Recent immigrants to the United States seeking health care experience frequent frustration as they attempt to breach language and cultural communication barriers. Hold Your Breath, a 2006 documentary directed by Maren Grainger-Monsen, MD, follows the struggles of Mohammad Kochi and his family as they interact with the American healthcare system. Mr Kochi and his family left Afghanistan to live in Fremont, California during the early 1990s. When the viewer meets Mr Kochi in the film, he is suffering from an advanced stage of gastric cancer and can speak little English. As Mr Kochi interacts with medical staff, the film traces failed communications between medical professionals, Mr Kochi and his translators. The audience also witnesses Mr Kochi’s struggles to maintain his Islamic beliefs while contemplating treatment options for his cancer.
The most poignant and persuasive theme of the film is the deleterious impact of miscommunication on the healthcare of American immigrants. Mr Kochi’s daughters Habiba and Noorzia Kochi along with a family friend, Ramattulah Nazari, serve as the primary interpreters between Mr Kochi and his health care providers. Key instances of misunderstanding occur when Mr Kochi is first diagnosed with cancer, after he requests medicine to relieve a sore throat, and there is confusion about the available treatment options. Habiba Kochi, serves as his first translator. In an early consultation described but not shown in the film, a physician informs Mr Kochi’s translator that he has cancer. Habiba Kochi’s brother-in-law tells her not to translate this word and instead tell her father that he has a strain of bacteria. When asked about this earlier interaction, Mr Kochi remembers hearing the word ‘cancer’ and insists that he knew what it meant, although subsequent interviews with family members cause the viewer to question Kochi’s complete understanding of his diagnosis. Ramattulah Nazari next acts as Mr Kochi’s translator. Mr Nazari fails to convey the anger Mr Kochi experiences when his physician, Dr Fisher, does not provide him with medicine to relieve his sore throat. This failure to communicate is exacerbated by Dr Fisher innocently chuckling and suggesting that Mr Kochi take fluids to relieve his sore throat. While Dr Fisher and other medical personnel at the appointment do not intend to convey disrespect or an uncaring attitude toward Mr Kochi, the failure or inability of Mr Kochi’s translator to fully relay his concerns leads Mr Kochi to feel as though the physician does not respect him. Finally, a heated exchange occurs between the third translator, Mr Kochi’s daughter Noorzia and Dr Fisher. Noorzia believes Dr Fisher had not previously presented chemotherapy options to her father and for that reason chemotherapy had been delayed. Dr Fisher insists that he has informed Mr Kochi of chemotherapy options, but the patient had rejected chemotherapy because of ‘some sort of religious objection’. In fact, Mr Kochi’s rejection of chemotherapy was tied to his (false) understanding that the only delivery vehicle for the chemotherapy drugs was through an intravenous tube which would not allow him to perform daily prayer rituals The fact that other less invasive options had been available comes as a surprise to Mr Kochi and his daughter/translator Noorzia.
The communication disconnects that occur between Mr Kochi, his translators and physician represent a common issue that disrupts health care communication between American physicians and many immigrant groups. A 2007 study documents failed communications between elderly Vietnamese cancer patients, their translators and physicians. These failed communications are quite similar to the exchanges seen in Hold Your Breath. The Vietnamese patients did not believe it was their responsibility to question their physician or seek information on their own, leading to confusion among family members, translators and patients.Footnote 1 Dr Daniel Dohan and Dr Marya Levintova demonstrate a similar phenomenon in their study on medical translation issues between Russian-speakers who have cancer in the United States and their American physicians. In their study, many non-English speaking patients claim they never heard the word ‘cancer’ or understood the implications of the disease.Footnote 2 The unfortunate result of these translation disconnects is poor health care for American immigrants.Footnote 3 The intimate moments caught between Mr Kochi, his translators and his medical care providers are laden with good intent but profound misunderstandings and provide a palpable, emotional illustration of prominent issues that plague health care communication in the United States.
A viewer unfamiliar with Islam might misconstrue the filmmaker’s intent as suggesting a dissonance between Islamic belief and western medicine. In one of the opening scenes, the narrator poses the question, ‘What will (Mr Kochi) do when his deeply held beliefs are put to the test?’ This statement could suggest a narrative framework that pits Islamic belief against western medicine. Throughout the film, the filmmaker presents situations in which Mr Kochi resists the advice of medical professionals due to his Islamic beliefs. Mr Kochi decides to fast during the Ramadan holiday against the advice of Dr Fisher.Footnote 4 Mr Kochi also decides to join the annual Hajj to Mecca, despite the negative implications this may have for his medical condition.Footnote 5 Mr Kochi is (falsely) thought to have resisted chemotherapy treatment because according to his daughter, the treatment would involve the use of an intravenous delivery system – a treatment that would not allow Mr Kochi to clean himself properly for his daily prayers.
Dissonance in presented images furthers the impression of Islam and western medicine at odds. In the film’s opening frames, the filmmaker presents images of Afghani mosques in stark contrast to scenes of everyday life in present-day California, encouraging the viewer to differentiate Islam from the west. Medical images of stomach lining are interposed with footage of Soviet helicopters in Afghanistan, relaying images of military and corporeal battles, but also inferring that Mr Kochi as a Muslim who had lived in Afghanistan, fought the Russians and now western medicine in similar ways. When Mr Kochi decides against his physician’s advice to make a pilgrimage to Mecca, images of his journey are viewed in succession with footage of thousands of Muslims participating in the Hajj. The interplay of these images portrays Mr Kochi’s decision as one that many Muslims would make in his position. Finally, images of chemotherapy being administered through an intravenous unit are contrasted with a Muslim washing himself for prayer. These scenes alert the audience to a barrier between Islamic belief and western medicine.
Mr Kochi’s decisions may be personal, but they do not represent dominant theological philosophies of Islam. Mr Kochi’s imam in the film contradicts the false dichotomy of Islamic belief and western medicine by stating: ‘In the Islamic way of life, you should not put yourself in danger. So a sick person can’t just sit in a corner and say, ‘Allah will cure me’. This is not what Allah tells us. Allah tells us to go to a doctor so that you can be helped. The patient must follow the doctor’s orders one hundred per cent.’ The majority of scholars of Islamic traditions argue that the Prophet Muhammad advised his followers to seek out medical remedies.Footnote 6 Specifically, there is a literature within Islam entitled al-Tibb al-Nabawai (Medicine of the Prophet) in which the Prophet Muhammad instructs Muslims to seek out medical treatment ‘for God created a treatment for every ailment, except the frailty of old age (haram)’.Footnote 7
Positing Islamic thinking and western medicine as oppositional forces (i.e. believers of Islam are fatalists who oppose medical technology) is a conclusion that does not reflect the lived experiences of many Muslims. Anthropologist Sherine F. Hamdy warns of the dangers of assuming that immigrants who practice Islam are ‘passive fatalists’ who refuse medical treatment because their lives are in the hands of Allah. Hamdy’s study of impoverished dialysis patients in Egypt undermines the assumption that Islam runs counter to the benefits of western science and technology. By focusing on Islamic submission to divine will as passive, Hamdy reveals that commentators fail to appreciate that religious devotion is active and pitting religious devotion against material conditions (such as medical care) does not reflect lived experience.Footnote 8 Therefore, placing Muslim immigrants into a category of ‘passive fatalists’ fails to enrich our understanding of this population’s interactions with the American medical system.
Despite this shortcoming, Hold Your Breath has much to recommend it. The film opens a much-needed discussion on the problems of translation and the quality of American immigrant health care. Mr Kochi’s personal struggles with gastric cancer and the health care system reflect many more untold stories of immigrants from other cultures and religions. The communications dissonance experienced by Mr Kochi and his family offers a call for pedagogical and policy change so that other voices are not lost in translation.
