People of Egyptian Heritage. People of Filipino Heritage. 700 WORDS MINIMUM

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Chapter 28

People of Egyptian Heritage Afaf Ibrahim Meleis and Mahmoud Hanafi Meleis

Overview, Inhabited Localities, and Topography Overview Egypt, the country of origin of Egyptian Americans, has a landmass of 386,900 square miles (about one and a half times the size of Texas) and a population of over 82 million people, giving it a population density of over 177 per square mile. More than 95 percent of the land is barren desert, resulting in 90 percent of the population’s living on 3 percent of the total land area, in the Nile Valley and Delta (CIA World Factbook, 2011). The Nile has been and still is significant in shap- ing life and living patterns in Egypt. The average annual rate of population increase is 1.75 percent, with a birth rate of 22.94 per 1000 and an infant mortality rate of 25.2 per 1000 (CIA World Factbook, 2011). The capital, Cairo, has almost 11 million people, followed in population by Alexandria with 4.3 million people (CIA World Factbook, 2011).

Egypt is bordered by Libya on the west, Sudan on the south, the Mediterranean Sea on the north, and the Red Sea and Israel on the east. The eastern re- gion, across the Suez Canal, is Sinai. Egypt’s climate is hot and dry most of the year. The average daily temperature on the Mediterranean coast is 68°F with a maximum of 88°F, and in Aswan, average temper- atures are 80°F but can reach 120°F with little or no humidity. The Mediterranean region receives most of the country’s annual rainfall (7.5 in.). The northern summers are balmy with moderate temperatures and 80 percent humidity. Between March and April, khamsi winds blow in from the Western Desert at up to 93 miles per hour. Except for a few hills outside Cairo, Egypt has a flat terrain on both sides of the southern Nile valley and the Sinai Peninsula. The Nile River, a main artery for Egypt and an orienta- tion point for its terrain, runs through the center of the country from south to north to the Mediter- ranean Sea. The Nile—considered to be Egypt’s lifeline—provides water and supports agriculture.

Egypt is considered by many politicians, historians, and social scientists to be part of 22 Arabic-speaking countries in North Africa. Others write about Egypt as a Middle Eastern country and count its population as Middle Eastern. A review of scholarly literature about Egyptian Americans is embedded in writing that aggregates them with Arab Americans, African Americans, and Middle Eastern Americans, as well as separates them out as Egyptian Americans. Scholarly literature about Egyptians in the United States is limited; therefore, the reader will find citations that reflect a broader geographic territory, which in turn reflects how Egyptians are often connected to or embedded in many Arab, Middle Eastern, African, and Muslim cultures.

This chapter is also based on the authors’ own experiences. Both authors are Egyptian Americans who came to the United States in the early 1960s and observed many Egyptian Americans as they defined themselves within the multiple identities generated by the different groupings, such as generation and length of time away from the country of origin. Both authors have been insiders as well as outsiders to Middle Eastern communities in the United States and glob- ally. They have participated in different community celebrations, experienced immigrants’ grief over the impending or actual death of a family member, pro- vided social and emotional support during times of crisis, and counseled many immigrants. One of the authors has been professionally involved with health care for this population for over 30 years as part of a project that was designed to provide health-care serv- ices to Middle Eastern immigrants in California. Therefore, data in this chapter are from our lived experiences in the two worlds Egyptian Americans claim as their own—Egypt and the United States.

Arab Americans are estimated to number any- where between 1.5 and 3.5 million (Shah, Ayash, Pharaon, & Gany, 2007). Over 80 percent of Arabs living in the United States are citizens (El-Sayed & Galea, 2009).

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bodies, and build elaborate tombs to preserve and pro- tect these bodies for the afterlife. Egyptians also devel- oped the plow, a system of writing, and medical skills such as surgical operations.

The Arab conquest of Egypt around A.D. 641, which spread the Islamic and Arabic culture among the Egyptians, has lasted to this day. The minority (Christian) Copts, who preserved the African-Asiatic language of ancient Egypt, now use the Arabic lan- guage and have been assimilated into the Arabic cul- ture. The Ottoman Turks invaded Egypt in 1517, adding it to their vast empire. While living under Turkish rule, Egypt enjoyed religious and cultural sta- bility because the Turks shared the Islamic and Arabic cultures. In the last two centuries, Egypt experienced invasions by the French, followed by the British in 1882, who remained in the country until 1954. In 1952, an Egyptian army group led by Lieutenant Colonel Gamal Abdel Nasser took control of the gov- ernment and removed King Farouk from power. Since then, Egypt has been an independent state called the Arab Republic of Egypt (CIA World Factbook, 2011).

An influential part of modern Egyptian history is the Arab–Israeli conflict. The conflict between Egypt, as part of the Arab League, and Israel ended in 1979 when the two countries signed the Camp David Accords. Anwar Sadat was the president of Egypt at the time. Egypt continues to be involved in diplomatic efforts to arrive at peace between Israel and its neighboring Arab countries. This long history and the diversity of popu- lations have influenced the value systems, beliefs, and explanatory frameworks Egyptians use in their daily lives and have contributed to the diverse thinking processes they use to resolve issues and conflict. Another important turning point for Egyptians, as well as Egyptian Americans, in their identity and connection to their cultural heritage is the February 2011 revolution that ousted President Hosni Mubarak.

Reasons for Migration and Associated Economic Factors Many Egyptians immigrated to the United States in an attempt to escape economic stagnation during President Nasser’s regime and his failed economic policies that nationalized all privately owned compa- nies and enterprises. The United States offered educa- tional opportunities, career options, and economic incentives that rewarded hard-working individuals. After the 1952 military revolution, Egyptians immi- grated in three main waves. The first wave, in the 1950s, consisted of graduate students who came to the United States to obtain advanced degrees. This was followed by Egyptians who escaped Gamal Abdel Nasser’s regime (Amer & Hovey, 2007). After the de- feat of the Egyptian army by the Israelis in 1967, many of these students, believing the totalitarian military regime of Egypt did not offer hope for

2 Aggregate Data for Cultural-Specific Groups

Egyptians reside in most states in the United States; 2.3 million of Arab Americans reside in 10 states: 1.2 million live in California, New York, and Michigan (Arab American Institute, 2011). New York alone has an estimated number of 405,000 Arab Americans res- idents (Shah et al., 2007). Michigan has a population of 490,000 Arab Americans, and California has the highest number of Arab Americans with a population of 715,000 (El-Sayed & Galea, 2009). Other heavily populated states are New Jersey and Illinois.

Approximately 94 percent of Arab Americans live in major cities, with the top five being Los Angeles, Detroit, New York, Chicago, and Washington, DC. Lebanese Americans are the largest group of Arab Americans living in the United States, comprising 37 percent of the total Arab American population. Egyptians comprise approximately 12 percent of the Arab American population (Shah et al., 2007). However, Egyptian Americans are the largest Arab American group in the State of New Jersey (Arab American Institute, 2011).

Egyptian Americans’ religious affiliations resemble those of others from the rest of the Arab countries. The majority are Christians, and among the Chris- tians are Orthodox (Greek and Copts), Catholics, and Protestants. Egyptian American Muslims who are Sunni are increasing in numbers and represent the fastest-growing religious group among Egyptian im- migrants (Salari, 2002). Ninety percent of Egyptians are Muslims, and the overwhelming majority of these are Sunni Muslims.

Egyptian Americans are diverse in other ways. They come from urban and rural communities, upper and lower Egypt, and diverse educational backgrounds, and they possess a wide range of cultural characteristics in- fluenced by colonialization, occupations, and a variety of immigration experiences that shaped their responses. However, only the most common patterns of responses and experiences of Egyptian Americans with regard to health and illness are presented in this chapter. Diver- sity among Egyptians is not well depicted, and this de- scription does not represent a universal profile. By defining the similarities among Egyptian Americans, we hope to stimulate interest in more systematic schol- arship about this unique community and their lifestyles, health, and health-care practices.

Heritage and Residence In spite of the many attributions of geographic belong- ing to Egypt, the Egyptian people have a strong sense of identity with their country and demonstrate pride in coming from such an old civilization. Egyptian his- tory is inextricably connected to the Nile River and dates back to about 4000 B.C., when the kingdoms of upper and lower Egypt were united by King Menes, who presented himself as a god. The ancient Egyptians were the first to believe in life after death, mummify

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economic recovery, changed their status to immigrant. For most, this ensured a promising future for their children, even though they would have been assured decent positions in Egypt because of their American education.

The second wave of immigration resulted from the heightened mass dissatisfaction, hopelessness, and anger toward the government of the educated and professional community after the 1967 war. A lenient government policy made it easy and safe for anyone who wanted to leave the country, resulting in the largest exodus from Egypt in modern history. In- cluded in this wave were many Coptic and other Egyptian Christians (Shaw, 2000).

The third wave, in the 1980s and beyond, had many more risk takers. They came to seek better lives and forsake the security of government jobs for unknown adventures. They sought new opportunities such as cab driving and working at food outlets in large cities (Meleis, 2002). Some of these immigrants are tempo- rary, others are permanent, and still others are in circular migration (Nassar, 2008). It is important to note here that the terrorist attacks in New York, Pennsylvania, and Washington, DC, and the tragic consequences of September 11, 2001, have rendered many newly immigrated Egyptian Americans vulner- able to profiling and stereotyping in their newly adopted country, the United States. Therefore, a newly acquired sense of stigma tends to influence their pat- terns of responses in ways that were not manifested previously. Long-term effects of this situation on their patterns of behaviors have yet to be studied and un- derstood. It remains to be seen whether the youth Tahrir Square Revolution of 2011 and the referendum in the constitution will instigate circular migration (Medina, 2011).

Educational Status and Occupations Most of the first-wave Egyptian immigrants were highly educated individuals with graduate and post- graduate degrees earned in the United States. Mem- bers of this group were able to obtain teaching and research positions in universities or work in industries. Some joined companies or started their own busi- nesses in the high-technology industries.

Egyptians in the second and third waves were more diverse in their educational backgrounds, although most of them were college graduates. Second-wave im- migrants worked as engineers, physicians, dentists, ac- countants, and technicians; however, some with college degrees initially accepted employment as gas station attendants, cab drivers, security guards, and other blue-collar positions to ensure employment. After improving their language skills and obtaining degrees from American universities, many obtained professional positions. A small minority never achieved an occupational status equivalent to their

original training. Many from this group returned to their home country or plan for such a return.

Communication Dominant Languages and Dialects The dominant language of Egyptians is Arabic, a Semitic language understood by all Arab nationals, who hear it in popular Egyptian movies, songs, and television programs. The written Arabic language is the same in all Arab countries, but spoken Arabic is dialectal and does not necessarily follow proper Ara- bic grammar. A number of Arabic dialects are spoken in Egypt. The Saiidis (Egyptians south of Cairo) have a different dialect from the northerners. The Nubians (who live around and south of Aswan) have another unique dialect, as do the Bedouins, who live in the desert. Despite these different dialects and their dis- tinct vocabularies, neither Egyptians nor Egyptian Americans have any noticeable communication barriers among themselves.

For Egyptian immigrants in the United States, English is the language of communication in business and contact with American society. Within their own gath- erings, they speak a mixture of Arabic and English, switch with great ease from one language to another, and sometimes speak a mixture of Arabic, English, and French. Egyptian social gatherings usually involve large numbers of people, with multiple conversations occurring simultaneously. When they are discussing subjects such as politics or religious issues, the level of excitement heightens and the tone of the speech is sharpened, so an outside observer may mistakenly characterize the exchanges as chaotic or angry.

Cultural Communication Patterns Several values govern interaction patterns among Egyptians. The first is respect (ihteram), which is ex- pected when speaking with those who are older and those in higher social positions. Respect is demon- strated in the Arabic language by differentiation in the words used to address those who are equal in age or position and those who are older in age or higher in position (see Format for Names). A second impor- tant value, politeness (adab) is related to what is ap- propriate, expected, and socially sanctioned. Truth and reality may be sacrificed for what is appropriate and polite. Politeness results in a preference for more indirect modes of communication. Sharing negative news directly or asking for things directly is not polite. Therefore, a poor prognosis of an illness is not immediately shared; calamities should be slowly and deliberately introduced and shared in stages. It is more appropriate and expected that such news will be shared first with other family members who will provide a buffer that helps those coping with and responding to such news.

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Significant value is related to the status of insiders and outsiders, the private and public spheres. Private spheres are reserved for immediate family, some mem- bers of the extended family, and friends who are ele- vated to the status of family. The public sphere includes acquaintances, public officials, and the rest of the world. Those who occupy a public sphere may get completely different communications and versions of the same events or incidents.

Because Egyptian Americans tend to be externally driven, they are concerned about what others think of their behaviors, which are considered a direct reflec- tion on their entire family. Therefore, parents tend to be overzealous and anxious about the good or bad be- haviors of children and adult sons and daughters. These behaviors reflect a measure of how well or how badly parents have raised their children.

Egyptian Americans tend to be in touch with their inner feelings and are highly expressive of them; how- ever, this expression is governed by external orienta- tion, spontaneity, and the differences between private and public spheres. Egyptians in America tend to share problems and the minutest details about their lives with their trusted circle of insiders. However, be- cause they are externally oriented, they tend to look outside for explanations of their feelings, rather than to focus on their own actions. Egyptians tend to be comfortable and generous in sharing ideas and giving advice to others who might be family members or friends. This behavior stems from close family ties and trust that ensures the family will always be there to provide help. Advice is offered (even when not re- quested) out of love, care, and a sense of loyalty to friends or relatives. They do not shy away from becom- ing involved in the problems, trials, and tribulations of those in their private sphere. The extent and depth of involvement is less for those in the public sphere. Al- though these behavior patterns are a part of the lifestyle of first-generation immigrants, second-generation im- migrants may not necessarily maintain them.

Egyptian Americans’ nonverbal communication patterns are expressive. Because their personal space boundaries tend to be small, they stand and sit very close to each other. In spite of their preference for closeness, women and men use personal space bound- aries differently during interactions. Women tend to keep male friends as far away as male strangers. Egyptian Americans speak with expressive words and facial expressions, gesticulating with hands and using body movements. They communicate with their entire body as much as with verbal language. Their facial ex- pressions are mirrors of their internal processes and reflections of their inner evaluations of their situa- tions. They tend to touch each other frequently and easily, and touch is both reflexive and deliberative. For example, they tend to touch others while speaking to solicit attention, concentration, and emphasis.

To demonstrate trust, increase trust, or emphasize a point, they tend to touch each other on the hands, arms, legs, and shoulders. Men, whether strangers or acquain- tances, touch each other. Similarly, it is acceptable for women to touch. Family members and friends of the same gender always hug and kiss on both cheeks. Friends of different sexes normally shake hands. How- ever, traditionally, it is unacceptable for women and men to touch each other. Touch between the sexes is accepted in private and only between husbands and wives, parents and children, and adult brothers and sisters. Levels of religiosity govern the protocols about touching between males and females. The more religious are the individu- als, the more prohibitions exist about touching between males and females.

Devout Muslim men and women do not touch each other; even a handshake is not practiced. In these sit- uations, a head nod substitutes for a physical greeting. Among devout Muslims, only mahrams, those individ- uals who are not permitted to marry (e.g., sisters and brothers) are permitted to greet each other with hugs. Among Christians and Westernized Egyptians and Egyptian Americans, greetings usually include formal courteous hugs and kisses on the cheeks. In Egypt, it is very common to see Egyptian men or women walk- ing in public places holding hands or embracing each other. In the United States, Egyptians are more self- conscious about touching members of the same sex, touching non-Egyptians only on the arm or shoulder as an expression of caring, assuring them that one is

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R E F L E C T I V E E X E R C I S E 2 8 . 1 Eshe Halabi, age 74 years, lives near Cairo, Egypt. She speaks an Arabic dialect, Saiidis, some French, and a little English. While visiting her son and daughter-in-law in the United States, she suffered a bowel obstruction and underwent surgery. She is now 2 days postoperatively and has been pro- gressing without complications. Her son and daughter-in-law have graduate degrees from the United States and speak English well. When her son visits, she complains of fire-like pain in her abdomen. Her son immediately contacted the nurse de- manding pain medicine for his mother. The nurse explained that Mrs. Halabi had received an injection for pain control about 20 minutes previously and that she should give the medi- cine time to work. He said this was unsatisfactory and that she should have the pain medicine intravenously right now.

1. Is the description of fire-like pain common among Egyptians?

2. What other descriptions for pain are used by Egyptians? 3. What response should the nurse give when Mrs. Halabi’s

son demands intravenous pain medicine? 4. What else might the nurse do to assist with pain control? 5. Do you think the son is an adequate interpreter for his

mother in this scenario?

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a friend. Some Westerners may be uncomfortable with these gestures.

Egyptians have their own nonverbal facial expres- sions. A momentary wide-eyed gaze to a child means “stop it now.” A wink to an adult means “watch what you are saying” or “change the subject because you are treading on dangerous ground.” Dissatisfaction is demonstrated by intentionally looking through the person or by avoiding eye contact. Egyptians think of those who do not maintain eye contact or have shifty eye contact as people who should not be trusted. Be- cause Egyptians tend to stand in close proximity to each other, eye contact is automatic for them. How- ever, among those who are more traditional, women and men who are strangers may avoid eye contact out of modesty and respect for religious rules. The situa- tion is different if the communication is between men and women related by marriage or by blood. Children are taught not to tebarrak (stare), which denotes dis- respect for those who are older or higher in status.

Egyptians tend to be congenial and personable, injecting humor to lighten stressful encounters or business meetings. There are differences in the nature of humor between Americans and Egyptians, and these differences may create communication issues. For example, Americans tend to have self-enhancing and self-defeating humor styles. This humor style may be misinterpreted and leave a negative impression on Egyptian Americans. Health-care providers or man- agers using self-defeating humor may be perceived as weak (Kalliny, Cruthirds, & Minor, 2006). They may may exaggerate and overly assert judgments of events and situations for the sake of emphasizing a particular point of view.

An Egyptian greeting involves every person in a room standing and shaking hands within gender norms. Not standing can be considered an insult. A greeting may be just a nod or a few words. Similar greetings are practiced in the United States among immigrants.

Temporal Relationships Older Egyptians cherish the past, remembering the days when life was simple and easy. Reminiscing is a cultural pattern that becomes more prominent with age. Younger Egyptians live in the present, with its de- creased availability of options, and in the future, with its potential, realizing that acquisition of goods comes with a high price tag. Thus, this generation is preoc- cupied with maximizing their incomes, often working two or three jobs to afford luxuries. For professional Egyptian immigrants, working hard has been their ticket to upward mobility and living the good life. It is this generation of young adults living for the present and the future who decided to organize using modern technology to demand more representation and voice in a government that has not been responsive to them.

While social time takes a high priority, engagements are not concluded because of other scheduled ap- pointments, and guests are expected to arrive late, they showed up in masses in Tahrin Square to make their united voices heard.

It is important to note temporal relations in Egypt- ian Americans regarding appointments. If a friend drops by as another is getting ready to leave for an ap- pointment, the appointment is missed and the friend is not told about the prior engagement. Arrival at a social gathering, such as a lunch or dinner, as much as 1 or 2 hours late and to be late for business appoint- ments because of heavy traffic and unanticipated and uncontrolled delays is common. A social custom is to offer coffee, tea, or a soft drink to business visitors. Therefore, a planned 10-minute office visit usually takes more time. Egyptian Americans’ perception of time is in the context of the nationality of the group. Therefore, they follow “American time” and are punc- tual for business engagements and meetings with non– Egyptian Americans but prefer to use Egyptian time for Egyptian American gatherings.

Format for Names In all Arab countries, both male and female children are given a first name, and the father’s first name is used as the middle name; the last name is the family name. In the Middle East, a person is called formally by the first name, such as Mr. William.

Respect for individuals is demonstrated in the use of certain titles. Inta (you) is saved for those in equal or lower positions, and hadretak (you) is reserved for those in higher-ranking positions or for older people. More flowery and more exaggerated variations of both of these appellations are used, such as seyadtak, which is reserved for the highest-level officials. Inta, used in place of hadretak, is an insult to older people and, more important, a reflection of bad manners and the poor upbringing of the young. Older people should never be called by their first names without an adjective or title attached to the name. The accepted custom in the United States of addressing patients by their first name may be insulting to people from other countries. An adjective, such as aunt, uncle, ostaz (Mr., Madame, Mrs.), or an adjective that denotes a profession, such as bashmohandes (engineer, doctor, physician) or a doctoral degree, may be used with the name. Family friends are addressed by both younger and adult children as uncle and aunt. Parental rela- tives are called either aunt or uncle or a special desig- nation such as ammeti (sister of father), ammy (brother of father), khalty (sister of mother), or khali (brother of mother). Some Egyptian Americans, par- ticularly those from rural Egypt, are addressed by the first name of their son, preceded by “Abu,” which means “father of.” This is more of an Arab custom adapted by Egyptians (Haddad & Hoeman, 2000).

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Family Roles and Organization Head of Household and Gender Roles The man is formally considered the head of the house- hold; however, the demands of life on immigrants and nuclear families drive couples to share responsibilities and decision making. Many Egyptian American men, however, tend to control family budgets, which gives them more power in the family and causes many in- terpersonal conflicts and much distress for Egyptian American women.

Egyptian American family roles change consider- ably after immigration. The fast pace and complexity of life in America, the many demands of child rearing, and the absence of an extended family to preserve tra- ditional roles contribute to a more egalitarian family organization. Husbands and wives experience greater fluidity in their roles, substitute for each other when needed, and participate fully in all family matters. Egyptian American women tend to work both in tem- porary occupations and in career positions. Many who do not work outside the home consider their sit- uation temporary, are between jobs, or are retooling their skills to become congruent with American job opportunities. Women who are not working outside the home tend to be more stressed than those who are employed. Unemployment brings with it economic limitations, social limitations in terms of developing a support network, or both. In the absence of ex- tended families, lack of this support network increases vulnerability, isolation, and stress. Immigrant women in general are at risk of not having a network of sup- porters, and this is particularly true for women who do not work outside the house (Aroian, Templin, & Ramaswamy, 2010). Women are expected to maintain Egyptian values and simultaneously ensure the inte- gration of the family in U.S. culture. This may increase the demands more for women than men, although some research findings indicate women and men do not differ in their stress and depression levels (Amer & Hovey, 2007). While some couples may share daily household chores, the norm is similar to that of other educated middle-class families in America. The woman is responsible for the daily management of family affairs. The man is the major breadwinner for the family. Husbands, however, participate in shop- ping, cleaning, and activities related to entertaining with their wives. Fathers also participate proactively in activities and education with their children.

Prescriptive, Restrictive, and Taboo Behaviors for Children and Adolescents Children are central to Egyptian families; they are treasured in the present and viewed as security for their parents’ future. During their early years, they are expected to be studious and goal oriented, respectful, and loyal to the family. When they become adults, they

are expected to take care of their older parents. How- ever, second-generation Egyptians tend to blend with other Americans. Their sense of responsibility toward their parents is a topic of major concern among Egyptian Americans. Egyptian children are not per- mitted to use foul language or swear in the home or in front of parents, although this is true to a lesser de- gree in the United States. Answering back to parents is not condoned and is seen as rude and disrespectful. Some families adjust better than others to the Western style of child rearing, which permits and encourages the children’s rights to question their parents’ instruc- tions. Families that allow their children more freedom to express their opinions and ask questions often end up with better-adjusted children and better-preserved family unity as their children grow into adulthood. Re- ligious beliefs and teachings forbid premarital sex and adultery for both Egyptian Muslims and Christians.

Gender is an important variable in parenting adoles- cents. Female adolescents in Egypt tend to report more psychological disorders than male adolescents perhaps due to authoritarian attitudes that exist toward girls (Dwairy & Menshar, 2006). Whether these findings hold true for Egyptian American adolescents would warrant more research in the United States. What we do know is that as girls reach puberty and questions of dating, courting, and prom night arrive, some parents cannot cope with the freedom allowed within American society. They worry more about the consequences of dating and their daughters’ getting pregnant and fleeing the home than about raising a healthy and well- adjusted young woman. In the extreme, a few families send their daughters with their mothers back to Egypt to complete their education through college under more restrictive conditions or to get married. Some families opt to return for good rather than raise their daughters in the American culture. Egyptian Muslim and Christian families usually have a hard time giving their young daughters enough space to grow (Meleis, 2002).

Hattar-Pollara, Meleis, and Nagib (2000) found that Egyptian American parents fear their daughters losing their virginity, representing a major stress in their daily lives. The greatest calamity that may hap- pen in a Christian or Muslim Egyptian American household is to have a daughter lose her virginity pre- maturely. This fear stems from a potential lack of marriageability of the daughter, loss of face for the father, and gossip within the Egyptian American com- munity. Therefore, parents tend to be restrictive about their daughters’ movements and to monitor their whereabouts carefully. Similar restrictions are placed on teenage sons, although they are allowed more free- dom and more autonomy in decision making. Most parents prefer that their sons not date and discourage sexual activities. However, if sons disobey the rules of the household, the incident is not regarded as gravely as when daughters do.

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Second-generation Egyptian Americans are rather philosophical about these restrictions. The open com- munication in the family allows children to see restric- tions as temporary or to devise ways to do what they want without their parents’ knowledge. Whereas sim- ilar situations may occur in their original country, the difference is that an extended family in the homeland may help mediate when confrontations between par- ents and children become inevitable. Without ex- tended families, Egyptian Americans are at a loss for help in resolving family issues. The option of going to counselors or health-care professionals for advice is rarely exercised. Preserving family secrets and honor is more important than external support. Just as fam- ilies have a strong need for virginity to be preserved, teen pregnancy is not openly discussed in the commu- nity. Because of the many restrictions placed on daughters’ movements and the limited opportunities for teenage daughters to go out without chaperones, such pregnancies rarely occur. Birth control is not usu- ally discussed in families until marriage, and Pap smears are not sought or accepted until after mar- riage. Egyptian American children are expected to marry Egyptian Americans. However, because many second-generation Americans do not reside in areas with other Egyptian Americans, cross-cultural mar- riages are becoming a trend. Many first-generation Egyptian Americans return to their home country to get married. Intermarriages among second-generation Americans are increasing.

Growing up as a Muslim and Egyptian in the post 9/11 era in the United States may contribute to the development of identity issues for children and ado- lescents. It could put their psychological well-being at risk. Formation of identity is influenced by peer group interaction, school environments, and media portrayal of Arab Americans. If these influences convey nega- tive stereotypes leading to discrimination and isola- tion, children and adolescents may face a dislocated sense of identities (Britto, 2008). The youth revolution in February 2011, which ousted President Mubarak, may support restoring a positive identity and sense of pride in Egyptian Americans, which was lost due to the 9/11 terrorist attack in New York.

Family Goals and Priorities The family is the most sacred institution to Egyptian Americans, and members of families are involved in all aspects of family members’ lives such as raising and ed- ucating children, finding work opportunities, and main- taining a moral code (Singerman, 2006). Although Egyptians in their own country have extended families, Egyptian American families tend to be more nuclear. Compared with other Arabs in the United States, most Egyptian Americans immigrated individually, were joined later by a bride, or immigrated as nuclear families. In some families, brothers, sisters, nephews, and nieces

may arrive later. Even when extended families arrive later, they tend to live apart.

Job opportunities dictate living choices and pat- terns of living among Egyptian Americans. Egyptians in their own country view the relocation of sons or daughters for education or an occupation with trepi- dation and concern. However, once children move, though not bound by their extended family’s geo- graphic location, they remain connected with them. In their home country, Egyptians tend to include the extended family in social activities and consult them for advice in all matters pertaining to health, employ- ment, and family. In the absence of such a family in the United States, they either resort to close Egyptian American friends or seek counseling from extended families in their home country. Christian families may resort to religious leaders in their church or commu- nity for assistance. Imams, who are Muslim religious leaders and therefore devout Muslims, who belong to a mosque may choose to consult with other Imams re- garding marital, family, or mental health problems (Ali, Milstein, & Marzuk, 2005).

The most important goal for Egyptian American families is to raise children who are well educated, employable, and able to secure occupations that allow career mobility, financial security, and an acceptable social status. To that end, many other goals are sub- ordinated. Because of this goal, parents may move to areas with better school systems and are willing to withstand financial or other hardships for the sake of their children.

Another goal of Egyptian American families is to keep children geographically close, if not living at home, until they get married to the right partner. Parents consider it their responsibility to assist their children, especially daughters, to find a suitable mar- riage partner, and they support children financially through wedding preparations. Raising children who are considered moaddabeen by Egyptian standards is important. A child who is moaddab is one who re- spects parents, defers to them for decisions, is mindful of older people, does not drink or indulge in immoral acts, listens to parents’ advice, and does not answer back during conflict. One final goal of Egyptian fam- ilies is to maintain a good face in public. This goal is achieved when children do not bring shame by engag- ing in activities forbidden by their parents, such as drinking, smoking, or going somewhere without their parents’ permission.

As Egyptians grow older, they are considered richer in experiences and wiser and command more respect. They are treated with gentleness and never made to believe that their usefulness is limited just because of aging or retirement. Their children and extended fam- ily are expected to care for them. Older people prefer to do less management of their own affairs and expect more services, respect, and reverence from family

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members and subordinates. Women gain status with age and with childbearing. Young women know that inequities they may suffer as young brides are more than compensated for when they get older. Older women, however, are expected to care for older men in the family.

Because most of the Egyptian American community immigrated as young adults, as they advance in age they are the first generation to experience growing old in the United States. Many parents have a morbid fear that they may be forced to move into a nursing home. Many consider returning to their home country to avoid the humiliation of aging in America, with the potential loss of home, family care, and respect. Egyptian Americans do not believe that they can expect or hold their chil- dren responsible for becoming their caregivers during old age Growing old in America is surrounded by many images of abandonment, humiliation, loss of respect, and above all, loneliness. Those who adapt to a life without extended family and create an extended family will likely establish a new means to deal with their old age. Health-care professionals may consider alternative ways to support this community and enhance their self- care activities to help them avoid feelings of loneliness and a sense of abandonment in old age.

Many Egyptian Americans are part of a network of friends with whom they share their celebrations and calamities. Where mosques or Middle Eastern Ortho- dox churches exist, these organizations are used to pro- mote social gatherings, maintain cultural norms, reinforce culturally driven restrictions on children’s behavior, and promote historical continuity. In the absence of such organizations, Egyptian cultural clubs promote meetings, discussions, and sharing news from the homeland. Comparative analyses of life in Egypt and the United States often dominate these gatherings. During social gatherings, Egyptians are recognized by their elegant clothes, the hustle and bustle of children playing, adults chattering, and fine Egyptian food.

Egyptian Americans prefer family gatherings to adult gatherings for celebrations such as Ramadan (the month of fasting), the Eid feast celebrations, Christmas, and New Year’s. Most often, they include extended family and their new networks of friends. Social net- works are connected by their heritage rather than by their occupations. Without these large gatherings, lone- liness and a sense of deprivation are exaggerated at times of crises or during normal developmental events such as the birth of a baby or the death of a family member.

In Egypt, extended family members play a strong role in the life of a family. It is an important goal of family members to live in the same city. Extended fam- ily members provide backup and support for working women by providing child care and for nonworking women with multiple children as they need tangible support. Families raise children, not mothers or

fathers. All family members freely give advice on child rearing. In the United States, Egyptian immigrants do not usually have extended family members living with them, but they continue to consider the extended fam- ily living abroad as their support network. For those who have extended family members and professional careers, the relationship tends to be more limited by time, responsibilities, and other demands.

Social status is gained through professional accom- plishments, financial success, and involvement in Egyptian community affairs. Respect is given to com- munity leaders who give of themselves and share life experiences. No caste system exists based on color, familial lineage, or ancestry among Egyptians or Egyptian Americans. In some communities, Egyptian Americans are divided by religion (Muslims and Copts) and by professional status, with clubs for pro- fessionals, blue-collar workers, and other white-collar workers.

Alternative Lifestyles The divorce rate among Egyptian immigrants is low, a pattern similar to that in Egypt. Most Egyptian Americans who are divorcing try to follow Egyptian and U.S. laws simultaneously because Egyptian laws have created many difficult issues for women as they do not have balanced views between men and women seeking to end their marriage (Bernard-Maugiron & Dupret, 2008). In cases of divorce in which one parent raises the children, the Egyptian community supports the single parent, including his or her own children. Divorce continues to be seen as a stigma and an unfortunate situation in which the children pay the greatest price. Who keeps and raises the children are governed by Egyptian laws which some Egyptian Americans continue to want to follow. In second mar- riages, partners work hard to make a new life together and are committed to raising their stepchildren.

Communal and same-sex families are concepts that do not exist in Egyptian societies. Although a commu- nity of gays exists, homosexuality is rarely disclosed. They do have meeting places that are frequently ignored, intentionally overlooked, and more recently, raided, with jail as a result for those suspected of same-sex ac- tivities. The Web site GayEgypt.com includes stories of gay men who have been imprisoned, facing hard labor and torture. To be gay or lesbian is considered immoral and is not accepted by any Arab or Middle Eastern re- ligion. To discover a gay son or lesbian daughter is akin to a catastrophic event for Egyptians and Egyptian Americans.

Workforce Issues Culture in the Workplace Egyptian American nurses, who usually hold a mini- mum of a bachelor’s degree, cope well with the demands

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inherent in providing nursing care in the United States. In the beginning of their careers in the United States, however, they encounter three challenges. First, Egypt- ian American nurses frequently expect detailed and careful communication of all steps and aspects of nursing care. This expectation is inherent in both their cultural patterns and their educational preparation. Although interactions and communications come nat- urally to Egyptian Americans, this naturalness is usually reserved for family and close acquaintances. In addition, their professional preparation does not emphasize com- munication skills for interacting with patients. Because Egyptian patients do not expect detailed information from physicians and nurses, the routine of informing patients about the rationale for interventions may challenge Egyptian American nurses.

The second challenge relates to the systematic and careful recording and documentation of nursing care. Egyptians are inclined to an oral tradition; therefore, the need to document in writing what can be shared verbally seems foreign to Egyptian American nurses.

The third challenge involves the work environment. For Egyptians, the work environment is also their so- cial environment in which friendships are built and life experiences and personal issues are shared with a se- lect few. The emphasis on privacy and separating work and social life expected in American work settings seems artificial to Egyptian Americans. Therefore, they tend to view American work relationships as su- perficial and often experience a sense of loss in terms of close, meaningful work relationships and a sup- portive collegial network. This feeling is similar to how women in other professions view satisfying and stressful aspects of their work situation.

The fourth challenge is similar to the challenge that all nurses face, which is the integration of technology in their daily nursing care. With the implementation of electronic health systems and recording of nursing care notes in hospitalized patients’ notes, immigrant nurses in particular will face English and computer language challenges.

Many Egyptian communities in the United States form Egyptian cultural clubs to which a small percent- age of these immigrant nurses belong. Such clubs help to decrease their sense of marginality. Activities usu- ally include parties, dinners, picnics, and dances. Some of these clubs offer Arab language classes for the chil- dren. The more religious socialize around their local mosques and churches, which are good and safe fo- rums for their teenage sons and daughters to meet prospective marital partners.

Egyptian American nurses, like other Egyptian workers who work internationally, most likely will have the ambitions to learn new knowledge and mas- ter new skills on the job. They seek new job opportu- nities and work hard to reach the next levels in their positions (Sidani & Jamali, 2010).

Egyptian immigrants to the United States work hard at becoming integrated into the Western work en- vironment. They thrive on professional satisfaction, defining success in terms of advancement. They tend to be team players and effective contributors to the so- ciety at large. They are usually punctual and follow work rules and procedures. Being well assimilated, they create a close network of colleagues.

Issues Related to Autonomy Most Egyptians prefer to work in a job setting in which they are employees of an organization. They do not experience difficulty in reporting to a superior and following instructions. These cultural patterns do not preclude their being professionally motivated to work hard and advance their careers within respective or- ganizations (Sidani & Jamali, 2010). As managers, leaders, or supervisors, they bring a personal touch and demonstrate human interest in their dealings with subordinates and coworkers. They demand loyalty and respect. On the whole, their religious affiliations do not pose problems for them when dealing with coworkers outside their own religions. However, the long history of Egyptian and Arab Israeli animosity causes some of them to approach their dealings with Jewish coworkers cautiously. Egyptian immigrants tend to be respectful of female coworkers, and often, their protective responses may be interpreted as pa- tronizing by some women. They treat women as sisters or daughters.

International market competition, economic changes, and transitions to free market in Egypt have provided new opportunities for Egyptians to embrace risk taking and become entrepreneurs (Farid, 2007). Few Egyptian Americans are entrepreneurial in developing their own businesses. Those who opt to start their own businesses tend to struggle to make them successful. Egyptian Americans in general value job and economic security over the risk taking inherent in operating a business. Therefore, they join established organizations with long- term goals. Yet when they cannot find employment in organizations, the third wave of young immigrants have populated New York street corner food carts and devel- oped their driving skills for cab and limousine driving in some of the major U.S. cities such as New York City.

Egyptians learn British English in schools and uni- versities. On immigrating to the United States, they are confronted with unfamiliar slang and idioms. When viewed from an immigrant’s point of view and with only basic knowledge of British English, some of these expressions are hard to interpret and could be construed as insults. An example of this type of mis- understanding happened to one of the authors (MHM). As he narrates it:

When I arrived in the United States (over 30 years ago) as a graduate student in engineering, I had an occasion to be studying at a University of California Los Angeles

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library on a weekend day with my wife, a graduate stu- dent in nursing. When we decided to go to the local school cafeteria for a cup of tea, we noticed one of her psychology professors in the library whom we knew very well inside and outside of the school. I approached him, greeted him, and asked if he would like to join us for a cup of tea. He responded by saying, “No, I don’t care to have a cup of tea now.” This, of course, is a very sim- ple and totally acceptable American response. For me, a recent Egyptian immigrant (less than a year), this was a personal insult. The words “I do not care” meant to me that he did not care about me, not the process of having tea. We discussed this conversation a year later as he and I became close friends and laughed about it. He obviously meant no insult, and I just did not know enough about the idioms and commonly used expressions to “get it.”

With increasing exposure to the media and life in the United States, it does not take long for a new im- migrant to understand and accurately interpret idioms and commonly used expressions. The media is also a useful tool that helps Egyptian Americans and others to learn the English language and idiomatic and slang expressions.

Biocultural Ecology Skin Color and Other Biological Variations Most Egyptians have olive skin tones, some are fair skinned, and others are dark skinned. Northern Egyp- tians exhibit a fairer complexion than most other Egyptians. Southern Egyptians (Nubians) are gener- ally black, with very fine facial features. Upper Egyp- tians have a darker complexion. The average height of Egyptian men is about 5 ft 10 in., whereas women av- erage 5 ft 4 in.

Diseases and Health Conditions Several risk factors are peculiar to life along the banks of the Nile. Egyptians suffer from a host of parasitic diseases; the most common is schistosomiasis, known as bilharzia in Egypt. Schistosomiasis has been endemic in Egypt throughout history and has been found in mummified bodies from the pharaonic era. A high per- centage of the Egyptian rural population is infected with Schistosoma mansoni or S. haematobium. The life cycle of schistosomiasis includes snails and human be- ings as hosts. Microscopic cercariae leave the snail in the warmth of the midday sun and penetrate the skin of humans who enter the shallow canals to irrigate crops, wash dishes or clothes, or swim. The cercariae migrate to areas near the liver, in the case of infection with S. mansoni, or near the bladder, in the case of infection with S. haematobium. The parasitic worms mature, mate, reproduce, and are expelled with urine or stools. If urine or stools are deposited in or near fresh- water canals or rivers where snails live, the eggs seek out a snail to begin the cycle again.

In human hosts, as the female worm expels the eggs, some of them flow with the blood and become lodged in the liver or around the urinary tract. The body, treating the eggs as foreign irritants, surrounds them with granular tissue, leading to cirrhosis, liver failure, portal hypertension, esophageal varices, bladder can- cer, and renal failure. Filariasis is another challenging parasitic disease endemic to Egyptians.

Rates of blindness in Egypt are among the highest in the world. Trachoma and other acute eye infections affect both rural and urban populations. Trachoma, a chronic infection of the lining of the eyelids caused by infection with Chlamydia trachomatis, is most com- mon among children and can have severe disabling consequences in adulthood. Gel-like lymphoid folli- cles that subside over time, leaving residual scarring of the inner eyelids, characterize the active inflamma- tory stage. In the most severe cases, trichiasis, an end- stage complication of chronic trachoma, occurs when scarring shrinks the lid lining and turns the eyelashes inward, scratching the cornea. This painful condition often leads to corneal ulceration, opacity, and even- tual blindness. Injuries and corneal ulcers secondary to other infections are also common causes of blind- ness in Egypt.

Other infectious diseases include typhoid and paratyphoid fevers, which are more frequent in urban than in rural areas. Streptococcal disease and rheu- matic fevers are frequent among children, and tuber- culosis continues to be a major problem in Egypt. Egyptian Americans who have positive tuberculin tests should be questioned about a history of Bacille Calmette-Guérin (BCG) vaccination.

Diarrheal diseases result from environmental condi- tions and family lifestyles. Heat contributes to the de- velopment of bacterial diseases, and dehydration results from diarrhea and vomiting caused by bacterial infec- tions. Programs and campaigns using rehydration pack- ets with water, salt, and sugar have drastically decreased mortality rates caused by diarrheal diseases. These en- demic diseases are more common in rural areas than in urban areas. Egyptian immigrants come mainly from urban areas and, therefore, do not usually suffer from these diseases. However, some may have family mem- bers who come to the United States for treatment with complications caused by one of these diseases. Kidney diseases, lack of proper hydration, and eating habits may contribute to kidney failure and the subsequent need for kidney transplantation. Clinicians in the Middle East suspect that fasting during Ramadan in- creases the potential for dehydration, contributing to kidney problems.

The people of Egypt also suffer from diseases com- mon to developing countries, such as undernutrition and malnutrition, and diseases resulting from overindulging in foods with high-fat and high-sugar contents. Modern diseases such as obesity, hypertension, and lower back

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pain affect a high percentage of Egyptians. Similarly, cardiovascular diseases resulting from stress, obesity, lack of exercise, and hypertension are on the rise. Egyptians who immigrate to the United States are more likely to become victims of these diseases of modernization than of rural diseases. Whereas breast cancer does not appear to be a uniformly manifest pat- tern among immigrant populations in an Australian study, rates were somewhat higher among the Egyptian born (McCredie, Coates, & Grulich, 1994). Type 2 diabetes is of concern to Egyptians and is further complicated by obesity. In addition, Egyptians are at a genetic risk for thalassemias, which can be detected from a molecular genetic standpoint through carrier screening and prenatal diagnosis.

In spite of the increasing numbers of Arab Americans and Egyptian Americans among them and the available evidence that they may differ from other ethnic groups in the United States, there is still very little research to document the evidence related to prevalence and inci- dence of diseases and illnesses (El Sayed & Galea, 2009; Shah et al., 2007). In one study, the conclusion was that nativity status was not associated with diabetes and hypertension (Dallo & Borrell, 2006). However, others have determined that Arab Muslims in the United States are at an increased risk for heart diseases, diabetes, and cancer due to marginalization, stereotyp- ing, levels of acculturation, lack of knowledge needed for prevention, and barriers to health care systems due to their cultural beliefs such as modesty, gender preference in health-care providers, and illness causa- tion misconceptions (Yosef, 2008).

Variations in Drug Metabolism The literature reports few studies related to variations in drug metabolism and specific drug interactions among Egyptian Americans. Some evidence indicates that Egyptians are poor metabolizers of beta-blockers (Levy, 1993). More research is needed in this area to provide better health care to Egyptian Americans.

High-Risk Behaviors There is very limited research about Egyptian American risk factors and little consensus about the burdens of such diseases as cardiovascular diseases and diabetes among Arab Americans in general (El-Sayed & Galea, 2009). Certain behaviors may increase the risk of illness for Egyptians in America. One of these is a sedentary lifestyle and lack of regular exercise (Salari, 2002). In- formation about exercise has just begun to appear in the media in Egypt, and health clubs and gyms have begun to spring up in Cairo and Alexandria. This new phe- nomenon began after many Egyptians immigrated to America. Although exercise and fitness are regularly in- cluded in the curricula of schools and colleges, exercise is not part of the daily lives of adult Egyptians and, even less so, among Egyptian Americans. Recent studies tend

to report Egyptian Americans as being healthier than in earlier studies, having fewer health problems and higher activity scores (meeting the minimum public health guidelines for activity); yet they still have a long way to go to attain the level of physical activity that Healthy People 2010 calls for (Qahoush, Stotts, Alawneh, & Froelicher, 2010). It is important to note that as with other minorities, Arab Americans’ accul- turation, immigration, and discrimination associated with stress may trigger cardiovascular diseases, diabetes, mental illness, or adverse birth outcomes (El-Sayed & Galea, 2009).

Overeating food delicacies high in fat, sodium, and sugar; sedentary lifestyles; and an entertainment style based on eating contribute to obesity and immobility. Although no data exist on health risk factors for Egyptian Americans, the authors suspect that if such data were obtained, they would demonstrate an in- creased risk for coronary artery diseases, diabetes, and esophageal hernias. The premature deaths in Egyptian American communities are due to massive heart fail- ure. There are also indications of an increase in risk factors for different types of cardiovascular diseases. Hassoun (1999) demonstrated that Arab Americans suf- fer from hypertension, high cholesterol levels, and dia- betes more than other immigrants. These findings suggest that a similar pattern may exist among Egyptian Americans (Hatahet, Khosla, & Fungwe, 2002). Many Egyptians came to the United States as young adults; as the community of Egyptian Americans ages, ques- tions related to sedentary lifestyles, overindulgence in food, and genetic makeup should be of interest.

Egyptian Americans are at risk for stomach and in- testinal problems that include heartburn, flatulence, constipation, hemorrhoids, and fecal impaction. These conditions result from limited roughage, lack of fluids, and rapid consumption of food. Another factor con- tributing to constipation may be their expectations and the meaning they attach to regularity, which prompts them to push and strain to force a bowel movement prematurely. Egyptian Americans are also at risk for diabetes. Jaber, Brown, Hammad, Zhu, and Herman (2003) found that a decrease in acculturation to the United States is an important element in the increase in risk factors for Arab immigrants.

Like many less-developed countries, Egypt re- sponded with zeal to campaigns launched by the cig- arette industry. Cigarette smoking is on the rise in Egypt, mostly among men, but it is also increasing among women. Those who smoke, smoke heavily and are unwilling to quit. Rice, Templin, and Kulwicki (2003) reported that 17 percent of the adolescent Arab Americans in their study smoked, and 34 percent said they had never smoked. Predictors for tobacco use were poor grades, peer or family smoking, passive smoking, receiving free samples of cigarettes, adver- tising, and believing that smoking helps in networking

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and stress. Smoking cessation programs, therefore, should reflect cultural gender norms and religious messages (Islam & Johnson, 2003).

One of the most dangerous risk factors among Egyptians in Egypt is their driving behavior. Most drive recklessly and aggressively, do not wear seat belts, and drive without respect for speed limits. How- ever, the extreme traffic congestion in Egypt provides a safety cushion. It takes Egyptian immigrants a num- ber of years in America to learn to respect traffic rules, wear seat belts, and drive cautiously.

The terrorist attacks on the United States on September 11, 2001, have resulted in harsh treatment of Arab Americans, including Egyptian Americans. Perceptions of scapegoating, discrimination, racism, and stigmatization increase their experience of stress. Outcomes of stress and marginalization will most probably be the subject of future research studies (Salari, 2002; Zogby, 2001).

Health-Care Practices Two conditions increase the utilization of preventive health care by Egyptian Americans: having health in- surance and having a health-care provider with whom they can develop a trusting and responsive relation- ship. Egyptian Americans like prompt and personal attention; they are usually among the most compliant patients if these conditions are met.

One reason for Egyptian Americans seeking health care is a perception that they are experiencing high blood pressure. They believe it is important to have fre- quent readings but prefer to treat hypertension with medications rather than with changes in diet or lifestyle. Hypertension, the silent killer of many Americans, may not be so silent for Egyptians. Whether they can detect fluctuations in their blood pressure remains to be care- fully studied. However, this behavior of reading one’s own body cues should be encouraged and promptly addressed by health-care professionals.

Pap smears and mammograms tend to be new pre- ventive health practices for Egyptian Americans. Ed- ucation about the importance of these tests promotes compliance with regular checkups. As mentioned ear- lier, Pap smears for unmarried women are discour- aged and considered totally unacceptable because of the expectations for preserving virginity until mar- riage. Gynecological examinations are given only to married women, usually during the checkup for a first pregnancy.

A study about health concerns among 99 Egyptian women and 135 American women aged 19 to 27 years reported that the top 10 health concerns among Egyptian women were halitosis/body odor, colds, can- cer, poor teeth, population explosion, excess weight, birth control, water pollution, headaches, and heart disease. Among American women, the top 10 health concerns were birth problems, what the future would

be like in 10 years, auto accidents, excess weight, can- cer, use of contraceptives, death, nuclear war, child- birth, and air pollution (Engs & Badr, 2001). The differences in health concerns of these two groups are probably due to cultural values and the degree of so- cietal differences between the United States and Egypt. These results reinforce the need for community health education programs that address the specific needs of individuals.

Nutrition Meaning of Food Food is an important component of Egyptian social life. Egyptians entertain lavishly and enjoy good food, which represents nurturing. The more food one pro- vides, the more love is portrayed. Egyptians develop trust in each other by having a meal together. The saying Akalt eish wa malh maa baad literally means “eating bread and salt together” and symbolically signifies trust, care, and truthfulness.

In addition to being part of Egyptian social life, food is associated with health. The more food a person eats, the greater the potential for being healthy. Thus, children tend to be overfed. Food is also associated with the ability of the head of the family to provide for family members. Therefore, parents take pride in the amount and the quality of food they bring to their families. Because food is associated with caring and nurturing, mothers and wives spend much time and effort shopping and cooking family meals. Finally, food is associated with generosity and giving. To offer food and to accept food are indications of friendship. Mealtime is for eating and for socializing but not for conducting business or discussing issues.

Some beliefs surrounding meals may increase health risks. For example, Egyptians prefer not to drink water or fluids with meals because they believe that fluid displaces the volume that could be used for food, decreasing their appetite for solid nutrients. Some believe that fluids dilute the stomach “juices,” make digestion difficult, and cause indigestion. An- other potential risk factor to explore is the amount of salt added to food while cooking or at the table.

Common Foods and Food Rituals Egyptian food is tasty, well done, and well seasoned. Egyptian Americans take pride in the food they serve and the way they present it. Although in Egypt veg- etable dishes are considered main dishes to be com- plemented by meat and rice dishes, this conception has changed for most Egyptian Americans. Preferred meats are lamb, chicken, beef, and veal. Favorite veg- etables are peas, green beans, cauliflower, and molokhia, a green vegetable cooked like soup. Most consider meat dishes as main dishes, complemented by vegetables and rice. Rice, a main staple, adorns

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dinner or lunch tables on a daily basis even when po- tatoes are served. Tomato-based red sauces are popu- lar, and some pasta and vegetable dishes are dressed with rich white sauces such as bechamel. Egyptians use lentils, fava beans, and bulgur in their cooking. Whole-wheat bread is preferred.

Egyptians acquired a taste for tea from their years under British rule and drink strong tea with hot milk several times a day. Those who prefer tea without milk drink it with mint leaves. They tend to use several tea- spoons of sugar to sweeten their tea. Although it is not easy for them to decrease their sugar intake, Egyp- tians do so if they understand its relationship to caloric intake, insulin requirements for those who are diabetic, or for other health considerations. Egyptians also drink coffee, a habit acquired from Turkish rule. The coffee is thick, strong, and served in small demi- tasse cups, with or without sugar. Egyptians also con- sume a large quantity of soft drinks.

Hostesses insist on giving guests excessive amounts of food and act insulted if guests refuse the food. Those who understand the ritual may insist on refusal or may take the food and not eat it. Leaving some food on the plate is more polite than refusing it. Completely emptying the plate may be seen as an indication that the guest did not have enough to eat. Egyptian Americans use modified versions of this ritual, depending on the guests and their length of time in the United States.

In Egypt, three main meals a day are served with a late afternoon or early evening snack of sweets with tea. The main meal is lunch, usually consumed at the end of the working day between 2 and 3 p.m., gener- ally followed by a period of rest when many take an afternoon nap. Working men and women in the current economic climate of Egypt either return to work in the early evening between 5 and 6 p.m. or have a second job or business for the remaining part of the evening. Supper, usually a lighter meal, is eaten after 9 p.m.

On religious holidays, certain foods are prepared and shared with family and friends. An example is baking a variety of cookies at the end of the holy month of Ramadan, a time when Muslims fast daily from sunrise to sunset, and during the Small Eid feast (also called the El Eid Alsagheer or Small Barrium). During the Great Eid feast (also called the El Eid Alk- abeer or Big Barrium), a sheep is sacrificed; the meat is given to needy families, and the family keeps some for consumption during that feast. Most of these rit- uals are modified in the United States. For example, Egyptian immigrants follow American eating habits of a small meal for lunch and then dinner at home after work between 6 and 7 p.m. Some immigrant families still make cookies at the end of Ramadan, but very few have a sheep slaughtered. Whether in Egypt or in America, the most devout Muslims do not

consume pork or drink alcohol. Egyptian Copts may consume both in moderation.

For Egyptian American Muslims, many rituals are revived during the month of Ramadan, the ninth of 12 Islamic months that follow the lunar calendar. Therefore, Ramadan does not coincide with a particu- lar month in the Christian calendar; instead it rotates and can fall on any of the Christian calendar months. Ramadan rituals are based on the teaching of the Qur’an (Koran) that calls for a month of fasting to ex- perience the plight of the poor and the underprivileged. Fasting precludes taking anything by mouth or intra- venously and abstaining from sexual activities. Muslims are expected to donate food for those in need, and they may eat modestly from sunset to sunrise. Egyptian American Christians fast for a varied number of days for several major religious celebrations. For them, fast- ing constitutes not eating any animal products.

Ramadan is a month of prayers and family festivi- ties with many food rituals. At sunset, families gather to eat lavish meals consisting of several kinds of meat and poultry, rice, dried fruits, and desserts such as konafa (shredded phyllo dough stuffed with nuts and raisins and soaked in honey) and kataif (pancake-like dough dressed with nuts, raisins, and sugar and smothered in honey). The meals are usually high in protein, fat, sugar, salt, and calories. Just before sun- rise, families consume a lighter meal in preparation for a day of fasting. Some Egyptian American Muslims follow these rituals in the United States. Even Egyptian Americans who do not follow and abide by the teach- ings of Islam during the year consider this month holy, and they become more devout Muslims during Ramadan. Some Egyptian Americans join others in social clubs and plan weekly potluck “sundown Ra- madan breakfasts.” During these gatherings, Egyptian Americans, their friends, and children exchange sto- ries related to Ramadan, read from the Qur’an, and indulge in eating delicacies specific to Ramadan.

Dietary Practices for Health Promotion Egyptian Americans do not mix hot and cold nor sweet and sour foods at the same meal. For example, the ac- cepted habit in America of eating ice cream as dessert with coffee was a foreign concept for Egyptians during the early stages of their immigration. However, they easily accommodate to this food habit. Some Egyptian Americans grew up believing that mixing fish and milk may cause digestive problems or create behavioral prob- lems. Therefore, dairy products and fish are generally avoided in combination. Some may have practiced drinking milk with yeast to increase their intake of vitamin B complex, a popular custom in Egypt.

Most Egyptian Muslims do not eat pork, as pro- scribed by the Qur’an. They eat only well-cooked meat and do not touch rare meat. Recent Egyptian immigrants find it strange to eat cooked corn, which

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is only barbecued in their country. Most are partial to their own cooking, preferring not to eat in restau- rants. They prefer kosher meat, trusting the dietary restrictions and food preparation practices of the Jewish population. In the absence of kosher meat, they shop at regular supermarkets.

Nutritional Deficiencies and Food Limitations Egyptians, particularly those who live in rural and poor communities, experience fat-soluble vitamin and iron deficiency anemia. They eat more fresh vegeta- bles, fresh fruits, and enriched or whole-wheat grain breads. Egyptians in the United States, like other Arab Americans, may resort to eating more processed foods and high-protein diets in the form of red meats be- cause of increased availability (Hassoun, 1999). They also tend to eat more junk foods, preferring sweets. Therefore, Egyptian Americans may have a greater tendency to have diets higher in fat and consume fewer fresh fruits and vegetables. No literature exists about the changes in dietary habits and the effects on vitamin and mineral deficiencies among Egyptian Americans. Women may have more vitamin D defi- ciencies due to the conservative clothing they wear that does not allow them to be exposed to the sun (Henry Ford Hospital, 2009).

Pregnancy and Childbearing Practices Fertility Practices and Views Toward Pregnancy An Egyptian couple is not complete until they have a child and are usually under stress, fearing marriage

instability caused by a lack of childbearing, until they conceive their first baby (Hattar-Pollara et al., 2000). Even if the husband is the cause of delayed or perma- nent infertility, women are threatened by the potential of divorce and are expected to conceive within their first year of marriage. Egyptian American families are under less stress and pressure to conceive because of the absence of extended family, although extended families continue to pressure their daughters and sons through letters and telephone calls. Pregnancies cement marriages, ensure a more lasting relationship, and are a way of getting men and women to mature in their re- lationship. Pregnancy brings women a sense of security and their husbands’ and in-laws’ respect. Giving birth, particularly to a son, considerably strengthens the sta- tus and power of women. Pregnancy gives women per- mission to decrease their responsibilities.

Systematic and concerted efforts have been initiated to develop and implement birth control practices in Egypt, with birth control being far more apparent in urban Egypt. However, a very high proportion of unmet contraceptive needs still exist in Egypt (Sultan, Bakr, Ismail, & Arafa, 2010). Whereas Egyptian Americans may practice family planning and birth control, these are never advocated before conceiving the first child. Family planning is practiced through a variety of methods, including birth control pills, con- doms, and early withdrawal. Abortion is used in Egypt, as in other countries, as a method of birth con- trol. Desirable family size in urban Egypt is three or four children, whereas desirable family size in the United States among Egyptian Americans is two or three children. Women take an active role in limiting pregnancies; they are willing to use any method of birth control to achieve and maintain a small family size. Infertility is shrouded in secrecy and is attributed first and foremost to women. Among poor urban and rural families in Egypt Kabsa is considered to be the cause of infertility (Inhorn, 1994). Kabsa happens when vulnerable women come in contact with “pol- luted” individuals. Kabsa causes a threat to reproduc- tive organs, a concept close to the way in which the “evil eye” affects an individual. It is unlikely that Egyptians who immigrate hold such a concept about infertility; however, assessing individuals who may be suffering from infertility nonetheless requires commu- nication skills to uncover explanatory frameworks. This will lead to more compliance. It is also important to note that just like other underserved populations, Arab Americans tend to experience difficulties in ac- cessing and receiving care in general, but infertility care in particular because of social marginalization especially after 9/11. Egyptian Americans, like Arab Americans, are also unlikely to accept donor sperm or adoption as options (Inhorn & Fakih, 2006). Since the health-care entry point for women is usually for repro- ductive health services, and since there is a relationship

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R E F L E C T I V E E X E R C I S E 2 8 . 2 Jibade and Kakra Suleiman along with their teenage daughter and son have visited your health promotion and wellness infor- mational booth at a community event. Mr. Suleiman (Jibade) has suffered from hypertension for several years. Mrs. Suleiman (Kakra) has been overweight for many years. They have asked advice about health eating, Egyptian style. They want their chil- dren to start eating more healthy as well. They tell the nutri- tionist, David Thomas, that they have accessed mypyramid.com, the U.S. Department of Agriculture (USDA) food pyramid, but this pyramid is not for them because they eat Egyptian cooking at home.

1. What is the first step the nurse should do to assess this family’s eating habits?

2. Do you consider a 3-day diary of food intake to be adequate for assessing food habits?

3. Do you think that weekend food patterns are different from weekday food patterns?

4. How might you assist this family in adapting the USDA food pyramid to Egyptian food patterns?

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between exposure to violence and poor reproductive health outcomes, it is important that health-care providers assess any signs of intimate partner violence and manage it (Afifi, 2008).

Prescriptive, Restrictive, and Taboo Practices in the Childbearing Family Women are expected and advised to curtail physical activities during pregnancy for fear of miscarriage (Meleis, 2002). Women are also advised to eat more be- cause they are feeding two. Some Egyptian American women have strong cravings (waham) for certain foods that may extend to such scarce items as out-of-season strawberries. If these foods are not consumed, babies may be marked with the shape of foods that were craved. Therefore, every effort is made to provide the pregnant woman with the needed foods.

Providing support during labor and delivery is re- served for the woman’s relatives, particularly her mother. Egyptian Americans invariably request that a female family member accompany the birthing mother. If an Egyptian American woman goes into labor with only her husband in attendance, it is considered an emer- gency. Acculturated Egyptian American men want to be included in the birthing experience, which may offend Egyptian newcomers. In Egypt, men are excluded from the birthing process because it is believed that men lack the ability to witness this highly emotional and painful process and lack the experience to support their wives.

The cold-and-hot theory for health and illness pre- vents women from bathing during the postpartum pe- riod. Bathing or washing hair could expose them to colds and chills. Egyptian Americans respond well to a sound rationale for bathing in a hot tub or taking a shower that dispels beliefs about the potential for infec- tion. Chicken and chicken broth are expected to help women during their postpartum transition. The post- partum period lasts 40 days, during which new mothers are expected to rest, eat well, be confined to the house with their babies, and not engage in any sexual activi- ties. They are usually cared for by family members and are not expected to have any demands put on them. This practice is eroding, however, because of increasing demands on women and the migration of families. In- formation related to birth control is always welcomed after the first pregnancy, although it may not be sought during the postpartum period.

Death Rituals Death Rituals and Expectations Among Muslims in Egypt, Islam calls for burial of the deceased as soon as possible. The burial ritual includes cleaning the body and wrapping it in a white cotton wrap. Verses from the Qur’an are read and a special prayer is recited at the mosque before the body is buried underground in a simple tomb. Islam prohibits

fancy tombstones; only a simple stone with the name of the deceased is placed above ground. The simple stone suggests that individuals are equal in death when meeting their creator. On the night of the burial, friends and family gather in a large tent outside the deceased’s home to give their condolences and respect to the grieving family. No food is served, but Turkish coffee is usually offered. Forty days after the burial, another mourning ritual takes place in the home of the deceased’s family. Family members listen while passages from the Qur’an are read by a religious man to console the family. Thereafter, a similar ritual takes place on the anniversary of the death. Egyptian Christian death rituals in Egypt and the United States are simi- lar to American Christian death rituals.

For Egyptian immigrants, some cultural rituals are followed. For instance, the Islamic burial rituals are carried out in designated cemeteries. The evening before the burial, the Qur’an is recited, and occa- sionally, the mourning ritual is observed for 40 days after burial. The annual death observance ritual is rarely carried out. Some Muslim families insist on having the deceased buried in Egypt, which is a very costly process involving approval from both coun- tries and transporting the deceased in a special cas- ket. Abdel-Khalek and Ahmed (1986) found that Egyptian Americans have slightly higher anxiety about death than Americans. Perhaps for observing Muslims this may be due to anticipating the judg- ment from heaven after death (Stadler, 2008). Health-care providers may be involved in and bewildered by the decision-making processes that Egyptian families go through on the death of family members. Plans for death are rarely made ahead of time, though a burial site is invariably selected in advance to protect families against being buried in non-Muslim burial places. Similar practices are observed among Christian Egyptian Americans.

Responses to Death and Grief Egyptians in Egypt and the United States react vig- orously and dramatically to the loss of a family member, expressing their grief outwardly. Wailing and public crying occur when first learning of death. This public reaction is an expected demonstration of their grief; otherwise, the community may regard them as lacking affection for the deceased. Death is seen as inevitable, although any loss brings shock and despair. Older people speak calmly about their own impending death. Egyptian Americans with a strong religious foundation do not fear the nearness of death but rather view it as a journey to the other world, which is believed to be better. Egyptian Muslims and Christians believe in an afterlife and expect rewards for good deeds accomplished in their first life. They anticipate reuniting with those who preceded them.

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Spirituality Dominant Religion and Use of Prayer Religious practices for Egyptian Americans are per- formed during marriage, death, and religious holidays. Egyptian Americans participate in two wedding ceremonies: One is a religious and civil ceremony performed by the mosque’s imam(usually in place of Maazoon, who performs these rituals in Egypt), and the other a social ceremony in which friends and family gather for a gala evening. Both could be per- formed on the same day or days, months, or years apart. A separation after the religious ceremony is considered a divorce, but it is customary for brides and grooms to live together only after the social celebration has taken place. Egyptian American Christians have one religious marriage ceremony.

Prayers, even for the nondevout Muslim or Christian, are significant during times of illness. Egyptian Americans may bring the Qur’an or the Bible to their hospital beds and usually put it under the pillow or on the bedside table. Prayers may be recited by the individual, in groups for Muslims, or in religious settings such as mosques or churches. Families and friends pray for each other, invoking good health, cure of illness, and peace. Prayers during holidays are enjoyed particularly in groups and in religious settings.

Meaning of Life and Individual Sources of Strength Religious Egyptians achieve inner peace through prac- ticing their respective religious rituals, including indi- vidual or collective prayers, reading from the Qur’an or Bible, and other religious texts written by religious scholars. Muslims who can afford the expense and are in good health make the pilgrimage to Mecca some- time during their lifetime. The journey is believed to provide Muslims with a source of inner fulfillment. Similar patterns of fulfillment through participation in religious activities are common in the United States.

Spiritual Beliefs and Health-Care Practices Most Egyptian Americans talk about their religious teachings during episodes of illness. They derive com- fort, strength, and meaning from verses in the Qur’an and of prophets. Family members use these verses to remind them that they are at the mercy and under the control of God and that God may have a particular reason for their suffering. To lose hope may mean they are losing faith in God and His abilities.

Health-Care Practices Health-Seeking Beliefs and Behaviors The health-care practices of Egyptian Americans can best be understood by looking at the historical roots and the meanings of health and health care for Egyptians. The pharaohs are credited with introducing medicine to the world, as evidenced by the writings on papyri from 4000 B.C. The practice of mummification, perfected to ensure that the pharaohs’ bodies were preserved to wait for the return of the departed spirit, may have helped the pharaohs to understand the intricate anatomy of the body. Papyri writings have been found describing body organs, gynecological conditions, surgery, and signs and symptoms of illnesses. There are indications that the early Egyptians also had dental knowledge and had de- veloped treatments for dental problems. Pharaonic writ- ings introduced the idea of body parts and segmentation.

Egyptian health care is also influenced by Greek, or unani, medicine. The most famous medical library in the world was built in Alexandria during the reign of Alexander the Great, housing almost all the medical knowledge of the ancient world. The books contained in this library, which was later burned, chronicled nu- merous diseases and treatments. The Greeks combined medicine and philosophy and expanded the understand- ing of anatomy. Their texts influenced the entire region. As early as the 10th century B.C., medical schools based on unani medicine were established by the Arabs. These texts, known as the laws of medicine, were written by early Arab scholars and embodied the teachings of preventive and curative health care.

Egyptian beliefs about health care are also influenced by humoral systems described in Greek documents. The principles behind the humoral system are based on di- viding many aspects of life into four: the year into four seasons; matter into fire, air, earth, and water; the body into black phlegm, black bile, yellow bile, and blood; and the environment into hot, cold, moist, and dry. Diseases follow these humors with treatments based on opposite humors. The pharaohs introduced the princi- ple of balance and imbalance as the cause of illness. Egyptians believe that cold and moist environments cause illnesses, by changes from cold to hot or vice versa. The opposite humor is used for treating the illness.

Other influences on the Egyptian health belief sys- tem came from the colonization of Egypt by the

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R E F L E C T I V E E X E R C I S E 2 8 . 3 Hosni Kanaan, age 34 years, has recently been diagnosed with diabetes mellitus. He is single but lives two houses away from his parents in a suburban neighborhood. Because Ramadan is approaching and he closely follows his parents’ wishes for fast- ing, he has asked the clinic nurse practitioner about his insulin regulation.

1. What is Ramadan? 2. What are the religious requirements for fasting during

Ramadan? 3. What recommendations will you give Mr. Kanaan regarding

his diet and fasting during Ramadan?

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Turks, French, and British. In addition to illnesses being caused by humoral imbalances, Egyptians be- lieve them to be caused by being presented suddenly with bad news (itkhad, “startled/surprised by unex- pected calamity”) or by a fight. Whereas a person’s mental and physical health are intricately interwoven, treatment sought from the health-care system is focused on physical or biomedical treatment. Family or religious people usually handle mental health prob- lems outside the health-care system. Egyptians tend to manifest symptoms of mental health problems somatically. Therefore, they seek medical care to deal with the physical manifestations of mental illnesses.

Whereas Egyptian Americans are usually well edu- cated, their views are colored by beliefs about the in- fluence of imbalances, the evil eye, and Islamic beliefs about the role God plays in their illness. However, they are firm believers in Western medicine’s miraculous ability to treat and cure illnesses. None of their beliefs prevents them from seeking or complying with the prescriptions of Western medicine. If they practice the belief of balancing or of warding off the evil eye, it is done in conjunction with Western medicine. Levels of acculturation and biculturalism play an important role in how Arab Americans respond and deal with health-care issues. For example, the level of accultur- ation was determined to be a risk factor for a number of health problems, such as dysglycemia (Jaber et al., 2003) and coronary artery disease (Hatahet et al., 2002). Egyptian American women whose conserva- tiveness may hinder their receiving of sun rays may suffer from vitamin D deficiency (Hobbs et al., 2009). They are also at higher risk because limited research studies use them as research participants (Sayed, 2003). Finally, they are also at risk because of stereo- typing (Soliman et al., 2001).

Responsibility for Health Care The Qur’an and the sayings of Mohammed, the Prophet of Islam, have made a major contribution to Muslim health care. In particular, preventive health care is embodied in many of Mohammed’s prophetic sayings. Cleanliness and hygiene are integral to prac- ticing Muslims. A number of elaborate prayer rituals are also related to health care and prevention of ill- ness. For example, before praying, Muslims must en- gage in a purification ritual, which consists of washing every exposed body part. Prayer, required five times daily, consists of elaborate bending and kneeling movements in systematic ways, increasing a person’s range of movements, limbering stretches, and medita- tive poses. Religion and prayers are believed to provide protection from illnesses.

In Egypt, a government health insurance policy allows every citizen to receive free care, treatments, and medications. However, Egyptians believe that to receive better quality health care, they must shop, bargain, and

negotiate. In the process, they learn that quality care means fees. If they can afford it, they prefer quality care. Most Egyptian Americans join a Health Mainte- nance Organization (HMO) or have private medical in- surance. Whereas they may refuse to have life insurance (Islam does not condone insurance), they realize the im- portance of quality health care. Newcomers, however, may wait to develop financial security before they join a health insurance plan. Typically, Egyptian Americans experiencing a health problem consult family members and friends before visiting a trusted health-care profes- sional. Once in the health-care system, they prefer im- mediate, personalized attention. They value tests and prescriptions for their illnesses and follow medical regi- mens and prescriptions carefully, particularly if they consist of oral medications, injections, or both. How- ever, they tend to be skeptical of treatments such as weight reduction, exercise, and diet restrictions.

The family of a client expects and prefers to be in- volved in all health-care decisions. Their focus on human relations and interpersonal contact make it dif- ficult for Egyptian Americans who encounter chang- ing staff and assignments during treatments. They believe they have a better chance of receiving quality care if trusting relationships are formed. Thus, con- stancy and consistency of contacts decrease potential conflicts in their relationship with the health-care sys- tem. Health care developed within or in cooperation with religious organizations tends to be more success- ful in reaching immigrants (Shah et al., 2007).

Egyptian Americans may practice self-medication. They tend to share medications freely and use Western medications and home remedies such as herbs, hot com- presses, and hot fluids and foods. Many Egyptians keep a very active medicine cabinet filled with antibiotics, tranquilizers, sleeping pills, and pain medications. They also believe that vitamins given intramuscularly and in- travenously are more effective than vitamins taken in pill form. In Egypt, vitamin B complex injections and iron supplements are common self-medicating activities. Some common herbal and home remedies are boiled mint leaves for a stomachache; boiled cumin for gas; boiled caraway for coughs; and hot pads for aches, pains, and boils. Regulation of prescription drugs in the United States restricts the use of prescriptions, prompt- ing some Egyptian Americans to get their supply of medications from their home country or friends. Use of illegal drugs is minimal in this community. Although some Egyptian Americans may overindulge in alcohol, the teachings of Islam prohibit its use. Many who drink alcohol tend to do so socially and in limited quantities.

Folk and Traditional Practices According to Islam, illnesses are caused by lack of hy- giene, exposure to diseases, or environmental condi- tions, although it is up to God who gets sick and who does not. People are expected to care for themselves

People of Egyptian Heritage 17

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and work at preventing illnesses when possible. In ad- dition, beliefs related to the healing powers of shrines and holy men or saints and the counterpowers of the devil (jenn) and evil spirits (arwah) influence health care. Thus, ceremonies are designed to eliminate the devastating powers of the Jenn; among them is the fa- mous zar ceremony and the hegab. The zar ceremony includes gathering friends and relatives around a sick person, with loud music playing and drums beating to increase the frenzy of dance and movement. The en- ergy of the group and their solidarity help eliminate the bad spirits from the body, taking with them the ill- ness or the handicapping condition. Zar is rarely prac- ticed among Egyptian Americans. A person who is trying to get rid of an illness wears the hegab, an amulet with sayings from the Qur’an. Some also use the amal which is designed to bring bad luck or illness to an unloved person.

Egyptians believe the evil eye is responsible for per- sonal calamities. The evil eye is cast by those who have blue eyes, by those who tend to speak of an admired person or object in a boastful manner, or by the mere description of beauty, wealth, or health without saying some verses from the Qur’an or Bible. These verses protect the person from losing whatever good they possess. Some Egyptian Americans use blue beads or religious verses inscribed on charms to protect them or their children from the evil eye. Children are particu- larly at risk for the evil eye and need more protection than adults.

Barriers to Health Care Barriers to health care among Egyptian Americans are related to economics, work demands, and full schedules. Fitting appointments into their schedules proves to be somewhat difficult, particularly in fami- lies in which a spouse is working long hours and the family owns only one car. When the family has two working members, access to the health-care system at designated times is even more challenging. Another barrier is the difference in explaining health problems. The degree of specificity required in the U.S. health-care system, the narrative storytelling nature of Egyptians, and the contextual way in which Egyptians, like many other Arab Americans, view a situation may con- tribute to a frustrating experience for both the immigrant and the health-care professional (Aboul- Enein & Aboul-Enein, 2010).

Cultural Responses to Health and Illness Egyptians avoid pain at all costs by seeking prompt in- terventions. They tend to be verbally and nonverbally expressive about pain; moaning, groaning, sighing, and holding the painful body part tightly are common ex- pressions of pain. As Reizian and Meleis (1987) demonstrated, Arab Americans tend to respond to an episode of pain depending on the intensity, severity,

and their audience. Although they tend to be more constrained in front of health-care professionals or other “strangers,” they are quite expressive in front of family members, using grunting, pushing, screaming, guttural sounds, or gasping for air. These conflicting behaviors are confusing to health-care professionals when family members insist that the client needs pain relief. The absence of these responses in front of health-care professionals makes verification of the intensity of pain difficult.

Egyptian descriptions of pain may not be as specific as the Western health-care system prefers. Egyptians present a more generalized description of pain, regard- less of whether it is localized. They usually describe general weakness, dizziness, or overall tension and stress associated with pain (Reizian & Meleis, 1987). They also use metaphors reflecting humoral medicine such as earth, rocks, fire, heat, and cold to describe their pain.

Age and birth order correlate significantly with in- dividual responses and descriptions of pain. Younger children and first-born children are often more expres- sive about pain. Higher intensities of pain are also associated with increased behavioral responses in chil- dren. Egyptian children tend to describe their pain with sensory descriptors such as sikkeenah, or “it’s like a knife” (Essaway, 1987). Giving birth is associated with severe pain, and it is not to be endured alone. Therefore, birthing mothers tend to be highly expres- sive of the intensity of their pain. Having a close family member present during the pain episode may be helpful for Egyptian Americans. Children prefer their mothers (Essaway, 1987), whereas adult women and men prefer female family members who are more nurturing, caring, and capable of comforting a person in pain (Meleis & Sorrell, 1981).

Although mental illness has been considered a stigma that should not be disclosed, more tolerance of emotional problems is the norm in modern Egypt. Rural Egyptians explain mental health problems within supernatural frameworks, including the amal (a curse) or Jenn (the devil). Urban Egyptians explain emotional problems in terms of grief, losses, and wrongdoing by others or by blaming the victims for not being able to control and snap out of their distress. Mental and emotional issues tend to be expressed so- matically, and therefore, psychosomatic interventions are more effective than psychologically based inter- ventions. Although Egyptians may seek therapy and counseling, they prefer to seek the advice of family members or trusted friends rather than go to strangers. They also do not like to call treatments psy- chotherapy or analysis. They prefer to call it counsel- ing. However, with the mental health reforms that occurred in Egypt in 2001–2009 which integrated men- tal health into the health sector, we could expect new younger waves of immigrants to be more accepting

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of mental health diagnoses and treatments (Jenkins, Heshmat, Loza, Siekkonen, & Sorour, 2010). Egyptians tend to place the blame externally, looking for external actions or events to explain the situation. Because Egyptians are more community oriented, they tend to seek the approval and sanction of others; therefore, shame rather than guilt tends to explain their actions and their reactions.

Assessing and treating mental health problems among Egyptian Americans requires careful attention to gender relations, the history of how mental health is viewed in their country of origin, the individual’s and family’s level of acculturation, and their explana- tory framework (Al-Krenawi & Graham, 2000). Inte- grating modern, Western, and cultural approaches will make the intervention more successful.

Disabilities are usually hidden from public view. Whereas there is public sympathy and acceptance of people with disabilities, families still tend to be protec- tive and shield them from public display. Families as- sume responsibility for the care of their disabled members, not expecting help or services from society. Egyptian Americans, however, tend to hide their dis- abled family members from other Egyptian Americans for fear of evoking reactions of pity. They are open, however, with health-care professionals in the hope of receiving better health care.

Egyptian Americans have a general belief that chronic illnesses can be controlled by the scientific so- phistication of Western medicine. Therefore, health- care professionals and patients have a general pattern of cooperation on long-term treatments. Less regard is held for complementary therapies but patients are willing to accept it if prescribed by a trusted health- care provider. However, the demand is greater for sci- entifically supported remedies, regardless of their intrusiveness. Egyptian Americans tend to be hopeful, persistent, and optimistic about their prognoses. Therefore, they may shop around for health care that promises a better diagnosis and prognosis. Reha- bilitation programs that include drastic changes in lifestyles are less appealing if the programs are not scientifically supported.

Egyptian families take care of their sick members. Promotion of self-care is viewed with suspicion by Egyptian Americans, just as by other Arab Americans, and sick people are not expected to participate in programs to enhance their self-care capabilities. Rather, they are expected to preserve their energy for healing. Attempts to engage Egyptian patients in self-care by promoting responsibility for daily care, for example, by keeping a colostomy incision clean, are resisted and perceived as a request to decrease the work of the nurse and the other staff. Sick people are also relieved from making major health-care deci- sions. Their families make all health-care decisions for them.

Blood Transfusions and Organ Donation Egyptian Americans have no taboos against blood transfusions or organ transplants. All measures needed to heal, cure, or prolong life are welcomed. Their trust and respect for the health-care system and health-care professionals facilitate their decision making, and they support recommendations offered by the health-care provider. They are hesitant, how- ever, to pledge their own organs to others or to permit an autopsy. Because of their belief in the afterlife, they favor being buried whole.

Health-Care Providers Traditional Versus Biomedical Providers Although Egyptian Americans may consult family members and friends about their health and illnesses, they do not consult traditional or folk providers. In fact, they may be reluctant to seek health care from anyone but physicians. Using the services of acupuncturists, po- diatrists, chiropractors, and physical therapists is foreign to those not integrated into the American culture. In general, members of the Egyptian American commu- nity have a positive perception of the American health- care system. They believe that physicians and nurses are experts and are caring and responsive to the needs of their community. Egyptian Americans are in awe of Western medicine, its scientific basis, and its vast re- sources. One of their most common responses is, “We were lucky to be in the United States when the illness occurred.” They would be willing to use complementary and alternative health practices if prescribed by their physicians, particularly because the popularity of these alternative ways of treating diseases and preventing

People of Egyptian Heritage 19

R E F L E C T I V E E X E R C I S E 2 8 . 4 Negad and Chione Said bring their 7-month-old baby girl to the emergency room of a local hospital. The father, Negad, works as an Arabic translator for an Embassy in Washington, DC. The mother, Chione, does not work outside the home because she has three other children ages 7, 5, and 3 years old. For 2 days the child has had diarrhea and a tender-to-touch abdomen. The parents tell the nurse that their neighbor gave the baby the evil eye and even though they have been saying prayers, the child has not gotten any better. The child has blue beads on her wrist and a charm with “foreign” writing tied to her pajamas.

1. What causes the evil eye? 2. What are some of the treatments for evil eye? 3. What is the significance of the blue beads and charm with

the “foreign” writing? 4. As a health-care provider who does not believe in the

“evil eye,” what would you do to provide culturally competent care?

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illnesses is increasing in the Middle East (Azaizeh, Saad, Cooper, & Said, 2010; Yesilada, 2011).

For some Egyptian Americans, however, the metic- ulous diagnostic approaches practiced by American physicians may be misinterpreted. Accustomed to Egyptian physicians whose clinical judgments and skills have been developed within a system that lacks adequate resources for meticulous diagnoses, some may misperceive an American physician’s thorough- ness as a lack of experience or appropriate knowledge. Therefore, they may shop for physicians whose clinical judgments are congruent with their cultural expecta- tions of a prompt and firm diagnosis. Others may view the laborious and involved diagnostic process, which uses many resources and tests, as an indication of the gravity of the diagnosis.

A recent trend in Egypt is to consider gender as an important variable in the selection of health-care professionals. Although rural and less-educated ur- banites have always valued this, religious influences have prompted a renewed preference for health- care providers of the same gender. Many Egyptian Americans immigrated before the wave of Islamic fundamentalism and its influence on life patterns and expressions. Therefore, first- and second-wave Egyptian Americans may not consider gender as an important criterion in the selection of their health- care providers. Third-wave immigrants may prefer gender-congruent health-care providers, although this preference may be mitigated by their respect for Western medicine. In addition to religious funda- mentalism, modesty may influence the desire for gender-congruent health care. For some Egyptian Americans, sharing the intimate details of their health history is enhanced if the health-care provider is the same gender. Egyptian Americans may also view older female physicians as more experienced and, therefore, more trustworthy than younger female physicians.

Status of Health-Care Providers Physicians are highly respected by Egyptians and Egyptian Americans. As in most health-care systems throughout the world, Egyptian physicians expect to be the head of the health-care team and the primary decision makers for all aspects of clinical care. Egypt- ian Americans prefer physicians affiliated with large, respected organizations because they believe them to be more experienced. For some, the physician’s age, years of experience, and position in the organization may indicate better qualifications.

As in the United States, nurses in Egypt are edu- cated at many different degree levels and have similar patterns of practice. Most graduate from high school programs developed to meet the nursing shortage. Limited resources, an overabundance of physicians, limited educational preparation of the majority of

nurses, low pay scales, and long work hours contribute to poor nursing care in Egypt. Consequently, nursing care in Egyptian hospitals is left to family members, who usually surround the client every waking moment. They are expected to carry out most of the care and act as advocates for the patients. Hence, they appear to us in the United States as more intrusive to Western routines, when in fact, they have been conditioned to be vigilant advocates for their family members.

Egyptians’ contacts in the homeland with nurses who are knowledgeable and expert in their fields have been minimal. Consequently, their expectations of nurses are usually far below their experiences in the U.S. health-care system. They view American nurses as well educated and well qualified and are grateful for their expertise and for their attention.

Egyptian American physicians tend to be im- pressed with American nursing. Their limited views and expectations of nurses based on Egyptian expe- riences are drastically altered after short contact with American nursing practices. They consider nurses in the United States to be well educated and view their expertise as enhanced by years of experience and availability of resources. The emphasis on higher levels of education for American nurses is congruent with the high value Egyptians place on education. Egyptian physicians also believe that the better pay for American nurses is congruent with better educa- tion and better expertise.

R E F E R E N C E S

Abdel-Khalek, A., & Ahmed, M. (1986). Death anxiety in Egyptian samples. Personality and Individual Differences, 7(4), 479–483.

Aboul-Enein, B. H., & Aboul-Enein, F. H. (2010). The cultural gap delivering health care services to Arab American popula- tions in the United States. Journal of Cultural Diversity, 17(1), 20–23.

Afifi, M. (2008). Physical violence and some reproductive health variables among currently married Egyptian women. Journal of Egyptian Public Health Association, 83(1/2), 49–66.

Al-Krenawi, A., & Graham, J. R. (2000). Culturally sensitive so- cial work practice with Arab clients in mental health settings. Health & Social Work, 25(1), 9–22.

Ali, O. M., Milstein, G., & Marzuk, P. M. (2005). The imam’s role in meeting the counseling needs of Muslim communities in the United States. Psychiatric Services, 56(2), 202–205.

Amer, M. M., & Hovey, J. D. (2007). Socio-demographic differ- ence in acculturation and mental health for a sample of 2nd generation/early immigrant Arab Americans. Journal of Immi- grant and Minority Health, 9, 335–347.

Arab American Institute Foundation. (2011). Arab Americans; Demographics. Retrieved from http://www.aaiusa.org/pages/ demographics

Aroian, K., Templin, T., & Ramaswamy, V. (2010). Adaptation and psychometric evaluation of the multidimensional scale of perceived social support for Arab immigrant women. Health Care for Women International, 31(2), 153–169.

Azaizeh, H., Saad, B., Cooper, E., & Said, O. (2010). Traditional Arabic and Islamic Medicine, a Hre-emerging health aid.

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