Bridging a cultural divide

Carmel Salhi

[Winter 2010]

Are better tools needed to identify emotional distress in non-Western refugees?

More than 17,000 Iraqi refugees arrived in the United States in 2009, carrying the deep physical and emotional scars of war. Many are widows with young children. Some have been tortured. Highly educated, for the most part, many expect to obtain professional positions like those they left behind, but find that in the current economy, even low-wage jobs are hard to come by.

With their lives hanging in the balance, Iraqi refugees, like other dislocated populations, are at risk for severe mental health problems such as post-traumatic stress disorder, depression, substance abuse, or suicide. But as overstretched and underfunded resettlement agencies struggle to help them, the symptoms of deep problems may slip by unobserved and untreated.

According to HSPH doctoral student Carmel Salhi, these emigrants represent a serious public health challenge. Western psychological research may not connect with the ways in which displaced Arab populations perceive their own well-being and exhibit symptoms of distress, he says. To find out, Salhi is planning to conduct field research for his thesis with Iraqi refugees in the Boston area, analyzing data from previous studies about Iraqi mental health and seeing how the findings match up.

“You can do any number of epidemiologic studies, and discover which disorders are most prevalent, but interpreting how they’re actually experienced by people requires a deeper understanding,” he says. “I want to do research that can be used, as opposed to research that answers interesting questions but fails to apply to real experiences.”

Researchers such as Theresa Betancourt, Salhi’s adviser in the Department of Global Health and Population, have noted that symptom checklists used by mental health workers to diagnose behavioral and emotional problems in the United States can be misleading or inappropriate in other cultural contexts. Social researchers commonly draw from these diagnostic tools when crafting surveys for epidemiologic studies.

During an internship in Beirut while a master’s student at HSPH, Salhi observed a range of problems with the surveys, from concepts that simply don’t translate to invalid assumptions about gender behavior. Asked to help lead a youth focus group for an urban health study, Salhi, who is fluent in Arabic, noted a colleague’s adjustment to one of the standard survey questions: “Do you feel blue?” “If you asked that literally in Arabic, you would be asking, ‘Do you feel the color blue?’” he says.

The picture he gleaned from speaking with the boys was the opposite of what he had anticipated. Rather than acting out aggressively when they were sad, the boys were able to talk about their emotions. They also experienced frightening dreams about their family’s safety, a symptom thought to be more common in girls, Salhi says. Assisting with data analysis on Betancourt’s study of Chechen refugee youth, Salhi observed a similar phenomenon. He and his colleagues found that support from the community, family, friends, or a significant other had a measurable protective impact on the boys’ mental health, though, surprisingly, it didn’t seem to be a factor for the girls.

Salhi plans to develop what he hopes will be more culturally sensitive questions for his thesis project. He’ll be spending time with a core group of Iraqi families, observing the hurdles they face in their daily lives and conducting interviews both with them and with other local Iraqi refugees. He will then analyze data from other studies looking at pre- and post-displacement risk factors for mental illness in Iraqi refugees, comparing their findings with his own.

Salhi’s passion for understanding the experiences of displaced Arabs has deeply personal roots. Born in Syria to Palestinian and Jordanian parents, he moved with his family at age 3 to Dearborn, Michigan, a community with the densest Arab population outside the Middle East, living in the shadow of a Ford Motor Company factory.

“Difficulty breathing was really common in my neighborhood,” Salhi says. “I lived downwind from the factory and we weren’t able to play outside as much as the other kids, because we coughed and wheezed.” When he was in high school, an accident at the factory took the lives of several of his friends’ parents and left others severely injured. And he noticed early on that even in this community where they were the majority, Arabs were treated differently. These experiences led him to make connections between race, socioeconomic status, and health, he says.

“Since September 11, there has been a lot of great work in the social sciences showing the ways that Arab immigrant and Arab Americans’ experiences are unique but also parallel to other marginalized communities. I want to bring that perspective into the public health realm,” Salhi says. “I have a thousand questions and a thousand areas that I think are really important. But if I had a multimillion-dollar grant, that’s where I would start.”

Amy Roeder is the Development Communications Coordinator in the Office for External Relations at HSPH.

Photo: Kent Dayton