Lost in Transition – Dr. Andrew Hua

Impacts of diversity of culture, language and traditions among CALD migrants.


From Luke’s Journal May 2023  |  Vol.28 No.2  |  Unity in Diversity 

Image by Rodnae Productions, Pexels

When I first came to Australia in 1952, the population was largely Anglosaxon: meat pies and fish and chips were the main takeaway foods, and English and “Strine” were spoken.

There was no weekend shopping then. Meat could not be sold after 5pm. Evening shopping was only on Fridays. Many suburbs were DRY and alcohol could not be sold. Shelves were not replenished over holidays, so you had to stock up before Easter and Christmas.

At the market, you were not allowed to touch the fruit, and the fruit they gave you were often the smaller, imperfect ones from the back. If you jumped a queue, you were publicly humiliated.

When I migrated to Australia in 1973, it had become more ethnically diverse, with Greek, Italian and Chinese migrants introducing espresso coffee, pizza ‘pies’ and deep-fried dim sims to the menu. Since then, Australia has become one of the most ethnically diverse countries in the world. Melbourne’s cities of Greater Dandenong and Footscray have become some of the most culturally diverse centres in Victoria.

Language Diversity

In 1952, English, and its local version “Strine”, was the predominant language. Now, over 400 languages and dialects are spoken.

Conventions such as Yes and No, and body language, are often different in different cultures. “Yes” can mean affirmative, or “I agree with the statement”, or “I agree with the speaker”, or merely, “I hear what you are saying”.

Asking if you have eaten is a form of greeting and not necessary an invitation to a meal. This is said to be the origin of Chop Sui, which were assorted left-overs which were served up because an American guest of the first Chinese ambassador had answered truthfully that he had not yet eaten.

Many languages have different pronouns for different sex or age/seniority, and not using the proper pronoun is considered rude or insulting.

Body Language Diversity

Shaking the head can be a form of showing agreement in some cultures.

Strict rules for touching or even pointing exist in many cultures. In Australia, I learned that embracing and kissing on the cheek for ladies is a form of normal greeting and not a show of affection.

Diverse customs and practices in different cultures

In China under Mao, a cigarette used to be offered as a sign of friendship when you first met someone, and you were expected to let them light it for you and to smoke it. Over-ordering food in a restaurant is a form of courtesy as a host, and guests need to say that what has been ordered is more than sufficient. If you empty your teacup, the host is obliged to refill it for you until you leave some in your cup.

Picking up your bowl is seen as rude in Korean culture, while the Chinese shovel their rice into their mouths with the chopsticks instead of picking the rice up. At the end of the meal, you are meant to put up a fight to pay the bill in traditional Cantonese culture. You need to get an agreement to be host, or to go Dutch at the beginning of a meal.

Medical Situation Diversity

It is customary in Hong Kong to seek the opinion of several doctors before the patient or their relatives decide whose advice they will follow, and often a combination of several doctor’s advice and medicines. Politeness may result in patients accepting tests and prescriptions and then deciding not to follow through for whatever reason.

There is a diversity of value systems, and the decision-maker is different in different communities. Gifting is seen as a necessary protocol in many eastern cultures. The doctor may have to accept a gift out of courtesy and give a large Lai-see (Hong-bau, lucky red packet) with an appropriate cash repayment inside, for good fortune.  Here, it is considered bribery and criminal corruption.

Image by Rodnae Productions, Pexels

Concepts of Health and Disease can be radically different

How patients describe their symptoms differ and their concepts of the origin of their illnesses can colour their confidence in what is offered as treatment.

There may be distrust of Western medicine which is seen to be ‘too drastic, harmful to health, dispersing damage through the whole body’. So patients often reduce the dose secretly or omit drugs after a few doses – which is often the cause of resistant bacteria developing to antibiotics.

They may also store medicines for later use, or dispense their drugs for their spouse or friends with similar ailments.

Some cultures cannot accept the inevitability of dying

I have witnessed families go broke spending hundreds of thousands of dollars on life support for brain-dead relatives. In many cultures, the body must be kept intact as a mark of filial piety or to ensure a safe passage in the Underworld towards reincarnation. Surgery and organ donation work against such beliefs.

‘Face’ is all important to the Chinese

‘Shameful’ conditions such as domestic violence, incest, abortion, psychiatric illness, intellectual handicap, epilepsy, sexually transmitted infections, dementia, etc. must be quarantined within the family, to the extent of even withholding the information from doctors. In other cultures, ‘family honour’ must be protected at all costs, even to the extent of homicide of one’s family member.

After migration, generational conflicts can be very significant

Parents who have made sacrifices to enable their children to have a good education and prospects, are disappointed when their expectations are not met. Their children can’t wait to become independent from their influence. Yet, they are not shy to ask for ongoing financial support from their ageing parents.

Generational differences towards lifestyle and habits, such as sexual freedom, smoking, drinking, gambling and drug use are often points of conflict.

Elder abuse is real – financial, emotional, physical

One kind son with Enduring Power of Attorney bought a BMW sports car with the parents’ money, “to take his elderly parent to the doctors.”

Adjustments to the Australian way of life

Although they may be recipients of racist slurs, migrants can be just as racist against members of other races (foreign devil (番 鬼) , Goyim (גויים ), Ajam (عجم )). 

As migrants, we are minorities transplanted into another society. Prejudice, discrimination, and racism can be overt, covert, real or perceived. The expectations of migrants have changed over the years from assimilation to multiculturalism. Migrant families often ‘import’ prejudices from their own countries. Tensions can run deep between families from the same country, but holding different social or political perspectives.

In Australia, migrants have to learn new social norms and views. Gender equality, queuing for everything, having a fair-go, respecting personal space, not asking embarrassing questions, supporting the underdog, rules of mateship, and so on, are all lessons for survival. Bringing a plate to a meal is more than bringing a clean plate. Christmas Dinner is held at lunchtime.

“Depending on their experience, trust or mistrust of government agencies and officialdom can be extreme…”

Attitudes to social welfare can vary with different generations of migrants. Many elderly migrants shun social welfare and benefits since welfare was known as Almony (Alms, Almoner), and indicates penury. Others see it as a right. Depending on their experience, trust or mistrust of government agencies and officialdom can be extreme – information gathered can be used against you (eHealth debate). Chinese often do not like discussing ‘bad omen’ topics, believing that mentioning them brings them on. Death is a taboo topic and cancer must never be revealed to the sufferer.

Particular problems with Older migrants

The common theme is a progressive reduction in the ability to adapt to change.

As Shakespeare observed, all our senses fail with age. People put more salt on food because of reduced taste. My wife complains that I appear not to have heard what she said to me. I now hold out my hand when I close my eyes in the shower in case I fall. In winter, I have to apply moisturiser to my skin and eyedrops to my eyes. I can no longer open bottle-tops like I used to. Righting reflexes are delayed.  Falls are frequent, often complicated by fractures and hospitalisation. We gradually become frail – frailty is a new field of research in geriatrics. Healing of wounds is slower. We lose teeth and ability to eat hard foods.

Many elderly and their families are not aware of gradual declines in cognition, and make excuses that they are just forgetful, playful or clumsy. Cognitive and psychological disorders, cognitive changes, confusion and delirium, changes or accentuation of previous personality traits, mood disorders (depression, panic attacks), loss of insight, inability to self monitor, inability to multitask or make choices all take their toll. For the increasing number developing dementia, behavioural and psychological symptoms of dementia (BPSD) are a difficult complication which often leads to families giving up. 

Against this backdrop, there are triggering events – external and internal. External events include death of a carer, moving house (tree change, downsizing, supportive accommodation), accidents (floods, fires, storms), financial crises, wars, etc. Internal events includes falls, infections, strokes, chronic diseases complications, cancer, pain syndromes, etc.

Cost of living – Financial, human, support systems

As we live longer, we can also outlive our resources. This is not helped by stubborn inflexibilities, fears, distrust and denial.

Moving into a new community, you lose your support systems – you have to adapt to a new environment, you have no friends. Having a sea change or tree change can be an isolating journey. Losing a spouse can be devastating.

“Moving into a new community, you lose your support systems – you have to adapt to a new environment, you have no friends.”

Ageing can cause you to lose your identity and role, your routine, your self image. Hair loss, skin changes, incontinence and deteriorating looks can cause a loss of confidence and reluctance to socialise.

Problems facing Culturally and linguistically diverse (CALD) migrants

I will illustrate with some examples I have encountered.

Separated families. Taikonauting (TaiKongRen 太空 Chinese astronaut) is a phenomenon for businessmen who maintain their businesses in China while sending their wives and children overseas for security, financial independence, schooling, and securing a second home in a safe foreign country in case things go wrong at home.

You can often recognise Taikonaut families from the fact that the children follow their mothers’ surnames. These families are generally poorly supported and children often have adjustment problems. Some families have come from rural backgrounds and are unused to city living. Many fire alarms have been set off in high rise apartment buildings due to smoking under a smoke alarm. By contrast, we have had Hong Kong apartment dwellers being resettled in rural towns where they miss the city conveniences and feel isolated.

Literacy among CALD elderly cannot be assumed. Many large cities have high English illiteracy rates. Numeracy cannot be assumed. Many migrants hide their problems cleverly, eg. by pretending they have left their reading glasses at home, and asking you what the sign means. This can make assessment of cognition difficult.

Difficulties communicating in English for children settling in schools is common. Maths in Australian schools is considered ‘too elementary’, and it is novel that creative thinking rather than rote learning is encouraged. Parent-teacher interactions can be a challenging experience.

Image Mikhail Nilov, Pexels

Some elderly migrants live in virtual ghettos surrounded by their own culture. They can face isolation and denial of services. There are many barriers that face migrants, finding a job with your overseas qualifications is hard. Renting a property without any prior rental history can involve payment of a year’s rent in advance.

Working with colleagues from different backgrounds takes some adjusting. Sometimes barriers are perceived, and prejudices can go both ways. Without language and social contacts, it is easy for elderly migrants to get bored. There are many organisations and individuals that prey on this to lure them to spend time and money and investments in dubious products and schemes.

Coming from an authoritarian environment into a ‘free’ society can be both an opportunity and a challenge. Children of migrants often go to extremes with the liberty they experience, and experiment with illicit substances and relationships without parents who understand the dangers or have the ability to guide them.

Finally, there remains a lack of CALD-friendly Aged Care Services and facilities, and relying on Translation and Interpreting Services (TIS) have their limitations.

Nevertheless, many families choose to migrate.

Even back in the days of the Old Testament, Abraham, Jacob and their descendants left their native lands to venture into foreign ones, often out of necessity. I have been intrigued by the repeated narratives in Genesis 12, 20 and 26 of the patriarchs, Abraham (two accounts) and Jacob, deciding to pass off their respective wives as their sisters, in fear of being killed.  In all these instances, misunderstanding of the local custom, values and practices, led to serious jeopardy for the integrity of their clan and the fulfillment of the promises of God.  Nevertheless, God miraculously intervened and blessed His chosen people despite their stupidity. 

Likewise, as God’s children, we are often faced with unforeseen problems when we leave our own homes and cultures and encounter new concepts and challenges in a diverse world. Yet we can be assured that our Sovereign Lord is watching over us and will guide us through. When seeing patients from migrant backgrounds, we need to ensure a level playing field, provide the necessary language assistance, and double check that they truly comprehend what is being communicated.

Dr. Andrew Hua MBBS, FRACP
Dr. Andrew Hua is a recently retired physician and geriatrician who migrated to Australia from Hong Kong fifty years ago.  He lives in Melbourne, Victoria with his wife.  He is a guest academic with the University of Melbourne’s Healthy Aging Project where he supervises postgraduate students.


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