Keywords

The first step in understanding the cultural beliefs of diabetes is to build an emic cultural beliefs model. Studies on the cultural beliefs of diabetes have been carried out across many cultures using different approaches (Adejoh, 2012; Arcury et al., 2004; Caballero, 2005; Luyas et al., 1991; Weller et al., 1999). Following the steps of Weller et al.'s (1999) study of diabetes among American Latinos, first, I collected free lists of the causes, symptoms, and treatments of diabetes for Arab American Muslims using the methods detailed in Chap. 4.

This study advances the work of Jaber et al. on diabetes among Arab Americans in Dearborn (Jaber, Brown, Hammad, Nowak, et al., 2003a, 2003b; Jaber, Brown, Hammad, Zhu, et al., 2003a, 2003b; Pinelli & Jaber, 2011) and develops a cultural model of diabetes. Being an Arab American Muslim with diabetes presents unique challenges that are not present in other US ethnic groups. For example, observant Muslims fast for a month each year for Ramadan and have many dietary restrictions, including the avoidance of alcohol and pork. In addition, Arab American Muslims in Dearborn, Michigan, have immigrated from war zones such as Syria, Lebanon, Yemen, and Iraq, which adds a layer of complexity to their health; this will become apparent in the data.

This chapter answers the following questions: What are the cultural beliefs about diabetes among Arab Americans in Dearborn, Michigan? Specifically, what do Arab Americans in Dearborn understand to be the causes, symptoms, and treatments of diabetes? How do people with diabetes manage fasting during Ramadan?

5.1 Causes, Symptoms, and Treatments of Diabetes

The process of creating a cultural model begins by specifying a semantic cultural domain for diabetes. A cultural domain is “simply the subject matter of interest, a set of related items” (Weller & Romney, 1988, p. 9). In this research case, the cultural domain includes the causes, symptoms, and treatments of diabetes among Arab American Muslims. Chapter 4 details the methods and techniques used in the collection and analysis of the causes, symptoms, and treatments of diabetes.

5.1.1 Causes of Diabetes

The participants in this study (N = 31) listed a total of 34 items for the causes of diabetes. Table 5.1 shows the free list of statistics calculated using ANTHROPAC (Borgatti, 1996). In analyzing the free list, two things must be explained: (1) the frequency (i.e., how many times an item was listed; shown in the second column in Table 5.1). and (2) the salience (i.e., how early an item was mentioned in a list; shown in the fourth column of Table 5.1). The salience was calculated using Smith’s salience index (Smith, 1993). The more important and most shared items were mentioned earlier in the list.

Table 5.1 Free list descriptive statistics for causes of diabetes (N = 31)
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As shown in Table 5.1, the causes of diabetes list has at least 12 core items, where core means that the items were listed by at least three participants or 10% of the respondents (Bernard, 2017). Those 12 items include the following: runs in the family, unhealthy diet, lack of exercise, obesity, eating sugary food, eating too much sugar, stress, high level of blood sugar, high blood pressure, pregnancy, alcohol, and eating fast food.

As mentioned in Chap. 4, as each participant listed the items, they were encouraged to explain what they meant exactly and were told that they could discuss each item listed if they had specific stories to share. Of the 31 participants, 12 said that at least one person in their family had diabetes; thus, many stories were told about the item “runs in the family.” Table 5.2 shows responses for the question, do you know someone with diabetes? One participant claimed to know at least five diabetics family members or friends, two knew four, and the others knew 1–2. Regarding their relationship with the known diabetic, they listed the following: mother, father, brother, grandparent, uncle, aunt, cousin, niece, and friend.

Table 5.2 People they know who have diabetes (n = 12)
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The second most frequently listed cause of diabetes was “unhealthy diet.” Each time a respondent listed unhealthy diet or any type of food that can cause diabetes in their list, they were asked what they considered to be unhealthy and to provide examples of foods that people with diabetes should not eat.

A participant from Yemen (F1Y188) said, “People who have diabetes should be on a special diet. Eating food that has a lot of sugar can cause diabetes.” I asked the participant for her opinion regarding two famous Yemeni dishes (staples in every Yemeni home) that are made up of flour, oil, salt, and plenty of honey; other participants listed this as an example of unhealthy Yemeni food. She said,

“It’s heavy on the stomach, but maybe good, not sure.” In addition, people listed other examples of unhealthy foods such as chocolate, cake, sweets, pizza, fries, burgers, and packaged foods.

It is important to highlight here that honey has a significant cultural relevance, especially among Yemenis, and many participants mentioned that elderly members in their family start their day with a glass of water mixed with honey, even if they are diabetic. Instead, other participants mentioned that they stopped eating it after realizing that US honey is not pure and has added sugar, unlike Yemen honey; thus, honey in the United States “can’t be trusted.”

On the other hand, the city of Dearborn has no shortage of food options. West Warren Avenue is one of the city’s main streets where one can find all types of restaurants, coffee shops, grocery stores, and bakeries run by Arab Americans from Lebanon, Iraq, Syria, and Yemen. One of the busiest and most famous bakeries in the area is located on West Warren Avenue, and it has become a regular, if not daily, gathering place for Arab Americans. Fresh Lebanese traditional sweets, fruit juices topped with custard, nuts, honey, locally made ice cream, cake, chocolate, and pastries are on offer. When asked about diabetes, Participant M1L269 explained his struggle with having daily access to this type of food:

If you don’t want diabetes, work at an Arabic bakery . . . you know how I don’t have diabetes? I don’t eat anything from my work . . . while I am there working. When you see the same food every day, you don’t want it anymore. People always ask me in the bakery how I stay fit. I say, “just don’t eat it”. . . yeah, if you don’t want to get fat and have diabetes, then don’t go to the bakery with all the sweets and cakes . . . it’s impossible!

So, what should people with diabetes eat? Participant F1Y191 said, “People who have diabetes should eat a healthy diet, like eating chicken, green tea, salad, Samak [fish in Arabic], and hummus.” Another participant, F2Y186, said, “My dad does not eat sweets, he only eats bananas.” When asked about the type of food people with diabetes should eat, participant M2L183 responded, “They should eat salad, lettuce, carrots, fish, and chicken breast.” Participant F2Y197 suggested replacing sugar in coffee or tea with honey.

Six people mentioned “high levels of stress” as a cause of diabetes. When I asked them about the causes of stress, the reasons included the following: financial difficulties, missing home, immigration status, fleeing war, and losing family members. Participant F1Y191 said,

My mom got diabetes because my family was going through a very bad time. We had debt, and we were financially struggling to pay it. Also, at the same time, my brother got shot [in Dearborn], and my mom was really stressed at the time. He is fine now.

This story was not different from or unique to the other stories, where participants listed stress as a cause of diabetes. Arab Americans in Dearborn are mostly made up of people coming from war zones, leaving their countries of origin with almost nothing. The data show that Fleeing war has a tremendous effect on the mental health of Arab Americans and, therefore, a large consequence on their physical health. As F1L376 said,

People that are coming from war-torn areas—their bodies are very stressed. We see hypertension in 14- and 15-year-olds; this is not what we see among the general population. So, if we compare Arab Americans to regular Americans, Caucasians, that’s not going to work. That’s never going to work; the numbers are too skewed.

One of the other themes accrued during the interview was related to the relationship between stress and faith. Based on the data, Arab Americans have religious and cultural beliefs that affect the way in which they perceive illness or even think about the possibility of having an illness such as diabetes. During the interviews, most participants recited “in God well” and “in Allah’s hands.” Based on the data, in most cases, having a strong faith helps tremendously in dealing with the stress related to having diabetes, but in a few cases, it seems that faith can be used as a reason for refusing to receive treatment, thus trusting in God’s power to treat them.

In addition, people listed a lack of exercise and obesity as causes of diabetes. When it comes to obesity, it cannot be understood without linking unhealthy diet (covered above) and physical activity. Many participants described a decrease in physical activity after immigrating to the United States, saying, “we don’t feel safe walking to places,” “the weather is so cold,” and “we leave the house to visit who? I don’t know anyone here.”

5.1.2 Symptoms of Diabetes

The participants (N = 31) listed 45 symptoms of diabetes. As shown in Table 5.3, 15 items were mentioned at least three times. These included the following: dizziness; headache; fatigue; weight loss; dehydration related; fainting; feeling tired; sweating; weight gain; high blood pressure; shaking; dry mouth; weakness; foot, hand, and joint pain; and vision problems.

Table 5.3 Free list descriptive statistics for symptoms of diabetes (N = 31)
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Participants listed 15 items when talking about symptoms of diabetes, but “fainting” was one of the symptoms that prompted the most stories. Participant F1Y191 said, “We found out that my mom had diabetes after she fainted after feeling very tired, and we took her to the doctor; her sugar levels were not balanced.” Participant F2Y197 told a story about her grandmother’s symptoms of diabetes, saying, “One time, we were at a park, and the weather was so hot. She got sweaty and dizzy, and we immediately gave her pop; her blood sugar was really low.”

Participants also shared stories about “eye problems” or “vision problems.” Participant F2Y215 said, “My aunt had two surgeries, including one in her eyes because she had water in her eyes; also, her kidney used to hurt a lot, all because of diabetes.” In addition, Participant 2F1I313 said, “My grandmother lost her vision; she can’t see anymore. For a long time, she has had diabetes, the doctor said, but we didn’t know. She hates going to the hospital.”

Participants mentioned that another symptom of diabetes was tiredness. As some explained, the feeling includes the inability to finish daily tasks without taking a break to lay down, napping, and watching TV instead of doing anything else. According to the participants, this can cause worse diabetes complications because it results in decreased physical activity and weight gain.

5.1.3 Treatments of Diabetes

The participants (N = 31) listed 20 treatments for diabetes. Out of the 20 treatments listed, six were mentioned at least three times: taking medication, maintaining a healthy diet, exercising, getting tested, eating less sugar, and eating sugar (Table 5.4).

Table 5.4 Free list descriptive statistics for treatments of diabetes (N = 31)
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When analyzing the narratives based on the free lists for the treatment of diabetes, two points stood out. First, when people listed “medication” in their lists, they were asked if they had specific stories about diabetics taking their medication. Participant F1Y191 said,

My grandmother takes insulin shots. She does not take care of her insulin shots; she throws it in a sunny room all day, and she uses the same needle more than one time instead of using it one time only, which she must do. Also, my grandmother injects herself with different insulin quantities without thinking of how much she needs.

While visiting one of the Arabic pharmacies in Dearborn, I chatted with an Arabic pharmacist who told me about her experiences with diabetics and her struggles getting people to take their medication:

Non-complaints, drives me nuts! They don’t take their medication. They say things like “My sugar was not that bad, I didn’t eat anything sweet. I’ve been watching my diet. God will protect me, and it’s in God’s hands.” Nonsense . . . nonsense, but this is how it works. They ask questions like, “Do I have to take it every day?” There are some . . . I don’t want to say they are stupid. “Can I give this to my neighbor? Can I use my neighbor’s insulin when I run out? If I stopped sugar, can I reduce the number of shots?” I had a patient who took 60 units every night; he stopped sugar on his own, so he lowered his unit to 13. It’s amazing that he did not have a stroke.

The second major theme that emerged in the narratives was people not knowing they had diabetes until they went for their regular checkups or visited their doctor for a reason other than diabetes. The item “getting tested” was listed as one of the steps to treat diabetes. When I asked people to tell me more about that, Participant F1Y191 said,

My mom had diabetes before coming to America. She was in Yemen, living in a small village. She got pregnant and lost two children. She lost the first baby because she got internal bleeding one day . . . she was bleeding so badly, I remember seeing the blood; it was awful and scary. We thought she was going to die. We took her to a doctor; she lost the baby, and the doctor told her she has type-2 diabetes. This is when she first learned about her diabetes. She was only 32 years old. Also, she lost the second child after she gave birth; the baby was too sick and died.

Participant F2I205 told me that her cousin did not know she was diabetic until she got tested after discovering she was pregnant. Her cousin gave birth to a healthy child but now has diabetes for life. In addition, the participant listed “getting tested” as a treatment for diabetes and said, “When my aunt got older, she got diabetes. She went for a regular checkup and found that she got it, so now she is watching her diet and taking medication.”

In addition to the lists of the causes, symptoms, and treatments of diabetes, participants were asked questions related to who can have diabetes who is susceptible to diabetes, the fear of having diabetes, the severity of diabetes, experience of fasting in Ramadan while having diabetes, diabetes family care, diabetes health-seeking behaviors, and diabetes healthcare access. The questions were driven by the theoretical framework of Kleinman (1988) discussed in Chap. 1. The following sections of this chapter will cover each subject in detail.

5.2 Who is at Risk of Diabetes?

Following the interview guide, all 31 participants were asked the following: who is at risk of diabetes? Are some people at a higher risk of having diabetes than others? Why? I used probes such as age, weight, and sex to elicit more comparison.

Out of the 31 participants, 28 thought that age had an influence, as people are more likely to get diabetes as they age. Participant F2I205 said, “The older the person is, the body weakens so that they have more chance of getting diabetes.” Only three people did not think that older people have a greater risk of getting diabetes. Participant F1L192 said,

I mean, you have people that are in their 90s and healthier than people in their 20s, so it all goes back to taking care of yourself and being as healthy as possible. So, if I don’t take care of myself, I can be in my 90s; heck, I can be in my 60s and dying. For someone taking care of themselves, they can last until their 90s, and they are healthier than me. So, it goes back to, when you were young, how you took care of yourself.

Most people agreed that obesity can increase the risk of having diabetes. Participant M2Y204 said, “People with heavy weight have more sugar stored in their body and therefore have more chances of getting diabetes.” Participant F1Y244 shared her fear of her sister’s obesity and the possibility of having diabetes:

My sister is 10 years old now; she is fat . . . the only thing she does all summer long is eat and watch TV; she does not move or do anything. I always tell her, “Please move, you will have diabetes,” but she does not listen. A few days ago, we took her to the hospital for a test; we don’t know yet if she has diabetes or not. I am really worried about her.

Two people did not think that weight gain necessarily leads to diabetes. Participant F1Y191 said, “Weight does not necessarily contribute to diabetes; it more likely depends on health... if someone has diabetes in the family, a high level of stress, and a bad diet.” Participant F2Y203 shared this opinion: “It’s not necessary; you can be skinny and have diabetes or overweight and have diabetes.”

Do women or men have a greater risk of having diabetes? All participants, except for one, agreed that it does not matter: both men and women are equally vulnerable to diabetes. The one who disagreed, Participant M2Y204, said, “Men have more chances of getting diabetes than women. Men do whatever they want to do; they don’t listen, and women are more likely to take care of themselves.”

5.3 Fear of Having Diabetes

What do people fear most when it comes to having diabetes? During the first stage of the interviews (N = 31), each participant was asked to discuss what the people around them feared most about having diabetes and what they would fear most if they personally had diabetes.

Out of the 24 participants who answered the question, 12 people mentioned that they and the people around them are most worried about the inability to eat whatever they want. Participant M1L269 said,

What people are most afraid of, in my opinion, is not being able to eat freely and control what they eat. People don’t want to be told what to eat. You know, us Arabs, all we do in the house is eat, so you want the person who has diabetes not to eat like everyone in the house! It’s hard. They want to eat just like everyone else; for them, it must be like fasting all the time . . . not being able to eat whatever they want.

Participant M2Y204 expressed his fear about diabetes and food by saying, “I fear not being able to eat as much sugar as I want.” In addition to sugar, other participants mentioned the fear of having to stop eating fast food or junk food and drinking coffee in the morning. Furthermore, Participant M2Y231’s response to the question suggests an additional diet management difficulty for older people who have or might have diabetes:

The worst thing people fear about having diabetes is not being able to eat what they want. Older people—maybe overseas more than here—can feel neglected. Older people—especially overseas but also here—find it harder to stick to a diet. They just don’t want to give up, like in Yemen, where older people eat assal baladi [honey in English] every single day . . . so they don’t listen when they are told not to do so.

In addition to diet, four people feared that diabetes could lead to death; five mentioned fears about having to exercise more and increase their physical activity; two mentioned the fear of having to take medication on a daily basis; two mentioned the fear of losing their vision; and one feared the possibility of passing diabetes on to her children in the future. Regarding loss of vision, Participant F1Y244 said, “I fear losing my vision; losing my vision means staying home and not doing anything.” When discussing the fear of other diabetes complications, Participant F1Y191 said,

My uncle does not want to have diabetes; when my mother is checking her blood at the house, he asks her to check for him, too. He thinks that because he is the oldest brother in the family, he will probably get it. He does not want to have an illness and has problems like my mother: fainting and going to the emergency room.

Only Participant F1L192 did not have any fears; she said, “I know a lot of people might be saying, ‘Oh my God, I have diabetes,’ and get stressed about it. I think people are ignorant, and they fear what they don’t know.”

I also asked the participants the following questions: What does diabetes do to the body? What does diabetes do to the body of the person who has it? How does diabetes work? Will it have a long or a short course? When I asked these questions, 21 participants responded. For the first and second questions, 10 said they did not know exactly how diabetes worked in the body, and two said that diabetes can cause health complications. Participant F2Y197 said that “their body does not produce more insulin. People start to have health complications... diabetes affects their kidney and pancreas. My grandfather’s feet got swollen. He went and saw a doctor; now he wears special socks.” Participant F1Y188 said that “when people have diabetes, the body becomes weaker; they can’t do certain stuff like physical activities.” Participant F2I205 said that when it comes to the effect diabetes has on the body, it causes people to have high levels of sugar in their blood. Participant F1Y244 added that “diabetes makes you fat; my dad goes to the gym. It does not help; he is still fat because of the insulin he takes. My aunt is fat, too.”

In response to the question about diabetes’ effect on the body, Participant F2Y186 said that it increases the level of sugar in the body. In addition, she stated that people with diabetes “get very tired when they do too much work.” Many of the participants did not have a clear understanding of diabetes’ effect on the body.

When asked if people can cure themselves of diabetes, out of the 21 participants who answered the question, 11 did not know, two thought that diabetes can be cured, and eight thought that it cannot be cured. Based on this, it is clear that people understand diabetes in the context of its symptoms and complications more than its effect on the body. Furthermore, knowledge about the possibility of a cure seems to be limited among the participants.

5.4 Severity of Diabetes

Twelve people answered the following questions: How severe is diabetes? Can diabetes cause death? Out of the 12, nine people thought that diabetes can be severe and can cause death if people do not take care of themselves. Participant F2Y203 said, “It can be severe; people can make it severe by doing all of the things that cause it and not eating right.” Other participants mentioned that refusing to take medication can result in increased severity of diabetes. Participant F2Y215 said that diabetes can increase in severity and even cause death for the following reasons: “people not watching their health as they used to, now always on their phones, not moving much, and using elevators.” Participant M2Y204 stated, “I don’t think that diabetes is severe; it’s not like AIDS, but eating so much candy can lead to death.”

Only one participant did not think that diabetes can cause death, and Participant F1L192 thought that death can be caused by anything. She said, “Anything can be severe; it’s just luck with some things, you know? I think anything can cause someone to die.”

Overall, participants thought that the severity level of diabetes depends on how well diabetics comply with their medication regimen and take care of themselves, which includes eating a healthy diet and increasing their physical activity. Furthermore, participants seemed to understand that the increased health complications caused by diabetes can lead to death.

5.5 Fasting in Ramadan

In Dearborn, the month of fasting, Ramadan, is unlike any other. The city sees dynamic changes. During the day, the streets are empty, and businesses are closed. The streets come alive at night, as restaurants and coffee shops open late to accommodate those attending Iftar (the meal eaten after sunset to break the fast). Long lines of people wait for their turns at the buffet in restaurants, and passers by can smell and see busy outdoor hookah lounges with loud Arabic music and smoke.

Ramadan is known for its feasts. Breaking fast begins with water and dates, followed by all types of traditional foods. People then snack for hours on sweets, tea, and Arabic coffee. One day in Ramadan 2017, I ate at an Iftar buffet in one of the Lebanese restaurants in Dearborn. I arrived 15 min before sunset, chose a table, and sat down. The restaurant was already packed. I saw at least 25 tables filled with families and even some with at least three generations sitting together. The tables had dates and water on them, and all I could hear were people talking about what they were going to eat.

A group of Arab American men in their 60s and 70s was sitting next to my table. They discussed how they were going to get their food from the buffet. One of them said, “Let’s line up from now so we get our food first.” The second said, “I will get a big plate of rice and lamb to share before anyone, and you guys get the rest.” They argued about what to get in addition to the rice and lamb and even stopped the waiter to ask him what dishes were available in the buffet. As I continued to observe, these men were not the only ones with this plan. Lines started to form in front of the buffet, even though it was still too early to break the fast. Everyone was ready with a plan.

When it came time to break the fast, the tables were filled with food, but no one ate immediately. Everyone was looking around, making sure that it was indeed time to break the fast and they were not the first ones to eat. This awkward situation happens for several reasons. In the Middle East, breaking the fast happens immediately after the sun goes down and the sunset prayer call goes out from the mosques on their loud speakers. In Dearborn, you cannot hear the prayer calling, so you are limited to Islamic websites that publish the time for breaking the fast. The time for this announcement changes by a few minutes each day, according to the actual time of the sunset in each location and is difficult to keep up with. Therefore, if you are in a restaurant and do not have access to the Internet, the best option is to wait for someone near you to eat first so that you can save yourself the embarrassment of eating before the appointed time. After a few awkward looks, everyone began eating. The men next to me ate about 20% of what they got from the buffet, and leftover food was noticeable on everyone’s table. One of the men said that he needed to take his medication and that he was feeling tired and sleepy. The other men suggested going to smoke hookah for the rest of the night.

After the Iftar, I left the restaurant and went to the Arabic bakery on West Warren Avenue. As I arrived in the parking lot, street parking was almost full. People were lining up to buy sweets, children were running around playing, and families were sitting and chatting at full tables. I saw many of the same families from the restaurant I had just eaten at. We looked at each other and smiled, sharing an unspoken understanding: “Great minds think alike: Iftar is best followed by sweets.”

Thirty-one participants were asked the following questions: How do people with diabetes survive Ramadan? What are their struggles? Do people think that it is possible to fast? How do families accommodate a person with diabetes when having Iftar?

People with diabetes who want to fast during Ramadan must consider whether their medication needs to be taken during the hours of fasting or not. If they need to take their medication in the daytime, they cannot fast during Ramadan. Many of the stories my participants shared demonstrated diabetics’ fasting struggles during Ramadan.

Limiting physical activity and resting are a couple ways diabetics cope with fasting for long hours. Participant F2Y186 said, “My dad does fast; he sometimes gets really dizzy, so he does not do a lot; he prays, sits all day, and takes naps.” Participant F2Y197 said, “Although the doctor told my grandmother that she should not fast, sometimes she fasts. She wants to keep her pride, you know. So, she sleeps or lays down the whole time.” Fasting in this case is a sign of strength and ability, not of weakness and inability.

Participant M2Y231 shared an experience he had with his friend:

My friend was working in the kitchen on Ramadan, and then he was dizzy and fell down, fainted. We tried to put water on his face, but he did not wake up. So, we called 911. He was taken to the emergency room, and doctors told him not to fast again. This is after fasting for 2-3 days. So, he did not fast after that.

In addition to the struggle of fasting during Ramadan, evidence from the narratives suggests that families do contribute to the diet management of diabetic family members eating meals with them. Participant F1Y191 shared how her mom copes with Ramadan and the food choices she makes:

My mom can fast in Ramadan, but the first two or three days, she gets very tired. Also, when she makes sweets, she does not use a lot of sugar. For example, in Mahalabia [pudding], she does not use sugar at all. Our whole family is now used to eating Mahalabia without sugar.

What do people do if they cannot fast during Ramadan, especially because fasting is one of the five pillars of Islam? Participant F1Y191 provided this insight on community practice: “When my mom or dad can’t fast, they give zakah [amount of money] to the local mosque or they send it back home and tell someone back home to give it to people in need.” This practice of giving alms is one of the most important obligations in Islam and is known among Muslims across the world, though it is not necessarily practiced by all. Participant M2Y231 has a friend who cannot fast during Ramadan because of his diabetes. I asked if the friend was doing anything to make up for the days he was not fasting. The participant answered, “No he does not pay zakah or anything like that, I just don’t think he thought about it that deep, you know.”

“Let’s make it simple and easy,” Participant M2Y204 said, “Everyone is tired in Ramadan,” implying that anyone with diabetes can simply do what they want. Still, ethnographic data show that one of the main struggles for people with diabetes during Ramadan is managing their diets when they have limited physical activity all day and are confronted with feasts after Iftar. Giving alms to charity as a penance for not fasting indicates an added layer of stress for those in this position.

5.6 Family Role in Diabetes Care

As noted earlier in this chapter, the roles of the family in providing care for diabetic members are not limited to food management. Out of the 31 participants in the first stage of data collection, 29 agreed that diabetes not only affects the person who has it but also everyone around them. Participant F1Y191 said, “I feel bad for my mom [who has diabetes]. When she is tired, I try to help her with housework.” Participant F1Y244 stated that her responsibilities toward her father increased when he was diagnosed with diabetes: “I need to take care of my father, listen to him when he is complaining, call the doctors, drive him to the doctor, and all that.” She added, “Feelings affect everyone; physically, only the person who has diabetes is affected.” Participant F2Y203 emphasized a similar point: diabetes “is not a virus,” so it is not contagious, but the responsibility of taking care of a person with diabetes is a task for everyone around them.

Participant F2Y197 noted that as the diabetic ages, their care becomes more challenging. She said, “Diabetes affects people around the sick person, especially when they are old; my grandparents don’t know when it’s time for insulin, so we keep reminding them.” Participant F1Y188 said, “If they [people who have diabetes] are old, the family needs to remind them to take their medication.”

In addition to the care that families provide to diabetic members, diabetes can bring financial stress to the rest of the family. Participant M2L183 said that “diabetes affects people around them, like the payment of medical bills.”

Only two participants in my sample (N = 31) did not think that family effort is required. Participant M2Y204 stated, “Diabetes only affects the person who has it,” and then told me to make sure to write, “Take care of yourself.” He explained that he does not think that anyone should care for other people in the family; every member should be able to take care of themselves.

Some patterns in the type of care provided are worth noticing here; female participants’ support for diabetic family members involves in-home care, such as preparing food, medication management, scheduling appointments, and accompanying them during doctor visits. For male participants, support was mostly related to the financial backing required to pay for medication. This reflects the classic role of women and men in Arab culture, which I elaborate on in Chap. 3.

5.7 Diabetes Health-Seeking Behaviors: When is It Way Too Much?

As shown above, some of the data suggest that diabetes was not discovered until visiting the doctor for a casual checkup; in other cases, the data also suggest there is a tendency among Arab immigrants, especially recent immigrants, to go to the hospital “way too much” or more frequently than they used to in their country of origin. But would this not be beneficial? Is it better to be “safe than sorry” and go to the doctors as much as possible? Why would some immigrants go to the hospital and others refuse or prefer not to go?

The data suggest that Arab Americans’ behavior of seeking medical treatments falls within two main categories. The first category includes people who tend to see doctors way too much. Participant F1L376 explained the reasons driving this behavior in her own opinion:

There is, for some reason or the other, a lot of people who come with the old-school mentality of war, and so they come from war-torn areas. People are coming from the Middle East, specifically Syria, Iraq, and Yemen—all these areas—because they made it out of war, I think they panic . . . they start to panic, saying, “I made it out of war; let’s make sure my health is okay,” so they overdo it.

Going to the hospital is positive in the sense of being safe, but it may have other negative outcomes. First, during the interviews, many participants shared the struggles they experience with their family members during their hospital visits, such as difficulties driving them to their appointments, especially during work and school hours. In addition, going to the hospital too much requires more appointments and visiting medical facilities with more frequency. This can put pressure on the medical system, especially when it comes to doctors who speak Arabic in Dearborn. This is because most recent immigrants, or even first-generation immigrants, prefer an Arab doctor because of the language barrier and the shared culture.

The second category in health-seeking behaviors is related to people who refuse to seek medical help. During the interviews, many participants outlined why someone with diabetes, or any other chronic illness would not go to the hospital, and it all came down to two main reasons: (1) they view a chronic illness to be a sign of weakness; and (2) they have limited understanding of the illness. First, chronic illness as a sign of weakness is an outlook that is more apparent among Arab men. The Arabic culture places Arab men in a position where they should be “strong” and “unbroken,” which is jeopardized by the prospect of an illness; therefore, they tend to avoid the hospital or delay visits as much as possible. Second, regarding the lack of understanding of the illness, during the interviews, many participants expressed their struggles when it comes to monitoring their diabetes and receiving medication for the rest of their life. One of the participants, a pharmacist, described this gap in knowledge as such:

Patient knowledge is what is missing; a lot of doctors depend on the pharmacy: “You have diabetes, I am going to give you insulin, and this is how you take it,” and bam! So, when they get here, they say, “Oh, I have diabetes” . . . “Do you know what that means? Do you know the details? Do you know the steps going forward?” None of them know.

5.8 Diabetes Healthcare Access: Arab American Doctors’ Availability

Finding an appointment with an Arab doctor is not an easy task. One of participants said, “We have Arab doctors here. The problem is that they are so overwhelmed; they are not even taking new patients now.” The question here is, why do Arab Americans prefer to visit Arab doctors over non-Arab ones. The data provide two main reasons: First, first-generation Arab Americans have difficulty communicating due to language differences. Having an Arab doctor eases these challenges and ensures mutual understanding between doctors and patients. The second reason that they prefer to see an Arabic doctor is related to the fact that the doctors are familiar with the patients’ cultural beliefs and behaviors.

Having a shared culture is important with regard to choosing a doctor, as it might affect the healing and diagnosis processes. One of the participants shared a story about her sister who had a non-Arab doctor when she was being treated for cancer. She said that her doctor did not know that her sister was taking traditional medicine, which negatively affected her health. She said that Arab doctors ask if their patients use traditional medicine before anything else because it is a common practice among Arabs.

An Arab pharmacist described an additional motive, other than cultural beliefs, to see an Arab doctor. She said,

We are sending the overflowed to other cultures that do not have an accurate understanding of this, especially people coming from Syria, Iraq, Yemen, and Libya. All these places have conflict issues, so they’re coming with a lot of PTSD, a lot of mental issues, so there is no ground to understand . . . because, for example, if you have a doctor from India, I know they have their own conflicts, but it’s not the same as with people coming here, you know . . . or a Chinese doctor is not going to fully understand or even encompass with someone who is coming from the Middle East.

This shows that shared cultural beliefs and an understanding of the political and social struggles of the Middle East are important in choosing doctors to Arab Americans.