of their patient and meet the patient's expectations.
"Western medicine" in Vietnam consisted of many things, mostly antibiotics, Vitamin B12 shots for "feeling bad", and IV fluids.
Many Vietnamese had severe health problems on arrival to this country as a result of poor living conditions during the war and in camps, little access to health care, injuries, starvation, and abuse. Problems suffered in this population include TB, hepatitis B, malaria, malnutrition, conjunctivitis, trichinosis, anemia, leprosy and intestinal parasites. Once arriving in the US, poverty and crowded living conditions still pose health risks, along with under- utilization of health care.
One survey of Southeast Asians done at the University of Washington Refugee Clinic showed that many continue to use traditional methods of healing in this country. The continuance of native practice seems to be linked more to rural (increased traditional practice) vs. urban living prior to migration than to the length of time in this country. Many Vietnamese (especially elderly) do not trust western medicine and use it only as a last resort. Many use traditional remedies in parallel to western health care, but may be reluctant to reveal this to a western provider.
There are several western trained Vietnamese physicians practicing throughout Seattle. Their practices tend to serve mostly Vietnamese people. Others in the community seek care at Harborview and public health clinics. Several of the Vietnamese doctors' office staff I spoke with stated that time is not a priority in Vietnamese culture as it is in US culture, and it is often difficult to get patients to arrive at appointed times. Vietnamese doctors seem more understanding of this than non-Vietnamese.
Though the numbers are unclear, many refugees suffer from PTSD, depression, anxiety, psychosis and adjustment reactions. In traditional Vietnamese culture it is not acceptable to discuss stress or emotional disorders, so many with these disorders present initially with somatic complaints.
There are many cultural barriers to care in the US. Laura Uba characterized these barriers in a 1992 publication, as summarized below. Many Vietnamese interviewed in Seattle agreed that these factors are relevant to this community.
Many see suffering and illness as an unavoidable part of life. Some also feel (the H'mong in particular) that the length of one's life is predetermined, and life prolonging or saving care is futile. Also within the community, stoicism is a highly respected personal trait which can prevent people from seeking care.
Etiology of Illness: Illness may be attributed to organic or physical problems, an imbalance of yin and yang, an obstruction of chi (or life energy), a failure to be in harmony with nature, punishment for immoral behavior (in this or past lives), or a curse placed by an offended spirit. Most Vietnamese believe in organic causes of illness unless there is an obvious upset of supernatural forces, while most H'mong believe minor illness is organic but serious illness is supernaturally caused. Though immigrants may wish to use a shaman or spiritual healer, they can be expensive. Also, they are not easy to find in the US, and since many specialize in different types of disorders, one may not be able to find the right healer for their malady.
Distrust of Western Medicine: Many seek western health care only after more traditional methods fail. Also, many know people who have used western care and died anyway. Rural people have had less exposure to western medicine and distrust it more than those who were urban dwellers prior to arriving in the US. Many think physicians should be able to diagnose a problem in the first visit by looking at the patient and feeling their pulse. They do not understand the concept of using further techniques for diagnosis. They may think procedures are meant to cure or alleviate pain, and feel frustrated when, for example, they still cough after the X-ray. If they feel the procedure is ineffective, they may not seek further care or return for follow up.
Resistance to invasive procedures: Many believe that surgery upsets the soul or can actually cause one's spirit to leave the body. Some think injections may hurt the spirit, and therefore be hesitant to receive immunizations. Resistance to venapuncture is common for fear of upsetting the hot/cold balance. Also, during the war, peasants thought that when military doctors drew their blood, it was being given to the US troops to strengthen them. Many less educated people do not realize that the body can make more blood, and believe venapuncture will weaken them.
Beliefs about Asian physiology: Many Vietnamese believe that Asian people have a very different physiologic constitution than white people. Western medicines are thought of as "hot" and too potent for SE Asian physiology. Therefore, western drugs, doses, and interventions may not be seen as appropriate for Asian bodies. Thus, Vietnamese may not take medicines as prescribed, may shorten the duration or decrease the dosage. If symptoms resolve or no effect is seen, patients may discontinue medication.
Poor physician-patient communication: Southeast Asian cultures value politeness, respect for authority, and avoidance of shame. Because of this, many will not ask questions, will not voice disagreement or concern, and will not reveal intentions or actions that seem in contrast to the physicians wishes. If patients disagree or do not understand, they may simply listen and answer yes in respect, then not return for further care or comply with recommendations.
Community Structure: The Department of Social and Health Services Division of Refugee Assistance estimated the population of Vietnamese refugees in Washington to be 37,352 in 1994. Of this, 30, 558 live in King County, and 5,770 live in Pierce County. Thurston, Spokane, Snohomish and Clark counties all have from 1000 to 2500 refugees.
Refugees from Vietnam include a heterogeneous group of people other than Vietnamese. The divisions and prejudices have continued with relocation to the US.
Chinese: The Chinese occupied Vietnam for almost one thousand years, leaving a large ethnic Chinese population in Vietnam. This population spoke Chinese, and was mostly urban. By the turn of the century, about 745,000 ethnic Chinese had settled in the cities of Saigon and Cholon, playing a major role in trade throughout the last 100 years. Many Vietnamese harbor anti-Chinese sentiment and see Chinese as untrustworthy, especially in business.
Cham: With a pre-war population of about 30,000 centered in South Central Vietnam, the Cham had Hindu and Islamic influences. In Vietnam they were associated with Malay people and looked down upon. This has continued in the US.
Montagnards: (French for mountaineers). This group was made up of an estimated thirty tribes, or 800,000 people, prior to the war. They lived in the mountains of Northern and Central Vietnam. The groups were migratory hunters who practiced some rice cultivation. During the war they were often linked to the CIA by the Northern army, and were marked for annihilation by the North Vietnamese government. Many fled to the US.
Khmer: (Mostly associated with Cambodia). About 500,000 lived in pre-war Vietnam. They maintained their own language, customs, and religion, though many intermarried with ethnic Vietnamese. Most lived in the south around the Mekong delta and adopted Vietnamese customs in addition to their own. They were generally accepted by mainstream Vietnamese.
Fall 2002, (6 page pdf file)
Many Vietnamese people have adopted western customs, but it is important to remember that these customs are not necessarily internalized, especially by older refugees. It seems that the Vietnamese community in the US has a mixture of western and Vietnamese beliefs. Nguyen Quoc Tri summarized and compared American versus Vietnamese philosophy as follows: Americans generally believe that human nature is evil but perfectible; that humans should have mastery over nature; they live oriented to future time; they are accustomed to movement, migration and mobility; they value accomplishment, individuality and self-reliance.
In contrast, Vietnamese traditionally believe that human nature is basically good but corruptible; that man should strive for harmony with nature; they live oriented to the past, not the future; they are traditionally attached to one place, the ancestor's land; they value the process of being or becoming, mutual dependence and lineality.
Buchwald D, Panwala S, & Hooton TM: The Use of Traditional Health Practices by Southeast Asian Refugees in a Primary Care Clinic. West J Med 1992 May; 156(5):507- 511.
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