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© 2009 International Society of Travel Medicine, 1195-1982Journal of Travel Medicine 2009; Volume 16 (Issue 4): 284–285

Case Report

A 34-year-old man recently emigrated from Senegal pre-sented at our Outpatient Department (OPD) for Illegal Migrants in April 2004, complaining of long-lasting fa-tigue and chest pain. He had been living in Italy, without returning to his origin country where his wife and two sons still lived, since 2002. He had a precarious job and no residence permit.

He had previously presented to the Hospital Emer-gency Department, where a diagnosis of “ fl u like illness ” was made and symptomatic therapy was prescribed.

His clinical history was diffi cult to review because of language barriers. However, physical examination was normal. Routine blood test, chest X-ray, and Mantoux tuberculin skin testing were then performed. Chest X-ray and routine blood test results were within the normal ranges except for slightly elevated serum creat-inphosphokinase (CPK) values (179 IU/mL). Viral hep-atitis markers and HIV test were negative, while tuberculin skin test showed 11 mm induration.

During the following months, the patient came several times to our OPD. Thanks to a language and culture me-diator, we were made aware that he had been suffering from migratory pain at chest, spine, and limbs and had been losing weight during the past 4 years. In his opinion, the problem was in his blood and the literal translation of

his suffering was: “ There ’ s dead blood under my skin! ” While still in his origin country, he underwent traditional remedies, such as hot sand bathing to take the “ dead blood ” off. Over time, he became increasingly anxious, fearing a severe disease that could have prevented him from work-ing and carrying out his migration project successfully. The attending physician was doubtful whether to consider the patient ’ s problem a rare tropical disease or a psychoso-matic disorder. Diagnostic procedures for both problems were then started. The patient was admitted at the Depart-ment of Infectious Diseases of the Spedali Civili General Hospital in Brescia and psychological support was also provided. A wide range of serological (Epstein-Barr virus, Cytomegalovirus, Toxoplasma, Widal – Wright, syphilis, Leishmania , Dengue, Schistosoma , and Borrelia ) and immu-nological (autoimmunity and allergy panel) tests provided negative results, as well as urine cytology, blood and stool culture, stool and urine parasitological tests, mycobacteria search in feces, urine, and sputum. However, elevated se-rum CPK values were still present (299 UI/mL). Abdomi-nal ultrasound, electrocardiogram, and chest X-ray were normal. Finally, the diagnosis of tropical disease was ruled out. We then performed an upper and lower limb electro-myography that showed a proximal myopathic pattern, mainly evident at the shoulder muscles. A muscle biopsy was eventually performed 12 months after his fi rst contact with a medical facility and a diagnosis of “ metabolic con-genital myopathy ” was made. During these 12 months, he underwent fi ve psychological interviews from which we learnt he feared he had a bad disease and doctors did not want to tell him. He was afraid of the doctors but trusted in western medicine.

BRIEF COMMUNICATIONS

Dead Blood under My Skin

Issa El-Hamad , MD , * Carmelo Scarcella , MD , † Maria Chiara Pezzoli , MD, PhD , ‡ Antonella Ricci , MD , § and Francesco Castelli , MD , § for the Migration Health Committee of the ISTM

* Department for Infectious Diseases, Spedali Civili General Hospital, Brescia, Italy ; † General Directorate, Local Health Unit, Brescia, Italy ; ‡ Center for International Health, Local Health Unit, Brescia, Italy ; § Institute for Infectious and Tropical Diseases, University of Brescia, Brescia, Italy

DOI: 10.1111/j.1708-8305.2009.00312.x

The diagnostic attitude of western physicians toward migrants ’ complaints is often an unstable balance between the obstinate search for exotic tropical diseases and the overappreciation of the cultural dimensions of symptoms. Such attitude may divert attention from organic diseases. The careful assessment of all levels of possible misunderstandings ( prelinguistic , linguistic , metalinguistic , cultural , and metacultural ) may help the physician to discriminate between illness and disease . The long and diffi cult itinerary leading to the correct diagnosis of congenital myopathy in a migrant from Senegal is described, together with the barriers encountered by the caring staff.

Corresponding Author: Francesco Castelli, MD, Institute for Infectious and Tropical Diseases, University of Brescia, Piazza Spedali Civili 1, I- Brescia 25125, Italy. E-mail: castelli@med.unibs.it

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Communication Gap in Migration Medicine

Comments

Our case is a good example of a deleterious gap between the “ disease ” approach and the “ illness ” approach. 1 Actually, illness (patient ’ s perceptions of disturbing experiences including, but not limited to, disease) should be differentiated from disease (abnormalities in the structure and/or function of organs and systems, whether or not they are culturally recognized) to bet-ter appreciate the contrast between the perspective of patients and physicians in a sociocultural context. ” 2,3

Culture and ethnicity have often been quoted as barri-ers in establishing an effective and satisfying relationship between the patient and the physician. Current evidence exists that there is more misunderstanding, less compli-ance, and less satisfaction in intercultural medical consul-tation as compared to intracultural medical consultation, even after adjusting for socioeconomic variables such as education and outcome. 4 The vivid way the patient told us about his illness, together with the exotic origin of our patient, drove the physicians to consider fi rst a rare tropical disease, underrating the real clinical fi ndings of his disease. 1 The illness as perceived by our patient ( “ the dead blood under his skin ” ) was distracting from the appropriate and timely diagnosis and treatment of an organic disease, a variation of the “ hoofbeats and zebras ” analogy. 5

The relational aspect with the migrant patient is the cornerstone of medical care success. This can be im-proved by the use of transculturality tools properly addressing the fi ve levels for possible misunderstanding in communication as proposed by Geraci and Colasanti 6 : 1. Prelinguistic. Intimate experiences, often uncon-

scious, may not be expressed in words. 2. Linguistic. Due to language barriers. 3. Metalinguistic. Even if language is not a barrier, dif-

ferent concepts or symbols of disease and illness may make dialogue between the migrant and the physi-cian. The sentence “ … dead blood under my skin ” is a good example of the metalinguistic level of misun-derstanding.

4. Cultural. Due to different social customs, uncon-sciously acquired in the cultural original living context.

5. Metacultural. Due to different ideological, philo-sophical and/or religious beliefs. As noted by Kleinman and colleagues, there are often

discrepancies between the explanatory models of patients (heavily infl uenced by personality and cultural factors) and doctors (mostly based on a more narrow biomedical perspective), 1 resulting in gaps in communication. 4

If it is true that doctors consulting migrant patients need to develop their skill in dealing with medically un-explained symptoms working on communication and interpersonal relationship with the help of clinical, anthropological, sociological, and psychological exper-tise to fi nd a common conceptual ground, 7 they also need to avoid the risk to overemphasize the cultural dimension of the complaints thus underrating the clinical fi ndings. Our case is a good example of how diffi cult this approach is in real life.

In agreement with Hunter, 5 we believe that in a situ-ational and interpretative discipline such as clinical medicine, a balanced attitude should be adopted by the physician who should ask himself the following appar-ently competing and paradoxical questions: “ Which are the specifi city of the cultural and ethnic profi le of the patient that can have a role in this case? ” and, at the same time, “ How would I behave if this patient were from my own country? ”

Declaration of Interests

The authors state that they have no confl icts of interest.

References

1. Kleinman A , Eisenberg L , Good BJ . Culture, illness and care. Clinical lessons from anthropologic and cross-cultural research . Ann Intern Med 1978 ; 88 : 251 – 258 .

2. Hahn R . Rethinking “ Illness and Disease. ” Contrib Asian Stud 1984 ; 18 : 1 .

3. Young A . Anthropologies of illness and sickness . Annu Rev Anthropol 1982 ; 11 : 264 – 265 .

4. Schouten BC , Meeuwesen L . Cultural differences in medical communication: a review of the literature . Patient Educ Couns 2006 ; 64 : 21 – 34 .

5. Hunter K . “ Don ’ t think zebras ” : uncertainty, inter-pretation, and the place of paradox in clinical educa-tion . Theor Med 1996 ; 17 : 225 – 241 .

6. Colasanti R , Geraci S . I livelli di incomprensione medico-paziente migrante . In : Geraci S , ed . Argo-menti di medicina delle migrazioni (in Italian) , Busseto, Roma : Peri Tecnés , 1995 : 213 – 220 .

7. Salmon P . Confl ict, collusion or collaboration in consultations about medically unexplained symp-toms: The need for a curriculum of medical explana-tion . Patient Educ Couns 2007 ; 67 : 246 – 254 .