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Soc. Sci. Med. Vol. 40, No. 9, pp. 1243-1257.

1995
Pergamon Copyright 1995ElsevierScienceLtd
0277-9536(94)00230-4 Printed in Great Britain. All rights reserved
0277-9536/95$9.50+ 0.00

MAKING THE BIOPOLITICAL SUBJECT: CAMBODIAN


IMMIGRANTS, REFUGEE MEDICINE A N D CULTURAL
CITIZENSHIP IN CALIFORNIA
AIHWA ONG
Department of Anthropology, University of California, Berkeley, CA 94720, U.S.A.

Almtract--Linking the health profession to the normalization of citizenship, scholars influenced by Michel
Foucault claim that while biomedicine attends to the health of bodies, it is also constitutive of the social
and bureaucratic practices that socialize subjects of the modern welfare state. Yet, we seldom learn about
how patients themselves draw the medical gaze, nor how their resistances to biomedical intervention both
invite and deflect control. I try to show this by means of clinicians' and Khmer refugees' interpretations
of tbeir encounters. This study illustrates that refugee medicine is a mix of good intentions, desire to control
diseased and deviant populations, and the exigencies of limited resources which often favor medicalization.
Californian clinicians, many of them Asian-Americans, display a deep faith in the efficacy of modern
medicine for third world patients so that they can function in the new country. Khmer refugees, in contrast,
seek rather specific resources while wishing to elude control over the body and mind that goes with medical
care. I argue that the biomedical gaze is not such a diffused hegemonic power but is itself generated by the
complex contestation of refugee subjects pursuing their own goals. Cliniciansand refugees are equally caught
up in webs of power involving control and subterfuge, appropriation and resistance, negotiation and
learning that constitute biopolitical lessons of what becoming American may entail for an underprivileged
Asian group.

Key words--refugee medicine, Khmer immigrants, biopolitics, citizenship

FROM ABSOLUTE POWER TO BIOPOLITICS during the Cultural Revolution [2]. Thus for Khmer
refugees, most of whom came from rural areas outside
On a sunny afternoon in San Francisco, a young Phnom Penh, the United States represented a different
Khmer m a n wearing a U.S. army jacket told me the experience of state power that presents other kinds of
nightmare that recurred in his dreams. Some time in modern predicaments.
the early 1970s, he and his brother had been captured Michel Foucault argues that in Western democra-
by Pol Pot's troops. One day, he managed to escape. cies, modern state power is dedicated to ensuring "the
Hiding behind bushes, he saw soldiers kill his brother 'right' to life, to one's body, to health, to h a p p i n e s s . . .
and another prisoner. Their hearts and lungs were torn the 'right' to rediscover what one is and all that one
out, and hung on a fence as a warning to others. In the can be" [3]. These sentiments are expressed in the
silence following the story, the survivor held out his United States' Declaration of Independence, the most
hands, as if cradling the remains of his brother. Then, famous guarantees of modern citizenship [4]. From the
shuddering imperceptibly, he pulled his army jacket 19th century onwards, Foucault maintains, modern
closer. state power has been deployed mainly through social
Under the Khmer Rouge regime (1975-79), millions regulation that acts on the heart, mind, and the will,
of Cambodians (primarily Khmers) were forced to be dedicated to making individuals, families and
state laborers, while thousands were tortured and collectivities 'governable' [3, 5]. Social policy, in-
killed. By 1979, over a million had died, mainly from formed by the human sciences, came to constitute 'the
illness and starvation in the camps [1]. In their flight social.' 'Bio-politics' refers to the strategic uses of
from Kampuchea to the United States, Khmer knowledges which invest bodies and populations with
refugees escaped from a regime of absolute power over properties making them amenable to various
death to a democratic society defending life. They fled technologies of control [3]. Besides industrial policies
a preindustrial country where the Khmer Rouge [6], welfare services, public health, educational and
regime attempted to institute a modern bureaucracy of housing agencies administering the needs of citizens
terror. The central organ Angka Leou depended can be said to participate in the creation of biopolitical
largely on illiterate, teenage soldiers to enforce rule on subjects of a particular kind. The modern democratic
an uprooted and traumatized population, and state dominates through the m u n d a n e administration
continual surveillance to seek out 'enemies' and and surveillance of individual bodies and the social
document their crimes. These strategies are reminis- body, adjusting them to normalizing standards, and
cent of modern state terrorism like Mao's regime thus rendered governable as citizens.

ssM4o/9--F 1243
1244 AIHWA ONG

Among the schemes of knowledge/power regulating minority status. Next I consider a series of clinic
individual and social bodies, modern medicine is the encounters whereby health workers and refugees are
prime-mover, defining and promoting concepts, shown to be involved in overt and subtle struggles over
categories and authoritative pronouncements on medical knowledge, cultural beliefs and patient
hygiene, health, sexuality, life and death. According to objectives. I end by discussing the agency of Khmer
Foucault, the anatomical-clinical method is based on patients, viewed as the medical model of the chaotic
the pervasive medical gaze seeking out truths refugee body, and how it is related to the ways Khmers
embedded in the human body [7]. Thus the medical 'work the system' in their everday fight to survive in
gaze becomes a disciplining mechanism that by the United States.
defining human life as facts of the body, establishes the
normative identity and behavior of individuals, and
SCREENING AND DISCIPLINING BODIES:
populations. Scholars influenced by the Foucauldian T H E MAKING OF CERTIFIED REFUGEES
perspective have elaborated this argument further,
claiming that the health profession has a disciplining Following the Vietnamese invasion of Cambodia in
influence beyond the clinic in shaping the social needs, 1979, thousands of Khmers managed to escape to
rights and norms deemed appropriate for members of refugee camps near the Thai border. Many refugees
a modern civil society [8]. Thus while biomedicine is were peasants, most illiterate in their own language,
attending to the health of their bodies, it is also and the camps were the first places they encountered
constitutive of the social, economic and juridical Westerners. From the beginning, the encounters with
practices that socialize biopolitical subjects of the American service agencies, church groups and
modern welfare state [9] (p.248). immigration officials produced a portrait of the
But these observations of how biomedicine works to refugees that viewed them as threats, both ideological
define and reproduce biopolitical subjects cannot be and medical, to the American body politic where many
left unchallenged. Foucault notes that in social would be settled. The goals of of refugee recruitment,
regulation, subtle coercion takes hold upon the body processing and resettlement programs were to
at the levels of movements, gestures and attitudes [10] socialize refugees to a category of newcomers defined
(p.138), but he barely explores how the subjects of as both contagious to and dependent upon the civil
regulation themselves draw the medical gaze in the first society.
place, nor how their resistances to biomedical Officials from the U.S. Immigration and Naturaliz-
intervention both invite and deflect control. Using the ation Service (INS) used a system called 'Khmer
encounters between refugee medicine and Cambodian Rouge screening process' in selecting Khmers in
patients, this paper problematizes biomedicine as a Thailand refugee camps for resettlement in the United
mix of good intentions, desire to control 'diseased' and States. Although there was overwhelming evidence
'deviant' populations, and the exigencies of limited that only a tiny percentage of refugees were Khmer
resources which often compel medicalization. In Rouge members, thousands were rejected on
California, many clinicians, themselves the children of unsubstantiated grounds of participating in Khmer
immigrants, often display a deep faith in the efficacy Rouge brutality or Khmer Rouge affiliation [17]. At
of modern medical cure and practices for patients from the Khao-I-Dang camp, the most circumstantial
third world countries so that they can function in the evidence, like working involuntarily under the Khmer
new country. Khmer refugees, in contrast, seek rather Rouge authorities, or recounting stories that did not
specific resources while wishing to elude the control fit an assumed pattern of life in Khmer Rouge
over body and mind that goes with medical care. Thus collective farms, was used to reject applicants
the biomedical gaze is not such a diffused hegemonic [11](p.11) [19] . In addition to translation problems,
power but is itself generated by the complex the refugees' body language, of smiling under stress,
contestation of refugee/immigrant subjects pursuing and reporting the deaths of relatives with a
their own goals and needs, but within the bureaucratic dispassionate face, made them Khmer Rouge suspects
maze of American health and welfaie providers. in the eyes of INS officers [11] (p.19). A scholar
Clinicians and patients are equally caught up in webs reported that the "INS tends to perceive Khmer
of power involving control and subterfuge, appropria- Rouge affiliation where it does not exist" [11] (p.8).
tion and resistance, negotiation and learning that Although the INS interviewers had a great fear of
constitute biopolitical lessons of what becoming accepting the 'Red' Other into the United States, they
American may entail for a underprivileged Asian lacked cultural and political knowledge to accurately
minority. assess the applicants' stories, and many people who
I will begin by discussing how immigration were part of the Khmer Rouge organization got
authorities read the political and diseased bodies of through the screening process, along with thousands
Khmer refugees allowed into the United States. Their of others who were not. Between 1983 and 1985, the
arrival stimulated the invention of a field called United States accepted 50,000 Khmer refugees from
'Southeast Asian Mental Health' that through the Cambodia [12] (p.11).
systematic naming and ordering of refugee illnesses, Khmers who cleared the INS screening where
has the effect of controlling and reproducing their channelled to transit camps where they were subjected
Cambodian immigrants, refugee medicine and cultural citizenship in California 1245

tO language and cultural orientation classes aimed at diseases. Not only were they typecasted as having high
'transforming them' for the country of resettlement. In rates of TB and hepatitis, but some were susceptible to
the Philippine Refugee Processing Center (PRPC), what is referred to as 'the Sudden Unexplained
signs in the administrative buildings proclaimed: Nocturnal Death' (SUND) syndrome. Reports of
sudden deaths, especially among the Hmong, have
Refugee transformation, the primary goal of the PRPC
operations, is achieved through a psycho-social recuperative given rise to speculations about causes ranging from
process involving the 'criticalphases of adaptation, capability diet to the defoliant Agent Orange. Even before the
building, and disengagement' which result in changing a refugees streamed into the United States, health
'displaced person' into an 'Individual Well- Equipped for Life workers have constructed Khmers as a people carrying
in His Country of final destination' [13] (p.385).
exotic diseases as well as suffering from 'mental illness'
The transforming myth of the Overseas Refugee who must be treated [15], and 'transformed.' The
Training Program (ORTP) was to instruct refugees to stamping of Cambodians as 'certified refugees' and
"speak good English, be employable, be unwilling to their medicalization as 'diseased and sick' conditioned
accept welfare, and be happy" in America [13] (p.85). their reception in the United States [16]. The process
However, according to James Toffelson, the ORTP of 'transformation,' now passed into the hands of the
was an ideologically motivated strategy to instruct Voluntary Agencies (Volags) and health clinics
refugees in subservient behavior in order to prepare continue the focus on the problematized (interior and
them for limited occupational categories in the exterior, political and social) body of Cambodians.
American labor market [14] (pp.546,549). In Carol A. Between 1989 and 1991, I conducted research on the
Mortland's view [13], the institutional transformation relations between Khmer refugees and social agencies
of refugees as an underclass went further, in the in the San Francisco Bay Area as part of a larger
everyday regulation of camp relationships which project on cultural citizenship. My survey sample
reinforced the powerlessness of the refugees and their included 60 Cambodian refugees in two lower-class
structural dependence on American patrons for their communities. In East Oakland, I collected stories of
daily needs, movements and behavior. The effects of war, escape and illness, mainly from Khmer women in
these programs---in food distribution, health, edu- their homes, while in San Francisco, I participated in
cational classes, social activities--were to intensify the a Cambodian self-help group (with both male and
liminal experiences of the refugees, as they learned female members). In addition, I interviewed pro-
their place in the inter-cultural status hierarchy that fessionals working with refugees in community clinics,
foreshadowed their future positioning within Ameri- mental health clinics, county medical offices, volun-
can society. tary organizations and social welfare agencies. Since I
For liminal refugees, this process of social was not permitted to observe actual doctor-patient
debasement [13] (pp.389-390) includes their construc- interactions, my following account is based on the
tion as the contagious Other to American public interpretations both sides make of clinic encounters.
health. The Center for Disease Control (CDC) Doctors and nurses were interviewed in the
organized a transnational system whereby American workplaces, while Khmers were interviewed in their
public health advisors were stationed in asylum own homes.
countries (Thailand, Malaysia, the Philippines) to The Bay Area is a major destination for Khmer
monitor the health screening of U.S.-bound refugees. refugees, those coming directly from Asia or reuniting
All refugees were given age-specific immunization like with their families and friends from other parts of the
DPT, polio and measles for infants. Persons over two United States in the early 1980s [17]. As a first step in
years old were X-rayed to screen for infectious their resettlement, voluntary agencies handed out a
tuberculosis. Those with active or suspected active TB guide called 'Facts of Life in the United States,' issued
were placed in quarantine, and not allowed to leave for with the approval of the U.S. Congress and
the United States until deemed cleared. For many, Department of State. The booklet is available in 13
refugee camps functioned as quarantine camps. In languages, from Amharic to Khmer. After dealing
U.S.-arrival sites, CDC officers would notify local with the legal status of refugees, the rest of the
health agencies of each refugee's arrival, especially pamphlet covers hygiene and safety at home and in
those with active or suspect tuberculosis within 24 hr public. The introductory statement on sponsoring
of entering. In 1986 alone, the U.S. Health Services families is immediately followed by instructions to
administered $6 million for local refugee resettlement learn American ways of promoting healthy living.
agencies to conduct health assessments [15] (p.8). Interestingly, the focus on inadvertently offensive
Upon arrival, refugees were given cash assistance and bodies dwells on smells. It notes that
health care for up to 18 months. Such extraordinary Americans are very sensitive to personal body odors. Because
efficiency and expense ensured that although over of this, it is a good idea for people to bathe or shower and
700,000 Southeast Asian refugees have settled in put on clean clothing every day, and to wash their hair and
U.S.A. since 1975, they have not become a major clothes often . . . . Our dentists tell use to brush our teeth at
least twice a day . . . . Americans use many products to hide
threat to public health. their natural body odors. Most of us use deodrants and
Nevertheless, Southeast Asian refugees were mouthwashes. People do these things to prevent unpleasant
constructed as carriers of exotic and mysterious body odors that may offend other people . . . . [18].
1246 AIHWA ONG

Other instructions include ventilating the home so access to governmental aid and services, their rate of
that strong cooking smells would not offend the "mental health distress" is less than would be the case
neighbors. Lindsay French maintains that compared in the absence of state assistance [20] (pp.175-177).
to Americans, Khmers are much more sensitive to the This linear model of 'immigrant psychology' assumes
subtle distinctions and meanings of odors (personal that the sufferings of diverse populations follow
communication), and yet in this refugee handout, they generic patterns, and that 'mental health' constructs
are warned against offending American noses. are universally applicable, while ignoring the complex
Perhaps, smells, like viruses and diseases associated micropolitics and consequences of encounters with the
with refugees, are experienced by refugee workers as health profession. 'Immigrant psychology' is taken to
invisible but potentially offensive things that refugees be a thing that exists among (non-European)
bring with them, inadvertently invading the American immigrants who enter this country. No attention is
sense of 'place.' While bodies can be physically paid to how the biomedicine plays a role in defining the
contained, smells cannot. The focus on offensive nature and form of extent of this condition.
smells, those 'invasive' and invisible forces, highlights The arrival of Southeast Asian immigrants actually
anxiety over regulating refugee bodies in space. spawned medical terms creating a concept called
Refugee parents are urged to use diapers on babies. 'Southeast Asian Mental Health' that is unevenly
Other suggestions include not spitting or urinating in applied to Cambodians, Hmongs and Vietnamese [21].
public because 'Americans prefer clean public places' Since the early 1980s, American medical workers have
(Ironically, most poor refugees are resettled in used a range of universal diagnostic tools as the lens
low-cost, garbage-strewn neighborhoods). They are through which refugees from Southeast Asia are
also warned about sexually-transmitted diseases. viewed, represented and treated. 'Post-Traumatic
Refugees are thus immediately stigmatised at a very Stress Disorder' (PTSD), a symptom associated with
intimate level--the odors of their bodies and homes as survivors of the First World War, and later generalized
likely to offend clean-living Americans. By giving as an illness of survivors of concentration camps,
prominence to sanitary measures, the Facts of Life in became the health model for typecasting the problems
the United States booklet constructs cultural citizen- of Khmer refugees [22]. Sometimes recast as ~the boat
ship as attending to good hygiene, and its expression people's anxiety,' PTSD symptomology includes:
a sign of democratic sensibility. Refugees have to erase recurrent nightmares; feeling of sadness; social
the smells of their humanity, their suffering, their withdrawal; restricted affect; hyperalertness and
culture, in order to become like 'normal' Americans. startle reflex; sleep disorders; loss of memory; guilt;
I remember being greeted at a poor Khmer home with avoidance of activities that prompt recall of stressful
a woman spraying scent from an aerosol can. When I events [23] (pp.126-127). Another assessment tool
inquired why she was doing it, she said she had just freely applied to Khmer patients is a ~Depression
been cooking Cambodian food, which, she had Rating Scale' which has been slightly modified for
learned, 'smelled bad to Americans.' She had learned assessing 'cross-cultural psychiatric disorder" among
the lessons of stigmatized home and the necessity for Southeast Asians. Claiming that Asian immigrants
buying good status. The normalization of the refugee have a "private s t y l e . . , that suppresses expressions
body and home for the body politic has mainly fallen of dysphoric complaints," J. D. Kinzie and colleagues
to the responsibility of the health system, whereas developed the Vietnamese Depression Scale [24]. This
biomedical concepts and regimes determine what scale is sometimes used as the instrument for assessing
counts as healthy and culturally correct subjects. other Southeast Asia groups like the Khmers, who
have a rather different set of cultural beliefs and
practices [25]. Another diagnostic tool, the ~Children's
T H E EMERGENCE OF S O U T H E A S T ASIAN MENTAL
Global Asssessment Scale' (CGAS) has also been
HEALTH
applied to Southeast Asian immigrants. In one study,
This section examines the ways biomedical Khmer school children in Oregon were rated on a scale
hegemony defines the terms and practices whereby of behavioral deviance, and the doctors claimed that
Khmer refugees become a particular kind of American the CGAS was a better predictor of the children's
minority. It focuses on the truth effects of naming and distress than their own teachers [26]. By these codes,
classifying illnesses among an immigrant minority as Southeast Asian immigrants are medically defined as
relations of power between American academic and socially and culturally handicapped. The discourses
medical 'experts' and refugees from Southeast Asia. touch on Khmers' cultural and intellectual compe-
The control of the terms and practices that produce tence and their need for medical intervention. Khmer
various 'subjectivities' in the target population is itself patients have been described as 'passive, obedient' as
a source of social power [19] (p.7). well as 'non-compliant' [27]. This characterization is
Immigration scholars maintain that something explained as "the unique avoidance of thoughts or
called "immigrant psychology" depends to a great activities that reminded these patients of the past. The
extent on the immigrants' "contexts of reception" in patients often refused to tell their story in any detail,
the United States [20] (p. 175). They suggest that when and many have never told it to anyone else before.
lower-class newcomers like Khmer refugees have There was a conscious effort to deny events of the
Cambodian immigrants, refugee medicine and cultural citizenship in California 1247

past." [23] (p.127). Furthermore, "Many Southeast drug treatment. However, third world patients seldom
Asians have an unwillingness or an inability to make things easy: a doctor working with refugee
differentiate between psychological, physiological and patients notes, "Among the Southeast Asians, no one
supernatural causes of illness" [23] (p.116). These would come in and announce, 'I'm depressed'" [30]. As
statements seem to suggest that Khmers are 'difficult' we shall see below, although health workers solicit
patients whose noncompliance stems from cultural refugee stories, they use clinical labels to typecast
passivity, the traumas they had experienced in Khmers, who are urged to re-present their experiences
war-torn Cambodia, and their imputed intellectual in universalizable terms, and to cram the riot of their
limitations. suffering into little boxes on the psychiatrists' charts.
Mental health experts claim that Southeast Asians In many cases, the effect of mental health treatment is
are disproportionately afflicted with 'depression,' to by-pass or invalidate the patients' cultural
'over-dependency," 'isolation,' 'psychosomatic ill- understanding of their lives, as they are taken through
ness," 'somatization' and PTSD, compared to other a medical acculturation process that moves from the
groups in American society [23, 25]. In a report to the particular and cultural to the ethnic and the scientific
California Department of Health, an Oakland clinic American.
claims that 16% of Khmers suffer from PTSD; the An Argentinian psychiatrist in San Francisco who
condition was less prevalent among other Southeast has treated torture victims in his homeland criticizes
Asians in the sample [25] (pp,2-3) see also Ref.[23] local mental health practitioners for labeling South-
(p. 126). K hmers were said to be six to seven times more east Asian patients as 'depressed,' but rarely asking
likely to be in severe need than the general population. them about their war experiences.
Over 40% were in moderate or high need categories,
They don't tend to read about the killing fields. But with a
and should be "targeted for dramatically increased
little information, you know your patient went through hell,
services" [25] (p.9). Although the intention to help new a hell that no human being understands or is able to think
immigrants is genuine, the report interpreting Khmer about, if they never went through this or something like the
refugees" needs was released in time to buttress appeals 'mothers of the La Plaza de Mayo' went through. If you don't
by the mental health industry for more federal funds, know what political repression is all about and you are not
interested in asking the question, then you'll never know that
which had been severely cut back under the Reagan the patient has something in his or her past that is horrible.
administration. Getting the money is tied to the official
designation of Cambodians as a 'depressed' minority. He notes a similar situation in the ways some
Attempts to teach refugees medical concepts to doctors are ever ready to brand American veterans as
understand their experiences have inspired more costly suffering from PTSD, but almost never listen to their
and technologically-based innovations by health traumatic experiences or treat them with the attention
researchers. A wife-husband psychologist-psychia- they deserve. When I point out that Asian-American
trist team produced a videotaped "educational drama health workers also readily label the suffering of Asian
about PTSD" [28]. The PTSD videotape is distributed refugees PTSD, he rather harshly observes that they
to selected groups of Khmer refugees for viewing, in are "victims of their own repression," meaning that
the hope of sparking a catharsis of their (assumed) despite possible common cultural experiences that can
suppressed experiences. It is however a rather poor create more empathy between the clinician and the
version of the Southeast Asian TV soaps avidly refugee patient, the band-aid approach of bio-medi-
watched in Khmer households, and unlikely to elicit cine takes precedence.
greater emotional release. After viewing the 'edu- An important feature of Southeast Asian mental
cational drama," research assistants urge the partici- health is the significant number of Asian-American
pants to talk about their feelings and learn the new health workers whose task include instructing refugees
concepts. The professed aim was to "place PTSD in the American medical nomenclature. While it is
symptoms within their unique sociocultural context often claimed that their 'Asian culture' and third world
and then to teach basic problem-solving skills dealing family origins make them more able to empathize with
with major issues of daily living" [28]. This videotape the cultural predicaments of refugees, Asian-Ameri-
medical drama has been hailed for "exorcising the evil can doctors and nurses are at times even more insistent
that haunts Cambodians" [29]. on the by-the-book definitions of what ails their
By controlling the medical terms and practices, and patients. As we shall see, community clinics serving
seeking to instill them in patients, academic and refugee populations are the sites in which medicine
medical workers are part of an overall scheme of becomes a field of struggle over the cultural identity
power that defines the form and content of refugee and subjectivities of the Khmers.
illness and well-being, while producing the truth-
effects that shape the subjectivities of Southeast Asian
'CULTURAL SENSITIVITY' IN REFUGEE CLINICS
immigrants. Overworked and under-funded clinics,
swamped with clients from all over the world, seek an Northern California is the destination of refugees
efficient, though unsatisfactory, strategy to reduce the from all over the world, and local clinics are very proud
multicultural and personal details of patients' illnesses of their 'culturally sensitive' approach to health care.
into diagnostic categories, so that they can dispense Many of the health workers are American-born Asians
1248 AmwA ONG

"who may have been raised in bilingual households medicine' and 'refugee mental health' also reveal that
and witnessed firsthand the collision of old Asian while refugee medicine focuses on eliciting cultural
customs and new American ones." They understand talk that can be recast as symptoms recognizable to
concepts like yin-yang and the need to balance hot and biomedical diagnosis, clinicians as well as patients are
cold food intake, while practices like visiting shamans caught up in "webs of power" [35] that structure the
are supported [31]. As the children of immigrants, domination of biomedicine over (inappropriate)
refugees and holocaust-survivors, they are assumed to cultural knowledges, and the conflicts within clinicians
be especially sensitive to the cultural beliefs, practices as they try to enlarge the meaning of care for
and immigrant experiences of war refugees and Asian Cambodian patients.
newcomers. Cultural discourse is frequently deployed
to implant rational thinking in patients who are
'TALKING MEDICINE': REGULATING AND SUBVERTING
culturally different [32].
DRUG THERAPY
As first or second generation Americans, Asian
(especially Chinese) health workers have earned At one refugee clinic, culturally sensitive health care
professional degrees and moved out of Chinatown into is defined as an "appropriate use of Western
suburban communities. Partly as a result of this psychiatric methodology in non-Western population"
transition into the American scientific world and into [36]. The approach is inspired by Arthur Klienman's
the middle class, they can be among the most ardent distinction between disease, which is caused by
believers in rationality, and dismissive of pre-modern objective biological processes, and illness, or the
'superstitions' and practices. Perhaps because they are cultural experience and understanding of affliction
children of Asian immigrants who have suffered [37]. Other scholars have theorized cultural sensitivity
discrimination, some health workers consider it as a 'synthesis' between "psychiatry's biopsychosocial
necessary to root out non-Western cultural beliefs as model and an often different sociocultural model of
a strategy to gain acceptance and achieve assimilation. human cognition" in the "acculturating group" [38].
There is the suggestion that cultural loss is an However, in practice, the two perspectives, biological
unavoidable and necessary part of becoming Ameri- and cultural, are not held in dialectical tension, but the
can. But then rather ironically, some acculturated effect has been to subsume and invalidate the cultural
health providers express an underlying sense of beliefs of the minority group under the biomedical
Chinese cultural superiority towards Southeast framework. Although doctors and nurses make a show
Asians. Their location as a new category of health of collecting cultural data and talking cultural beliefs,
workers who are newly members of the middle class their medical knowledge is seldom questioned, revised
may also contribute to this faith in Western medicine, or relativized; it is in fact strengthened by the gap
and occasional disdain for non-biomedical forms of between the patients' cultural understanding and the
knowledge. doctors' scientific (not viewed as cultural) interpret-
Furthermore, although the health providers are ations. By constructing the cultural descriptions of
well-meaning and sympathetic, the pressure to 'do patients as "somatic complaints," the main treatment
something' with patients often means in practice that is "rigorous symptomatic therapy (drugs)" [36]
'cultural sensitivity' is used in a limited, strategic (pp.180-181).
fashion to win patients' cooperation, facilitate There are two aspects to what the clinic calls 'talking
diagnosis and buttress the doctors' authority, rather medicine.' One is to get patients to talk about their
than to give equal time or relativize biomedical experiences and beliefs in order to provide information
knowledge [33]. Such health workers are often unable that can facilitate diagnosis and the patients'
to take a critical view of their own professional role acceptance of medical authority. Doctors and nurses
when clinic discourse defines them as ideal care seek to elicit migration histories from reluctant Khmer
providers for Asian immigrants. Indeed, stereotypical patients, who have unpleasant memories of interroga-
cultural concepts are deployed to construct an tions by the Khmer Rouge and the INS. 'Talking
intersubjective reality that seeks to manipulate, medicine' is viewed as a way to put nervous patients
incorporate and supplant Khmer notions of healing, at ease, and by 'validating the patients' feelings about
body-care and knowledge. A main argument of this life events' doctors hope to carry on an ongoing
essay is that Khmer patients themselves learn to assessment of symptoms and treatment. The health-
manipulate these expectations for their own ends. givers, as much as the patients, are caught up in the
Ronald Frankenberg [34] notes that sickness is a regulatory effects of biomedicine, and cultural
'cultural performance,' a sequence of events in which material is appropriated only to be incorporated
disease narratives interact with patients' beliefs. For within the medical framework. Khmer health aides use
Khmer patients, refugee clinics become the sites in Khmer terms like 'hotness in the body, pressure on the
which a struggle ensues between biomedicine and their heart, and total body weakness' as substitute 'native'
own understanding of their experiences, and the terms for what doctors consider as symptoms of
skirmishes and standoffs are the key elements in a clinical depression. Furthermore, Chinese concepts
dynamic learning process of cultural belonging/citi- like yin-yang are assumed to be omnipresent in
zenship. However, the following cases of 'talking Southeast Asian cultures, and doctors invoke yin-yang
Cambodian immigrants, refugee medicine and cultural citizenship in California 1249

to explain "that chemicals in the brain can be out of set by biomedicine and clinic resources. While cultural
balance and that this can be the cause of their sensitivity and talking medicine as strategies to elicit
symptoms and sad feelings . . . . anti-depressant drugs information to aid diagnosis may reinforce biomedical
will restore this balance" [36] (pp. 182-183). control, they can at the same time be subversive of
Thus 'talking medicine' in fact buttresses a disease biomedical treatment, and provide the spaces for
narrative whereby stereotypical Asian patients' beliefs attending to sick hearts and souls. The dual and
are integrated and transformed within the medical conflicting aspects of clinic treatment describe a
paradigm. In practice then, 'cultural sensitivity' terrain wherein limited negotiation and empathy is
becomes a strategy that uses cultural difference not so possible, thus attenuating the cold and regulatory
much to understand particular experiences of illness as nature of modern medicine. Indeed, some refugees feel
to read symptoms that confirm universalized states of grateful to receive sympathy for their less tangible
biomedicine [39]. A doctor acclaimed for having dealt afflictions without having to go to the 'crazy house'
extensively with Khmer patients notes that "De- (mental health clinic). In practice then, the biopolitics
pression is depression in all cultures. It has the same of refugee medicine--mediated by the strategies of
vegetative symptoms" [30] (p.52). Although the cultural sensitivity and talking medicine---can only be
intentions of health workers are genuinely to respect accomplished and reproduced through a daily
patients' pain, their cultural difference is viewed as a cross-cultural negotiative and learning process on the
distorting screen that will, with difficulty, yield the part of patients as well as clinicians.
symptoms that can be identified in biomedical terms so
that appropriate drugs can be prescribed. The good
'REFUGEE MENTAL HEALTH': SILENCE, TELLING AND
intentions of the clinicians notwithstanding, the APPROPRIATE(D) MEMORIES
regulatory force of biomedicine absorbs cultural ideas
and transforms them into code-words that buttress The mental health clinic may unintentionally
medical authority, engender distress in immigrant clients through the
At the same time, 'talking medicine' also becomes a enforcement of rules regarding appropriate memories
strategy whereby health workers eager to provide to fit diagnostic categories, while the patient, once
more than drug therapy use the diagnosis process as medicalized, is urge to resist 'bad' memories. In an
a way to talk about the patients' past and current Asian mental health clinic, cultural sensitivity
experiences in order to provide a sympathetic ear. A describes an approach that elicits cultural information
nurse discusses how health workers deal with Post in order to be invalidated or erased so that
Traumatic Stress Disorder: self-discipline can begin the work of helping refugee
minds made chaotic and confused by war and
We do a couple of things. We make sure that we work the displacement. Mr Earn (a pseudonym) is a Khmer war
person up medically so that we are not missing some refugee who is being trained as a bilingual therapist.
physiological problem that can contribute to depression or
somatization and that can actually be treated... When the He finds it an especially frustrating job to mediate
workups start coming back all negative, which is often what between Khmer patients, many of whom are middle
happens, I will say to the people that it is very common for age and older women, and the criteria of mental
pain in life to cause pain in the body [40]. And now we are health. His job is to interview Khmer women referred
going to do something different. Now we are going to have
talking medicine. I frame talking about what has happened to his clinic, and using the Diagnostic and Statistical
in terms of medicine because it makes it a lot safer for people. Manual for Mental Disorders III (DMS III) as the
So we talked about your thyroid when you came in, we talked measurement, sort the patients according to DSM III
about your pelvic examination and now we are going to do categories of 'major depression,' 'schizophrenia,'
another kind of talking medicine about these complaints you 'conduct disorder' and 'bipolar disorder.' He then
are having. Usually I start with the present and what is
happening in your current life. "How many people are living presents the cases to Asian-American psychologists
in your house? Who did you bring over here with you? What and psychiatrists, who make the final decision of
is your community like?" And then, "Are you on welfare?" 'which category fits which patient,' and prescribe
"What kinds of financial concerns do you have?" And then drugs accordingly. Eam notes that although his
go back: "What was it like in the refugee camp? How was the
transition?" Then back to the actual flight experience. current job is not that of a policeman, he must find the
truth of his patients' lives:
She calls these 'mini-therapy' sessions because the There is nothing inside their minds thinking that ~Oh. 1 have
nurses are not trained psychotherapists. By stressing this thing called 'depression,' this thing called 'adjustment
their less strictly biomedical role, she reveals the staff's disorder,' or whatever..." Not only do they not know how
to tell their problems, but many do not want to tell the truth!
attempts to go beyond the dispensing of drugs to ask
questions that deal with the immediate h u m a n and Despite his own harrowing experiences as a war
social problems of the patients. 'Talking medicine' in refugee, in his current job, he can only subscribe to the
this sense seeks to provide, along with the aspirins, biomedical "truth" [41].
emotional comfort and perhaps referrals for patients In his view, patients lie because of shame over
who appear suicidal. Clearly, the clinic staff see seeking help at a mental health clinic which many
themselves as trying to give the best possible care to the Khmers consider as synonymous with 'a place for
multi-cultural refugee population, within the bounds crazy people.' Often, the shame comes from disclosing
1250 AIHWAONG

the collapse of family life and self-respect. He told a becoming healthy requires a mind that lets go of
story of a Khmer m a n whose wife had run away with painful memories.
another man. He got into a street fight with However, Khmer 'mental health' patients resist
African-Americans and was sent to a hospital which such losses, and take their prescribed drugs according
referred him to the clinic. to their own judgement of what is appropriate. One of
Eam's patients is a widow in her fifties who has had
He didn't tell what his problem was, he had been drinking!
high blood pressure and stomach problems for a long
He did not want to tell the truth because it's so shameful...
So my job is to find out exactly. In this country we expect time. She suffers from dizziness, and feels weak most
clients to tell us what's going on. It's the client's willingness of the time. When we met, she was sitting on the mat
to tell us what the problem is if they want us to help. But with in her living room, showing me a shoebox of medicine
the Cambodian, we have to dig it u p . . . to go deeper. bottles, many filled with pills:
Like his counterparts in other clinics, Eam's major The medicine I got from there is good and it sometimes
battle is simply to get Khmer refugees to talk. 'Mental relieves the headache... He tries to make all the women who
have mental problems happy. But I think a lot. He told me
health' treatment becomes a struggle between silences to forget about the past and not to think a lot. But how can
and truths, appropriate memories and diagnosis I forget? My husband was taken away from me and he has
according to psychiatric categories. Khmer refugees never come back. Some of my children [five] died because of
have survived war, labor camps, and flight by lack of food and medicine. In 1979, I was a single mother with
four sick children. When the Vietnamese occupied my
becoming masters in the contest between self-willed country, I carried all my sick children by turn, running from
silence and forced confession. Under Pol Pot, there one place to another to a find a place free from the Khmer
was a saying 'People would be saved if they plant the Rouge. I needed to find money to support my children. My
kapok tree (kor).' The word kor also means mute. A hands were full. I took my two older sons who were very sick
prophecy of doom noted that only by playing d u m b to the Battambang Hospital. I had to leave them there. I
escaped to the Thai border... When I arrived, all my energy
would people survive: "only the deaf-mutes would be was almost gone, and the two children who were with me were
saved during this period of misfortune" [2] (p.204). very sick too. We were sent to the Khao-I-Dang Hospital in
Silence and opacity become a shield of defense in the Thailand. We stayed at that hospital for several months.
face of authority. When I felt better, I wanted to go back to Battambang
Hospital to pick my two boys up. But I didn't know how to
The mental health quest for hidden 'truths' is made do this . . . . It had been very hard to escape to Thailand. I
more difficult when Eam tries to get older women to have felt sorrowful and sick since.
submit to the regime of confession. M a n y refugees
have great faith in Western medicine because they have In the United States, she reconnected with one of the
seen relatives and friends die because of lack of proper sons; the other had died at the hospital. Such memories
medical treatment during the war [42]. Now they desire are the connecting tissue to her past, and moral
the medical magic bullet that they think can ease their reasons for her current suffering. Her Buddhist faith
pains, but they detest the 'talking' part of the clinic may be defined as a 'deathlife' philosophy in which
culture. Some say to him, "I want to cooperate with consciousness of suffering and death is a moral
you, but the method you use is so difficult, it involves condition of existence [43]. This memory biomedical
discussion . . . . I fell dizzy, feel so exhausted." treatment seeks to blot out so that she can be freed
Furthermore, given their difference in age and female from the shadow of death, and participate more fully
modesty, female patients find it too humiliating and in her adopted country. But although she needs
painful to share stories of war deprivations and current medication, the old woman resists the medical
health problems with a younger man. dislodging of her past life, and what remains of her
In any case, Eam sees his job as getting them to say cultural self. Thus both the refugee clinic, with its
things that suggest symptoms identified in the D M S III conflicting goals of 'talking medicine,' and the mental
chart. The next step is to prescribe medication, which health clinic, with its judgement of what is appropriate
though desired, is carefully administered by the memory, provide very limited opportunities for the
patients. They complain that the drugs may be too telling of stories in a full and uncensored manner.
powerful, and have the effect of blurring memories Overall, given the fact that American medical settings
'constrain Khmers in expressing their own culture,' the
they may wish to retain, no matter how painful. This
effect seems to concur with Eam's understanding of the old woman seeks catharsis through talking of past
goal of mental health treatment: traumas, not in the clinics, but in the presence of
sympathetic relatives and friends who can share the
Our medicine is to knock you down in order not to think, not pain [44] (pp.138-139).
to think about what's going on, about the family.., just to
knock you down, to go to bed. We believe that the more the
patients sleep, the better the chance they will feel better. So MEDICAL AUTHORITY AND MEDICAL REGIMES
they forget whatever stuff that upset them.
In refugee clinics, daily encounters with health
Not only are memories deemed true or false, but workers are lessons in new bodily regimes or
they are then appropriated to medical knowledge. Mr "regularized modes of behavior" [45] (p.244) relevant
Eam, genuinely concerned with the suffering of his to the cultivation of behavioral traits like learning the
patients, is a cultural mediator who believes that routines of check ups, vaccination, family planning
Cambodian immigrants, refugee medicine and cultural citizenship in California 1251

and drug treatment, the temporal structuring of life Khmer) to have special insights into illnesses without
that they were first subjected to in the transit camps. cross-examining the afflicted [48]. Yet in America, the
However, again and again, Khmer refugees are doctors submit patients to an interrogation about
considered among the most problematic patients in many unrelated topics concerning themselves, their
learning medical routines. Their responses to medical relatives and migration history. A nurse in the refugee
orders are often found unsatisfactory, and labeled as clinic reports:
irrational, passive and face-saving. Some Asian- People sometimes doubt our abilities because we ask so many
American health workers interprete Khmers polite questions. 'Well, what's the matter? Don't you know? If you
smiles as expressions of their 'fear of authority.' Yet, have to ask these questions, then maybe you're not very
there is also a recognition that the smiles stand for good.' In this culture, we think the more questions you know
how to ask the more skilled you are. Oftentimes when I see
intransigence, and a subversive resistance to medical
patients I say, 'You may not be used to this but I am going
discipline. Khmer refugees deploy a range of to be asking you a lot of questions. This is how we do
tactics--silences, polite smiles, the resistant body and medicine in this country. I know that in the country you come
faking illness--to subvert and circumvent clinic rules from, people didn't ask you so many questions.' So we start
and control, and still retain the medical attention and from there.
resources they desire. Such cultural performances as Some doctors and nurses complain that Khmer
patients are important lessons in citizenship through patients seem to display scepticism when submitted to
which Khmers figure out how to obtain resources questioning. They wonder whether the doctors are
controlled by experts. tricksters, concealing their lack of knowledge by
A primary concern of Khmer immigrants is gaining asking many questions and relying on many
access to prescription drugs. In the Bay Area, a instruments, while failing to share the pain of their
majority of Khmers are on welfare, which also suffering.
provides health benefits (Medi-Cal). A major reason Some Khmers resist the doctors' authority by not
for remaining on welfare programs is to safeguard learning medication compliance. They complain that
their children's access to health care, which is very doctors prescribe too many drugs, giving them dosages
costly in California. In the refugee camps, Khmers, that are 'too hot.' Even after clinic reassurances that
who had lost almost everything, learnt to attach their dosage is proportionate to their 'smaller size'
themselves to someone who has power in order to gain relative to Americans, Khmer patients routinely
access to goods and services [43], thus adding a reduce their drug intake, or take their medicine
strongly instrumental cast to their traditional irregularly, i.e. when they feel bad [49]. For instance,
patron-clientelist orientation. This pattern of attach- some take drugs in combinations determined by the
ing themselves to institutionalized hierarchies of color or size of capsules. To instill a sense of medical
power was continued in the United States, where regime, the clinic gives each Khmer patient a card
American service providers and experts often became divided into columns represented by moon and sun
the focus of such deference because they can provide symbols to indicate appropriate times in the day for
access to important things like medicine [46]. taking medicine (Fig. l). Some patients misread the
Of all Western medicines, Khmers are most linear representation of time and substitute their own
interested in injectable drugs, intravenous drips and schedule. Thinking that the diagram depicts the lunar
pills in which they have an incredible faith. It is based cycle, they take their medicine according to the waxing
on the idea of putting good things into the body. An or waning of the moon. Through controlling their own
informant who was a pharmacist in Phnom Penh talks medication, Khmer patients hope to deflect the drug
about Khmers going to the hospital regularly for regime many are placed under, and ensure a continual
injections if they did not feel too well. Pregnant women source of medical attention and resources. One
wanted injections to be strong and healthy. (However, strategy is to stop taking drugs a few days before the
as mentioned earlier, Khmer Rouge 'medics' often next visit so that the doctor can see that 'I am still ill.'
injected injurious substances that badly harmed or Instead of directly challenging doctors' advice, Khmer
killed patients during the war.) Lindsay French reports
that in refugee camps, Khmers injected themselves
with B vitamins and treated themselves with stolen
antibiotic drips. She points out that Western medicine
I
is viewed narrowly in this light as a magic bullet, while
other aspects of Western healing are considered
unnecessary and obstructionist [47].
:o: I

However, in clinic encounters, Khmer's respect for


!
Western medicine is not matched by their respect for
American doctors, whose techniques and interpret-
ations they often find baffling and unable to heal their
suffering. Tactics are required to bypass or subvert
/MORNING NOON AFTERNOON BEDTIME
medical rules in order to get the medicine. Older
Khmers expect healers (like the Khmer shaman or kru Fig. 1. Card of daily schedule to take medicine.
1252 AIHWAONG

patients take the drugs while protesting that the illness body signs for pregnancy are often met by silence:
lingers on, and that they remain unhealed. "They don't say anything. They feel we're some kind
of authority." Using a maternal and teasing manner,
she urges Khmers to family plan. After the birth of a
PASSIVITY OF WOMEN, BODY OF RESISTANCE
sixth baby in a Khmer family, she said to the father,
In Cambodia, women played a major role in the "Papa, no more babies." "No one ever challenges or
daily care of their families, but in the United States refuses you," but the next time she visited, there was
they find themselves dependent on the modern medical a new baby. Harking back to her childhood in Hawaii,
system in which they operate as ignorant recipients. she compares Khmers to native Hawaiians as a gentle
Working with a Chinese-influenced humoral theory, people who love babies. In this case, the nurse accepts
Khmers believe that hot and cold winds affect the that her good intentions will be subverted, by a people
health of the body. Bodily aches (including headaches) whom she sees as grateful to America for accepting
are often treated by pinching, cupping and coining in them as refugees, and yet determined to follow their
order to relieve pain and bring toxic winds to the body own desires about having babies. The nurse continued
surface, thus restoring balances among elements in the to visit them. Through their passive pose as clients of
body, and between the body and the environment [27] the state, this Khmer family has subtly negotiated a
(p.437). Hot and cold foods are variously prescribed space for making their own decisions and yet still
to prevent imbalances in the body, or for restoring the maintain official connections that do not threaten their
sick body to health. Women's care of the body, family security.
through dietary and healing practices, together with Even more powerless than the men, Khmer women
their rituals commemorating dead ancestors, are social learned that they had no right to personal opinions and
obligations to ensure the health and safety of the open disagreements with authority figures in Khmer
family. The link between physical well being and communities and in American agencies. Furthermore,
nurturing one's social relations in this world and the the women's passivity may mask the loss of
next is clearly central to Khmer healing. self-respect, motivation and suicidal tendencies among
Perhaps not surprisingly, in the American clinic the survivors of war traumas [50]. One is never sure
encounters, Khmer women are viewed as a special how many have been tortured in their flight from
category of 'difficult' patients, perceived as more Cambodia, raped by Thai soldiers 'guarding' the
'traditional and superstitious' than men. Furthermore, refugee camps, or what kinds of compromises they
clinic workers characterize them as passive, silent and made to survive and care for their children, and how
fearful of authorities. Even Asian-American nurses deep their sense of dishonor. A Khmer woman told me
seldom talk to them in a such a way as to break that young girls arriving in Los Angeles were
through their silences. Whereas the health workers saw traumatized by the physical examination required of
Khmer women's passivity as simply a sign of their all refugees. Even if they had escaped rapes, Khmer
downtrodden cultural status, a passive posture can be girls have never been seen naked by anyone, except
read to mean a number of things, from tactics to deflect perhaps their mothers [27] (p.436). They were thus
control while maintaining a relationship, to attempts horrified to be told to strip, lie under bright lights, with
to shield a vulnerable self. In Khmer culture, authority open legs raised up in stirrups. Thus pelvic
figures should not be questioned or otherwise examination by male physicians, even with a female
embarassed, so both Khmer men and women tend to nurse standing by, becomes a painful rite of passage
display a passive obedience before authority [27] into the modern medical system.
(p.435). This pose of passivity was further honed Refugee clinics have learnt of Khmer women's great
during the Pol Pot years, when, as mentioned earlier, sensitivity about exposing their lower bodies to the
by playing the deaf-mute, Khmers avoided disclosures medical gaze. At the Northern California clinic:
and exposures that could result in terrible conse-
quences to oneself and one's loved ones. In refugee We have a policy here that we don't do pelvic exams on single
women or women who are not sexually active because there
camps and in American institutions, Khmers find that is so much cultural stuff that is attached to virginity and an
by being passive with powerful authority figures, they intact hymen.
can dissemble about what they want to do and the
reasons for doing so, while still maintaining the Only female health workers do pelvic exams on
patron--client relationship that would grant them married women or those whom they suspect have had
access to scarce resources. Often, the customary sex or been raped. They are told the medical reasons
passive obedience is "compounded by fear and for gyneacological examinations. Whenever possible,
ignorance of our legal system" [27] (p.435) as Khmer young women who are examined are told that they are
patients worry that by yielding up information about 'still virgins.' In preventive medicine, Khmer women
themselves to an American official, or deliberately are also taught to explore their own bodies, something
disregarding rules, they may be threatened with they are not used to doing:
deportation. I also teach women how to do their own breast exams which
For instance, a Japanese-American nurse who is kind of radical for them because they are not used to
makes home visits says her instructions about reading touching themselves in a specific way.
Cambodian immigrants, refugee medicine and cultural citizenship in California 1253

However, the nurse is not able to persuade Khmer constitute the proper medical and juridical subject.
women to go so far as to learn to use a diaphram. They Refugee women, especially those from Southeast Asia,
have to depend on patient coaching, and are perceived become the paradigmatic clinical pictures of disorder.
as being used to 'having things done for them.' In California, Khmers are perceived as large welfare
While Khmer women learn medical manipulation of families who are becoming part of the underclass [53].
the body, they sometimes draw the line at surgery. In They epitomise the fecund premodern women who
Khmer Theravada Buddhism, the physical body is must learn self-disciplineand new knowledge to fit into
viewed in unity with the social self and the soul; all modern civil society.
three are closely inter-related. A sacred essence resides Since sex is such a culturally sensitive subject,
in the head of each individual, and the head must be Asian-American nurses play a major role in
treated with special respect. After death, the soul reproductive health education. A Chinese-American
separates from the body and continues its existence, nurse sees her role as promoting "patient participation
hopefully in a higher reincarnated form. In her in the decision . . . to empower them as parents."
research among Khmer amputees in refugee camps, Collecting groups of refugee and immigrant women in
Lindsay French [51] observes that to be born her clinic, she discusses the whole idea that one can
able-bodied and then lose a limb is a sudden downturn plan pregnancies, and the different methods of
in one's fortune. It is a sign of bad karma, which contraception, and prenatal care. When her instruc-
represents not only a fall in status but also does not tions are received in silence by Khmer women, she
bode well for the future. Furthermore, for Khmer takes it to mean their "not wanting to lose face by
patients, surgery may unintentionally invoke torture asking an authority figure questions":
during the war years. Soldiers on both sides routinely
And 1 say, wait a minute, you have a right to ask questions,
cut open the bodies of fallen soldiers to eat the livers you have a right to refuse, you have a right to another
or mutilate them further [2] (pp.21-22). Many Khmers opinion. They say "yes,' but do not comply with my orders
saw family members killed under torture and . . . . Even though they are passive, they are even more
dismemberment, or injected with fatal substances [42]. demanding (than other patients) becausewe don't know what
they are questioning, or what issues are there for them.
As patients in clinics, Khmers are compelled to rethink
the relationship between bodily integrity, social status In her estimation, Khmer women are more passive
and war memories on the one hand, and biomedical than Chinese or Russian refugees. After her
forms of domination on the other. presentations, Chinese women would ask questions. In
Preventive medicine, for instance, requires medical one meeting, "the Russians ask, ~Can I have a
interventions into hidden bodily processes to control sonogram?"' [54]. Instead of seeking the latest medical
the spread of cancer or regulate pregnancy. A nurse technology, Khmer women "turn their bodies over to
reports that a Khmer woman, when told that she had authority figures. They will say yes to everything, leave
a breast mass, refused any medical procedure. Even and then come back p r e g n a n t . . , they're just saying
after seeing five specialists and shown the X-ray image, it at times to placate us." As the nurse recognises, the
she even resisted having a biopsy. She could not see a 'passivity' of Khmer women constitutes an unspoken
connection between her current feeling of health and resistance to medical regulation of their pregnancies
the image of the diseased body. And the idea of being and family life.
under general anesthetic frightened her. Her sense of Khmer patients are thus engaged in a complex type
well-being could not accept the connection between of contestation that both invites medical attention and
the X-ray image and a disease that she could neither yet repels it. Khmer women display polite smiles, stony
see nor feel. The X-ray, an invisible penetration of silences and pregnant bodies. Their sense of self refuses
one's insides, will lead to unnecessary surgery, a a clinical, detached attitude towards their bodies. They
procedure that may lead to dismemberment and appear uninterested in lessons on birth spacing, the
mutilation of the body. By following medical stages of pregnancy and phases in the birth-process
instructions, one will consign oneself to a karmic bad intending to teach the cultivation of a modern attitude
fortune, that will reduce one's status and social towards their bodies/selves. They are apparently
capacity to be effective in everyday life. Furthermore, impervious to medical interpretations of their
she was asked to sign over the custody of her body for problems, needs and goals. Thus the medical gaze can
the operation. Surgery thus recalls situations under the be said to be reproduced by such passive resistance,
Khmer Rouge, when being interviewed and signing which compels further medical instruction and
forms often resulted in one's torture, dismemberment resources to make them 'better patients' [55]. Because
and death. Her fears were so great that the clinic could the unregulated fecund Khmer body seems both
do nothing, but worry about the possibility of whether premodern and undisciplined, it confirms the image of
the patient's resistance to preventive surgery will also a new (Asian) American underclass already stigma-
dissuade her from pursuing a law suit further down the tised for its unwed, pregnant teenagers [56].
line. Furthermore, family planning is presented as an
Medical regimes thus not only socialize people to individualized decision to treat one's body as a
expected norms of patient behavior [52] but also manipulable machine, apart from its emotional, social
instruct patients about the rules and rights that and political contexts. Nurses try to 'empower' the
1254 AIHWA ONG

women in decision making about having children, but sufficient social support. Thus, while medical agents
cannot influence domestic patriarchal power that also try to enhance the disciplinary utility of the refugee
claims control over the female body [57]. body, Khmers manipulate their own bodies in order to
The loss of children to starvation and disease during circumvent control, while desperately seeking welfare
the Khmer Rouge years has increased the desire to rights to greater social benefits. Thus they do not
have more children. Furthermore, family-planning entirely refute the trope of the 'depressed Cambodians'
was an unknown concept and the women never talk to because of its utility for ensuring their access to
their husbands about sex, an area that is viewed as the medicine, continuing health care and additional social
husband's prerogative [58]. There is the stark reality support.
that having more children in the United States will Encounters in clinics then involve social contesta-
ensure greater government aid, in a context where few tions that go beyond skirmishes over medical
husbands have the skills to be employed. Thus discipline. Although doctors and health workers are in
although pregnant women attempt to deflect medical a sense socializing agents, the refugees are not
discipline, they wish to retain their claims on health 'normalized' in quite the ways intended: as better
care, and through their babies, on the wider welfare patients. Instead, through their own perception of
support system that will ensure the survival of their their own limited rights and security in America,
families. Khmer patients are negotiating, with and through
their health providers, for resources that will ensure
their survival in this country. The wider network of
WORKING AROUND THE MEDICAL SYSTEM
welfare bureaucracy, of which community clinics are
Resistance is seldom articulated, due to language a part, is the training ground in which refugees learn
problems, and an aversion to disagree with Americans what cultural citizenship entails for the poor.
who are all viewed as having provided safe refuge to
Khmer refugees, and who continue to be providers of
CONCLUSION: REFUGEE MEDICINE
everything from over-the-counter pills to a living
income. Instead, the locus of resistance is in their I have argued that the work of biomedicine goes
bodies, and its refusal and subversion of medical beyond providing health care to shaping, in both
discipline. However, despite their wish to remain intended and unintended ways, the cultural citizenship
unappropriated by medical regimes, Khmer refugees of different categories of patients. The biopolitics of
hang on to government subsidized clinics because it is medical production include institutions like refugee
a key institution that helps secure their other needs. clinics that attend to sick newcomers and through the
Because they feel the need to repel the perception that disciplining of everyday behavior, socialize them as
they are 'living offthe system,' Khmers use non-verbal governable citizens. However, I pointed to the
strategies to negotiate their specific goals with the limitations of a Foucauldian analysis for understand-
medical authorities. ing the micropolitics of clinic encounters since
Khmers in different age groups and family Foucault's concern was with the generalized effects of
situations are eligible for different combinations of biomedicine, and he did not extend his analysis to the
health, food and welfare supports, and strategies to complex intentions and manipulations of medicalized
secure these benefits have become a daily obsession subjects who in their everyday life must operate in
[59]. Women with children under 18 have access to different webs of power. The above discussion reveals
Medi-Cal (federal and state health benefits) together that the disciplining mechanisms of biomedicine, while
with the Aid to Families with Dependent Children linked to the bureaucratic apparatuses of Western
(AFDC) program. They also receive food stamps. democracies, are less powerful and all-pervasive than
Clinics are the gateway to other forms of supplemen- we have given them credit for. The clinicians
tary support. Pregnant women are asked to get a clinic themselves appear to be both agents and objects of
clearance in order to qualify for a supplementary food biomedical regulation. They seek to reduce patients'
program (Women, Infants and Children), which will cultural beliefs to biomedical terms, but at other times
provide food and diaper vouchers for a child up to five subvert medical procedures in order to provide
years. Older refugees, or those with no young children, emotional support; they instruct patients in the norms
hope to receive the Social Supplemental Income (SSI), of medical regimes and yet are must sometimes adjust
including food stamps, which are granted to people to patients' insistence on 'deviant' behavior. Perhaps
who are disabled, blind or 65 years old or more. Many the overwhelming sufferings of refugees daily remind
Khmers I met have tried to get doctors to exam their doctors and nurses about the limits of biomedical care,
eyes, ears, limbs and even mental condition in order to even when they believe in it as the best medicine for life
qualify for SSI. Young and old Khmers make repeated in modern society.
visits to clinics to get drugs and a health certificate One finding of the clinic encounters between Khmer
qualifying them for additional support. In some cases, refugees and American clinics is that the subtle
Khmers fearful of a life on the streets, fake blindness subterfuges of the cultural Other both frustrate and
and madness in their clinic examinations, creating compel the medical gaze. They reveal that biomedical
dysfunctioning bodies/minds that mime their lack of management and control are achieved and reproduced
Cambodian immigrants, refugee medicine and cultural citizenship in California 1255

only t h r o u g h a process o f negotiative, cross-cultural Pot regime and its devastating effects on Khmers, see
learning on the part o f doctors a n d nurses as well as Kiernan, B. and Chanthou B. (Eds) Peasants and Politics
in Kampuchea 1942-1981. M.E. Sharpe Inc., Armonk,
refugee patients. T h e K h m e r patients, a largely New York, 1982. For the situation in the camps, see Levy
illiterate peasant population, show themselves to be B.S. and Susott D.C. (Eds) Years of Horror, Days of
masters of inscrutability, skills that have helped them Hope: Responding to the Cambodian Refugee Crisis.
survive wars, a n d t h a t continue to be relevant for their Associated Faculty Press Inc., Millwood, New York,
1986.
everyday survival as the most d i s a d v a n t a g e d newcom-
2. A brief comparison between the Khmer Rouge in
ers in A m e r i c a n society. E n c o u n t e r s with clinics are a Cambodia and the Red Guards in China can be found in
necessary p a r t o f their lives, but biomedicine, a l t h o u g h Becker, E. When the War Was Over: The Voices of
part o f the everyday relations of d o m i n a t i o n , c a n n o t Cambodia's Revolution and lts People, p. 260. Simon and
offer the deep healing t h a t is sought. The following Schuster, New York, 1986. For an ethnographic account
of how the Cultural Revolution gave vent to extensive
example reveals the complex intentions at work in surveillance and terrorization of ordinary civilians, see
dealings with clinics. Chan A,, Madsen R. and Unger J. Chen Village under
A n elderly K h m e r widow, Mrs Yem, goes to a Mao and Deng (Expanded and revised ed.). University of
mental health clinic for her headaches, a n d to a private California Press, Berkeley, 1992.
3. Foucault M. The History of Sexuality, Vol. 1: An
Vietnamese doctor, h o p i n g that he will sign a medical
Introduction, p. 145. Vintage, New York, 1979.
certificate qualifying her for additional welfare aid. 4. The Declaration of Independence, read in the United
The clinic gives her shots a n d drugs. " T h e more I take States Congress on 4 July 1776, stated in part: "We hold
them, the more trouble they give me. Like here these truths to be self-evident, that all men are created
[tapping on her temple], it feels like someone is drilling equal, that they are endowed by their Creator with
certain inalienable rights, that among these are life,
away a n d it hurts so m u c h that I black o u t . " Rejecting liberty, and the pursuit of happiness. That to secure these
her medication, she sought out the kru Khmer who had rights, governments are instituted among men, rendering
foretold her h u s b a n d ' s d e a t h on the voyage over. N o w their just power from the consent of the governed...'"
he advised her t h a t she m a y have offended ancestral 5. Foucault M. Governmentality. In The Foucault Eff~ct
spirits. "Yes, I might have said s o m e t h i n g wrong. It is (Edited by Burchell G., Gordon C. and Miller P.),
pp. 87--104. University of Chicago Press, Chicago, 1991.
possible that I d i d n ' t t h i n k of the spirits, that we 6. Ong, A. The production of possession: spirits and the
arrived in the A m e r i c a and we d i d n ' t m a k e any multinational corporation in Malaysia. Am. Ethnolog.
offerings." The kru Khmer instructed her to set up an 15, 28, 1988.
altar in her b e d r o o m to appease the angry spirits. 7. Foucault M. The Birth of the Clinic: An Archeaology of
Medical Perception (Translated by Sheridan Smith
Praying to her ancestral spirits a p p e a r e d to give her the
A.M.), pp. 196, 198, Vintage, New York, 1973.
kind o f relief from suffering that the clinic could not. 8. Donzelot J. The Policing of Families. Hutchinson,
While K h m e r s desperately need a n d seek m o d e r n London, 1980.
health care, they c o n t i n u e their search for older, and 9. Hewitt M. Biopolitics and social policy: Foucault's
more satisfying forms o f healing. Nevertheless, account of welfare. In The Body (Edited by Featherstone
M., Hepworth M. and Turner B.S.), pp. 225-255. Sage
biomedicine continues to be very powerful as an Publications, London, 1991.
institution in the work o f producing s o m e w h a t 10. Foucault M. Discipline and Punish: the Birth of the
normalized patients in m o d e r n civil society. H e a l t h Prison, p. 138. Vintage, New York, 1979.
workers find themselves as m u c h c a u g h t up in the 11. Golub S. Looking for Phantoms: Flaws in the Khmer
Rouge Screening Process. U.S. Committee for Refugees,
regulatory processes o f refugee medicine as are the
Washington DC, 1986.
refugees themselves. These critical lessons in citizen- 12. U.S. Committee for Refugees (USCR), Cambodians m
ship reinforce the K h m e r s ' c o n s t r u c t i o n as underclass Thailand: People on the Edge, p. 11. American Council figr
subjects in society, while doctors a n d nurses find that Nationalities Service, Washington DC, 1985.
their sense o f themselves as good care-givers is defined 13. Mortland C.A. Transforming refugees in refugee camps.
Urban Anthrop. 16, 375, 1987.
in part by their unwitting role as socializing agents of 14. Toffelson J.W. Response to Ranard and Gilzow: the
the state. economic and ideology of overseas refugee education.
TESOL Q. 543, 1991.
15. Dan P.Q. Health issues of concern to the Asian
Acknowledgements--This paper is based on a larger research
immigrant population: epidemiological issues. In Tl~e
project funded by the Rockefeller Gender Roles Program. In
Asian Woman, pp. 5-11. Cicatelli Associates, Region 11
the field, I was ably and patiently assisted by Maeley Kim,
Family Planning Training Center (Sponsored by The
Vannary Om and Katharya Urn, who introduced me to many
subjects in Oakland and transcribed reams of interviews. This Asia Society), New York, 1986.
16. Many Americans think that the country is now under
project would not have been possible without their help. ! am
especially grateful for valuable comments on this paper by threat from the inexorable influx of immigrants from all
over the world. The medical construction of immigrant
Lindsay French, Lawrence Cohen, and anonymous
reviewers. Early versions benefitted from comments by subjects is not unprecedented in U.S. history. Since the
Donna Haraway, Kathryn Poethig, Vincanne Adams and late 19th century Asian immigrants have been viewed as
Anna L. Tsing. inferior racial bodies who should be excluded from the
body politic. See Horsman R. Race and ManiJest Destiny.
Harvard University Press, Cambridge, MA, 1981. The
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long-term American view that newcomers of all kinds
1. In this paper, Cambodians and Khmers are used were the source of "'germs and genes of an inferior sort"
interchangeably. For the most reliable account of the Pol See Kraut A.M. Silent Trat,elers: Germs, Genes, and the
1256 AIHWA ON(}

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17. Most Khmer refugees coming to the United States are of used to control 'irrational" incidents like 'mass hysteria'
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Asia, like Filipinos, Indonesians, Malaysians, Thais, 40. There is irony in the nurse telling Khmers that 'It is very
Burmese and Singaporeans living in California, the term common that pain in life causes pain in the body' since
'Southeast Asian' is normally not used to refer to or the Khmers themselves consider health as an inseparable
include them. They are called Asians or Pacific Islanders. part of maintaining one's relationships with family, both
'Southeast Asian' is reserved for populations from those alive and dead. For Khmers, illness is seldom a discrete
countries directly involved in the 'Vietnam' War, physical phenomenon apart from the social identity of
1962-1975. the afflicted. For instance, a Khmer peasant often
22. Kinzie J.D., Fredrickson R.H., Rath B. and Fleck J. Post attributes illness or misfortune to angry ancestral spirits,
Traumatic Stress Disorder among survivors of Cambo- which can deprive one of the vital life-sustaining essence.
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25. Gong-Guy E. The California Southeast Asian Mental 41. Before the Khmer Rouge took over, Eam was a
Health Needs Assessment. Asian Mental Health Services, policeman in Phnom Penh. In the subsequent slaughter
Oakland, 1987. of members of the Lon Nol regime, he was the only
26. Sack W.H., Angell R., Kinzie J.D., Manson S. and Rath member of his squad to survive.
B. The psychiatric effects of massive trauma on 42. Not only were people deprived of modern medical care
Cambodian children. II. The family and school. J. Am. under the Khmer Rouge regime, untrained "medics'
Acdy. Child Psyehiat, 25, 377, 1986. injected toxic and poisonous substances called ach
27. Muecke M.A. Caring for Southeast Asian refugee tunsiy, or rabbit's secretions, into the sick, thus causing
patients in the USA. Am. J. Pub. HIth. 73, 431, 1983. See their death. See Haing N. Haing Ngor: A Cambodian
also Ref. [23] (pp.123, 125). Odyssey, pp. 116--117. MacMillan, New York. 1986; and
28. White-Baughan J., Nicassio P.M. and Baughan D.M. The Tenderloin Times September, 2, 1991.
Educational drama and problem solving training for 43. Frankenberg notes that Western biomedicine is
symptoms of PTSD in Cambodian refugees. Talk and overly-focused on 'lifedeath," that part of life in which
videotape presented at the Refugee Information Exchange death is not yet consciousness, if not denied [34](p. 18).
Conference, Sacramento, 22-24 August, 1990. 44. Marcucci J. Sharing the pain: critical values and
29. Abramson B. Exorcising evil that haunts Cambodians. behaviors in Khmer culture. In Cambodian Culture Since
San Diego Tribune, 22 June, AI, A6, 1991. 1975: Homeland and Exile (Edited by Ebihara M.,
30. Krich J. Culture crash. Mother Jones Oct., 24~27, 52-53, Mortland C.A. and Ledgerwood J.), pp. 129-140.
1989. Cornell University Press, Ithaca, 1994.
31. TheNew York Times 28 June, 10, 1992. While laudingthe 45. Giddens A. Modernity and Seif-ldentity. Stanford
'cultural sensitivity' of these clinics, the article ends by University Press, Stanford, 1991.
mentioning a Chinese doctor who dissents from the 46. Ledgerwood J. Portrait of a conflict: exploring changing
approach. He said, "'What we have to do as providers is Khmer-American social and political relationships. J.
to be curious. We have to ask again and then again. This Refugee Stud. 3, 135, 1990.
Cambodian immigrants, refugee medicine and cultural citizenship in California 1257

47. Personal communication. underclass. Presented at the Population Association qf


48. In Cambodia, shamans (kru Khmer), both female and America Annual Meeting, San Francisco, 4 April, 1986.
male, heal the sick by prescribing herbs and setting bones, 54. Mentioned in a report on the clinic in The New York
but their primary work is in divining the cause of a Times 28 June, AI0, 1992.
person's illness and mediating with spirits to heal illnesses 55. See Martin E. The Woman in the Body. Beacon Press,
and remove misfortune. See Ref. [40]. In refugee Boston, 1989, for a critique of obstetrics as a medical
communites, the kru Khmer continues to do a flourishing control over women's bodies, and the birthing process,
trade attending to the sick who are also seeking Western so that the doctor, not the mother, 'produces' the baby.
drug therapy. 56. Social workers complain about the increasing number of
49. Many consider Western medicine too "hot" for Khmers, Khmer girls becoming pregnant and dropping out of
and should be taken only in small doses [27] (p. 436). See school. Workers in the Women, Infant and ChiM (WIC)
also Kinzie J.D. The establishment of outpatient mental program also note the increasing number of pregnant
health services for southeast Asian refugees. In Refugee Khmer teenagers among their clients.
Mental Health in Resettlement Countries (Edited by 57. Ong A. Refugee love and Khmer families: the cultural
Williams C.L. and Westermeyer J.), pp. 217-231. work of citizenship in California. Presented at the Am.
Hemisphere Publishing Corporation, Washington, 1986. Anthrop. Assn. Meetings November, 1993.
Self-regulation of health is common in the peasant 58. Older peasant Khmer women believe that the number of
society many refugees came from, In Cambodia, women children they have is predestined, as a reward or
deal with every-day health and birth-related issues as part punishment for their past lives. A woman becomes
of their domestic repertoire. pregnant after dreaming about a man who presents
50. See, for example, Boston Globe 8 June, 1986. In fact, the her with a gift, signifying the sex of the children. The
notion of Khmers being a 'passive,' 'less aggressive' bodies of partners having sexual intercourse must be
people (their recent violent history not withstanding) 'cool" or in balance to facilitate conception. See
than other Asians derives in part from writings that Kulig J.C. Conception and birth control use: Cambodian
attribute their "less disciplined' culture to Theravada refugee women's beliefs and practices. J. Commun. HIth
Buddhism, the main religion of Khmers. See Rumbaut Nurs. 5, 235, 1988. Though these ideas indicate a
R.G. and Kenji 1. The Adaptation of Southeast Asian moral or religious system of self-regulation, they
Refitgee Youth, pp. 75-77. Department of Health and radically differ from the medical model being taught in
Human Services, Family Support Administration, the hospitals.
and Office of Refugee Resettlement, Washington DC, 59. Inthelate 1970s and early 1980s, refugees from Southeast
1988. Asia were supported by the federal government for the
51. French L. Amputees on the Thai-Cambodia border: the first two years. Thereafter, their support was transfered
political economy of injury and compassion. In The Body to social welfare programs which are funded by a
as Existential Ground: Studies in Culture, Self, and combination of federal and state resources, the amount
Experience (Edited by Csordas T.J.). Cambridge varying by the state. Many people argue that Southeast
University Press, Cambridge (forthcoming). Asian refugees have migrated from state to state in
52. Parsons T. Illness and the role of the physician: a pursuit of get better welfare aid packages. Informants
sociological perspective. In Mass Psychogenic Illness: A maintain that movements into California, where the
Social Psrchological Analysis (Edited by Colligan M., benefits are among the highest in the country, were
Pennebaker J. and Murphy L.), pp. 21 31. Lawrence mainly prompted by family reunification, the large
Erlbaun Associates, Hillsdale, NJ, 1985. Southeast Asian communities, the weather and the social
53. Desbarats J. Cambodian and Laotian Refugees: an and political climate.

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