May 24, 2022

Ethiopians—What's "brain waste"? (Rahel Schwartz, S1, Ep 1)


Rahel Schwartz was born in Addis Ababa, Ethiopia, and lived in Kenya and Arkansas before making her way to Seattle in 1994. She's currently the Program Executive for Health Equity at the YMCA of Greater Seattle and helps design and implement culturally and linguistically tailored chronic disease prevention programs. 

In this episode, we talk about 

  • the history of Ethiopian immigration in Washington,
  • the problem of brain waste
  • making a traditional Ethiopian diet healthier
  • the role of religion in culture
  •  the complexity of living in a multi-generational household
  • gaining trust before providing health education.

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  • Language: Recognize the different primary languages Amharic, Oromo, Tigranyan and Somali
  • Gender Congruence: Remember gender congruence (ie female interpreters for female patients) or key information may not be divulged

Past Medical History/Family History:

  • Waves of Immigration: Ask about their journey to Washington State
    • Three waves of immigration
      • 1960s: university students, elite
      • 1970s: history of political turmoil and drought in Ethiopia
      • 2000s: diversity immigration visa

Social History:

  • Religion: Ask about religion and its role in their lives  (2/3s Ethiopian Orthodox, 1/3 Muslims)
  • Occupation: Ask about their occupation back home.
    • Brain Waste: People who are overqualified for their jobs (ie, people working as Uber drivers although they have PhDs). Due to a lack of support in navigating the system and the need to care for family, many people take jobs below their education and professional qualification.
  • Nutrition: Ask about what they eat and how they prepare their food
    • Vegetables are typically part of the traditional diet but may be cooked heavily in butter and oil and overcooked
    • Injera is typically made out of teff but due to cost, white flour may be substituted
  • Substance Use: Consider the role of alcohol and coffee in Ethiopian culture
    • Alcohol: Tej is honey wine, like mead, that is brewed and consumed. Beer is typically consumed by men.
    • Coffee: Can be consumed multiple times a day. The traditional ceremony lasts 1.5 hours or more with snacks so not commonly done.

  • Fasting and Holidays: Consider how fasting may affect your care plan.
    • In Ethiopian Orthodox Christianity, Christmas and Easter may involve 40-50 days of fasting.
  • Difficulting Navigating Cultures: Recognize the difficulty of incorporating American values and culture into traditional Orthodox Christian culture.
  • Multigenerational Households: Ensure that you assess the different generations in a household and how different messaging and communication plan may be needed for each
  • Mistrust: Consider collaborating with faith-based organizations, community centers and clinicians from the community to address mistrust
    • Examples of COVID mistrust:
      • Why are they giving the vaccine for only 65? and older? Are they trying to get rid of us?
      • They thought that the vaccine that are being provided in this communities were different, they must have a different batch of vaccines for black people.

  • Timespan: 33:20 Min
  • Transcription Type: Cleaned Verbatim
  • Speakers: 2 (Rahel & Raj)


Rahel: They say, well, we have a translator service, so we can just call someone to translate. I will not answer all your questions if I am a woman and an available translator is a man.


Raj: Hey everyone, welcome to the healthcare for humans podcast, the show dedicated to exploring the history and culture of Washington's diverse communities. So clinicians are equipped with the proper knowledge to care for all patients.

In this episode, we'll discuss the Ethiopian community in Washington. In all likelihood, you've probably eaten in an Ethiopian restaurant recently because Ethiopian food has become a staple cuisine in Washington. Over 13,000 Ethiopian immigrants live in King County, making up the most significant portion of the East African population. Before discussing this community, let's review some stats to set the context. First, Ethiopia is a resilient country. Ethiopia is the largest country in the Horn of Africa, has never been colonized, and it has the fastest-growing economy in Africa. Second, Ethiopia is diverse. There are 100 15 million people who live in nine regional states, and together they speak more than 80 languages and approximately 200 dialects.

Among these languages, there are two predominant ones. Amharic and Oromo. 33% of people speak Amharic, and 33%. Speaker Oroma. The two other main languages you should know about are Somali and Tigrinya. About 6% of people speak each of those languages. And the last statistic to know is about religion. Roughly two-thirds of the population identify as Christians, and the rest identify as Muslims. The majority of the Christian population belongs to the Ethiopian Orthodox Church. Now that you have that context let's dig deeper to understand what this means for providing clinical care. Rahel Short will be joining us today to explore the history and culture of the Ethiopian community here in Washington. Rahel was born in Addis Ababa, Ethiopia, and lived in Kenya and Arkansas before moving to Seattle in 1994. She is currently the program executive for Health Equity at the YMCA of Greater Seattle and helps design and implement culturally and linguistically tailored chronic disease prevention programs. Today, we talk about the history of Ethiopian immigration, the problem of brain waste, making a traditional Ethiopian diet healthier, the role of religion and culture, and the complexity of living in a multi-generational household and gaining trust before providing health education. Without further delay, here's Rahel. Okay, welcome to the show. Rahel.


Rahel: Thank you for having me.


Raj: Before we get started, tell me your story. What brought you to Seattle?


Rahel: So, I came to the United States in 1989 to pursue my education. But I moved to Arkansas to do my undergraduate studies in biology and chemistry, and I moved to Seattle in 1993. To do my graduate studies, I wanted to do clinical research and wanted to work at either red hatch or Seattle Children's. So I moved here, and I've been living here ever since.


Raj: It feels like you've achieved all your dreams, you do health equity work for the whole community, and you're on, I think, multiple community boards, right, Fred Hutch? So you can influence and guide those large institutions towards caring for the community?


Rahel: Absolutely. Having been here as a young person and having both my parents from Ethiopia, I have the perspective of both worlds, being educated and living here. I'm also very familiar with and close to our culture, which gives me a better view.


Raj: Yeah, we need people like you to bridge the gap to the glue that keeps it together. Right. Let's jump into today's episodes on the Ethiopian community here in Washington. Now we'll start with a bit of history, and correct wave needs more context when you talk about anything else. But I think relevant to Washington. Let's start in the 1970s. So after 33 years of continuous rule by Emperor Haile Selassie in 1974, a communist military junta called the Derg ceased power. I think that's when things got tough in Ethiopia because it was an oppressive regime that caused political turmoil and widescale drought. I guess 120 Ethiopians left the country during that time.


Rahel: Correct.


Raj: During that period, there was a lot of immigration to Washington. First, there was the 1960s wave of emigration from Ethiopia, where it was primarily university students wanting to study there and then go back to Ethiopia and work there. But because of the regime change, it became tough to go back. And a lot of people didn't want to go back. The second wave started in the 1980s when more refugees came to Washington under the Refugee Act. That's when we saw the most extensive growth of the Ethiopian population in Washington. Then the last way was in the 2000s. More Ethiopians relocated to Washington under the diversity immigration visa, which is more of a lottery system. And I think we do it a disservice and call Ethiopians just Ethiopians because there are probably smaller communities within that community.


Rahel: So, you're correct—all the right information. We have approximately 86 different languages and dialects spoken in Ethiopia. Parekh is the national language. And I only talk about that. So if I go back to Ethiopia and drive about 45 minutes outside the capital city, I will be the same as if you are travelling there because they don't speak the language. So the way we communicate and what we eat is different for each tribe. So you can't put all Ethiopians in one part. So if somebody is in the hospital in front of a medical provider, we think the best thing to do is have a translator, but usually, that doesn't work. So our background is so different unless you are intentional.


Raj: Yeah, there are so many ways. I think we could segment the diversity of the Ethiopian population. Let's try languages. So you mentioned you speak Amharic. I think the other two are Oromo and Tigrinya.


Rahel: Yes. So Eritrea used to be part of Ethiopia. But they became they weren't independent country about 20-something years ago; they speak to Tigrinya. But other tribes are part of Ethiopia who speaks Tigrinya. And then Oromo is one of the largest tribes, other than the Hara tribe, who speak Amharic. Those are the three major languages that Ethiopian and Eritrean communities speak.


Raj: Okay, so the languages are Amharic, Oromo and Tigrinya. Right?


Rahel: Correct.


Raj: You mentioned they live in South King County. I know because of what's happening in our city, people keep moving further and further south. Where do people live right now? And are there different neighbourhoods where people, for example, who speak a heart live? Is there a different neighbourhood where people with more of an Eritrean background live?


Rahel: Not necessarily so years ago, in the 60s, when people relocated here, most of the population lived in the central district. Yeah, 30 years ago, when I moved to Seattle, the population of black and brown people who live in the central district was about 72%. Now it's about 11%. So because of gentrification, as the communities are being developed, rent is getting expensive, and people are being pushed out more south, but there isn't one specific area. Not everybody moved to like Renton or Cantt, but most reside in South King County. Now we're going even further to Federal Way. It's not affordable to live in Seattle anymore. There is a large population who live in North End, which many people do not know. I live in Lynwood, and there's a massive population in Lynwood and Bothell.


Raj: Yeah, I think we assume that people only live in the south. But gentrification pushes people in both directions. Another phenomenon with Ethiopian immigrants is that there's a brain waste because people who have PhDs or doctors in Ethiopia come here but, because of the barriers to re-education or licensing, end up working as an Uber driver or in a small grocery store.


Rahel: The problem is when you come as an immigrant, even though you have a medical degree and you're a successful doctor when you come to the States, there is a system set up for you to transition and be successful. And then when you have a family in addition to that, and you have to feed your family. You don't know how to navigate the system to support their families, so many East African people actually in medical care; they work as nursing assistants because it takes about six weeks to get trained and certified. It's an easy way to start working and supporting your family. But people get stuck there. So you meet people who are doctors and practice medicine back home working as Uber drivers or taxi drivers, or they work at a parking lot. And the other thing I think a lot of times people don't know is people who are immigrated and come here, they still have families back home. And they do feel like they're responsible for supporting them, too. So they don't have the luxury of coming here and taking time to find a job; they just got to do what they got to do. As an immigrant, when you come here, you have six months that the government supports you; after that, you're on your own. So if English is not your first language, you don't have a lot of choices. So people do whatever they can to support their families.


Raj: You know, I have many patients from Ethiopia who work as CNAs and living facilities adults. As you just noted, it's such a privilege to know how to navigate a medical system. But on top of that, surviving in this country and supporting the family back home is necessary.


Rahel: Right.


Raj: Imagine how people get, as you said, stuck, unfortunately, and we don't create systems to facilitate people doing what they're good at. When I have Ethiopian patients, many want people that look like them because they want people that speak Amharic. And there are people in this community who are doctors back home who can care for people that way. And unfortunately, I feel like we still have some work to do to help people thrive after immigrating to a community like this.


Rahel: Alright.


Raj: This is my favourite topic to talk about eating. I've heard how that you're a great cook.


Rahel: I believe I am.


Raj: So Ethiopian food is a staple of the city's cuisine. Like wherever I go, there are a lot of Ethiopian restaurants. So people are aware a little bit of what Ethiopian food is. But I want to dig a little deeper into it. Because as a physician, I talk to people about food a lot. If people get diabetes or have high blood pressure, I want to know what they eat and see if they can modify their diet. Unfortunately, for many clinicians, all they can do is recommend a Mediterranean diet. It's completely overhauling a culture, right? As an Indian, I grew up eating a lot of rice with curry; if I were diagnosed with diabetes, I would not cut out everything related to my Indian culture, right? We must find ways to modify it to manage illness and help you feel connected to your culture. I preface that because I think it's essential to dig deeper into the food components of traditional Ethiopian times. I think most people know about injera. What other typical food items are in a conventional Ethiopian diet. What should we know about as doctors?


Rahel: So, the Ethiopian people would eat lamb and chicken. And most people eat fish just during fasting, like during Lent. Other than that, our food mainly consists of vegetables, so we have a lot of lentils, split peas, spinach, cabbage, potatoes, carrots,


Raj: sounds a lot healthier in many ways than in a typical American diet,


Rahel: Because it is a lot healthier. But that all depends on how you cook it. And I think we can take that and teach people to cook more nutritious Ethiopian food without losing its authenticity.


Raj: What's a healthier version? Is it the oil that it's cooked in?


Rahel: Yeah, we use a lot of oil because, in our culture, we don't measure anything. And also, in addition to oil, we use a lot of butter, which is cooked with different spices to have flavour. But we unnecessarily put in too much fat and butter, and when we cook the vegetables so much, it loses its nutritional value. So, I did a food demo a couple of weeks ago in collaboration with the Urban League. And what we were teaching people was to take two dishes from Ethiopian food and make it using fresh herbs in a minimal amount of oil so that you can still eat your traditional food, which is what people eat all the time. Many Ethiopians don't go to restaurants to eat sushi or Mexican food. Most people eat traditional foods day in and day out, like injera, made from a grain called teff. Now, in the United States, because it was hard to buy that they replaced it with wheat flour, not for wheat flour. So it completely changes what you're eating. So a lot of immigrants will come to the States. The first year, they say you gain about 10 to 20 pounds; you're eating the same thing. But the ingredients are different back home; most items are organic. So even though we eat it all day or out, obesity was never an issue. Now, one of the major issues in the United States in the East African Community is diabetes and high blood pressure and all these chronic illnesses. So when you look at the ingredients, say, This is what we want everybody to eat. That's just how we cook it.


Raj: It's such a good point. Since people cook at home, they have much more control than eating out. What I hear from you is that with the injera, many people use white flour. They do it because of cost because teff is hard to find or expensive. What is a healthy alternative to make injera?


Rahel: I think whole wheat, or Bulger are the healthier alternative. And also they're like they're not as expensive. Suppose you buy it in bulk, as you said; you're from India. If you develop diabetes, if I tell you what, you should eat Ethiopian food daily. But it's not realistic.


Raj: Yeah, I think that's true. So I hear whole wheat flour with teff for injera, less butter, maybe less oil when we're cooking the vegetables. It makes me excited to eat at your house sounds like I'll get fresh organic cooked meals, right?


Rahel: Yes! In two weeks.


Raj: Okay, we covered food. What about the role of alcohol and drinking? Anything we should know about that? I know there are local drinks in Ethiopia. I don't know if people are drinking that here, like tej and tela. Am I saying that right?


Rahel: Yeah. So tej is honey wine. So it's made of honey, fermented for days in and days out. And then thomna is made out, or I forgot the name of the grain. Same thing, but a lot of people drink beer. So, women don't drink alcohol. There are a lot of other alcoholic drinks that are made at home, but it's not popular here because you can't make it here other than the honey wine.


Raj: Yeah. Okay. And coffee is an essential part of Ethiopian culture. Right? There's a ceremony around it. Is that continued here?


Rahel: Yes. For people who do not know and will think that coffee originated in Colombia. It originated in Ethiopia. The name coffee came from a place found in a region called Kufa. That's where the name is derived from, but coffee is traditionally what we drink in the morning after eating lunch and dinner. And the ceremony takes about an hour to an hour and a half. So we usually don't do it in America because you don't have an hour and a half to drink coffee. Three times.


Raj: I wish! Yeah. And the ceremony is pan-roasting raw coffee beans and then brewing the beans in a clay pot. Right?


Rahel: Yeah!


Raj: It's called a jebena. Am I saying that? Right?


Rahel: Yes. And also, we have to have a snack. A popcorn or piece of bread, homemade bread, and we drink it in a very, very small cup. Because the coffee is very strong, it's like drinking the shots the people put in a latte.


Raj: Yeah,


Rahel: I usually drink a double shot or a triple shot. Triple Shot. It has to be strong. Yeah,


Raj: Yeah. And people in Ethiopia are still able to sleep. It sounds like coffee three times a day.


Rahel: Oh, it does nothing to drink coffee before I sleep; I'm serious.


Raj: Yeah, I think it's helpful to know how important Coffee is to Ethiopian culture. Because sometimes, with people with anxiety, it can make you feel a little more nervous. And sometimes, it can make your heart rate go a little faster and make you feel like you have palpitations. I'm not saying you need to stop drinking coffee. Still, it's helpful to know that needs to be part of the conversation. It has to be. Okay, next up is culture. That's a big word. I think starting the cultural aspect of it with religion would be helpful because the two major religions in Ethiopia are Ethiopian Orthodox Christianity and Islam. Anything Orthodox Christianity is a big part of Ethiopian culture. Some of the significant dates, I think, are important for people to know. One date is, I believe, Christmas is January 7; before that, there are 43 days of fasting.


Rahel: Right.


Raj: The second important date is Ethiopian Easter, with 55 days of fasting.


Rahel: Right,


Raj: Right. Are those the two important dates in your mind? Are there any others?


Rahel: Those are the two major holidays attached to the Orthodox Church and tradition. So culture and tradition in Ethiopia are intertwined. You can't just talk about culture without tradition because most of the population is Orthodox. My grandparents on both sides were conservative Orthodox. So when my father was converted and got baptized in the faith that we practice right now, he was disowned by his family. So as my mom, it's not so much that my parents didn't go to church every Sunday and participate in the worship service because traditionally, if your parents if your great-grandparents are Orthodox, you are expected to be one. So you lose your entire community, and you can lose your whole family because of that.


Raj: Well, because yeah, I think it's important, from what I think of when I have conversations with teenagers or kids who are forming their identities, that I have to navigate both American culture and Ethiopian culture. And we have to be careful about that.


Rahel: One thing to consider is that we live in a multi-generational home. So there are the parents, and then there are the grandparents, and then there are the kids who are born and raised in the United States. They're exposed to a different culture, no matter how long they live in the United States. And I mean, having kids in the United States, one of the most challenging things is to balance. I want to raise my kids with my culture, and they're exposed to it. But I also have to be open to learning the culture here so they won't feel completely excluded. But in our culture, kids don't have any say; as long as you are in the house, it doesn't matter if you're 18. During COVID, one of the significant issues and the vaccine became available for kids under 18. Young people want to get vaccinated because they understand the benefit. But they still need to get their parents' permission. And there are a lot of parents who do not want to give that permission to their kids. So navigating that is hard because you have to educate the parents; without their blessing, you can't do anything. So as long as you're living together to deal with three different, completely different populations of ideas and beliefs, culture and tradition. It's tough for someone from here to prescribe anything, and I can't do it. Now I'm from the community, and you need to design, like, what could I say to the parents that are not going to turn them off? And then also for the grandparents to understand and then the young people born and raised here, how could we feel that generational gap?


Raj: Yeah, there needs to be messaging specifically for each age group because their beliefs around health are different. You also made a point; just like many other communities, I think the Ethiopian community had multi-generational households, compared to some American families with nuclear families. And I think the experience of just life is different when you have a multi-generational household. This is a good segue into health beliefs because I heard about this event a few times during COVID. Ethiopia Community Center had a virtual call. And you all talked about vaccine safety and hesitancy. Some doctors spoke on Amharic, and people were laughing on the call; they asked a lot of questions. And after the event, people got vaccinated. It was remarkable because there was a lot of scepticism around messaging from healthcare organizations that the vaccine was safe. And there was a lot of vaccine hesitancy. As clinicians, I feel we're not the most trusted people in the community right now.


Rahel: Right.


Raj: But my question is, what are the health beliefs that people hold? What is crucial for us to know? And where do people turn for health information?


Rahel: I always say that, as a black woman, I have my own experience in navigating the healthcare system, even as educated as I am. I think the mistrust is not based out of nothing. But during COVID. When hospitals approached us and wanted us to help them vaccinate communities of colour who were disproportionately affected by COVID, we wanted to ensure that people get the correct information because there were so many messages. For a population who mistrusts the medical system already, when you are learning different information regularly, you don't know what to think. And we were adamant about providing workshops to create a space for people to come in and get information from people who look like them. Who are physicians who have worked in the community, know the culture, and know how to communicate some messages? It gave them the opportunity to ask whatever questions they needed. I remember one of the questions, which is really funny, one of the ladies said, Why are they giving the vaccine to only 65 and older? Are they trying to get rid of us? That was the mentality, oh, they're vaccinating us. They chose this population because we're older. So maybe they're trying to get rid of us. Some people decided to get the vaccine at the hospital instead of these mobile clinics because they thought that the vaccines being provided in these communities were different. They must have a different batch of vaccines for black people. So instead of coming to the mobile clinic, I want to go to where all the white people are getting a vaccine to make sure that they're not giving me a different one for the medical health provider. You don't think about these things, but this is what's in people's minds. A relationship is, is everything, working with the why? Whatever we do is based on relationships. So when we facilitate the COVID vaccine, we wanted to ensure we recruited community members on the day off to help fill out the information because people think we would invite them.


Raj: Yeah, they want people who look like that. Right.


Rahel: Right. I think that is the most important thing. And I think for medical providers, sometimes what they don't think about if I come to see you and I don't speak English, they say, Well, we have translator service, so we can just call someone to translate. Well, if I am a woman, and an available translator is a man, I will not tell you or answer all the questions you asked me. These are just basic questions like the intake form. Yeah, because in our culture, there are things that you don't talk to a man about. But you, as a medical provider, are trying to get as much information as possible to serve the person better. Yeah, small things you have to consider can make a big difference.


Raj: I was just saying gender congruence. So if it's a female patient, make sure a female interpreter is available, right? Not just anyone. That's an important point.


Rahel: Right.


Raj: I heard you say you're always working on creating spaces where you can build trust with the community and continue to build relationships. So people are open to receiving new information. Is there anywhere else they connect with or have relationships with, specifically around organizations? It sounds like the Ethiopian community centre is one. Are there organizations like that people have relationships with?


Rahel: Faith-based organizations most of our partners that we have done successful workshops or provided screening, whether it's vaccine or mammogram, have been faith-based organizations because faith-based organizations are the most trusted place for the Ethiopian population. That's where most people congregate. But other than the community centres, I do work on HIV research. And one thing we learned through formative data collection is trained, faith-based leaders themselves. You have to get there by in before you approach their congregation


Raj: Yeah.


Rahel: So, educating them is the best way to engage in health education. We have them lead us into their immediate needs, So you address them, and that's how you build relationships.


Raj: Yeah, yeah. Thank you, Rahel. I have one last question, which is, what is one thing that you want your doctor to know about your background as an Ethiopian?


Rahel: I don't assume I don't know about my health. I think that's the problem with many medical providers; they tend to undermine or treat patients based on their own biases, not necessarily based on what the person is. So take the time to get to know the person to treat the person. So if I come into your space as a patient, and I'm proud to say I'm from Ethiopia, don't put me in a box where you already make your decision. Well, because of people's lived experiences, navigating being an immigrant is not an easy thing. Learning a new language, adapting to a new culture, working, and surviving and thriving. But most of the time, people put us in a box like she's from Ethiopia. So she's this, and she's that


Raj: That's a good takeaway. What I hear from you is that this podcast is designed to teach clinicians about the different parts of culture, but don't put anyone into a box. So always be open to listening and building relationships. But hopefully, this podcast will help people get closer to at least knowing what questions to ask, so they can be relevant and earn the trust of the people caring for them.


Rahel: I agree. 100%


Raj: Thank you so much, Rahel.


Rahel: I appreciate you. Thank you for having me and for the opportunity.


Raj: Thanks for joining me, Rush Sundar, in this episode of the healthcare for humans podcast. If you enjoyed this episode and would like to help support this work, please share it with others, post about it on social media, or leave a rating and review. Thanks again, and I'll see you next time.


This podcast is intended for educational and entertainment purposes only. Views and opinions expressed in this podcast do not represent any of the participant's past, current or future employers unless explicitly expressed, so always seek the advice of your physician or other qualified healthcare providers concerning your personal questions about medical conditions you may be experiencing this healthcare for humans' project is based on Duwamish land and makes a regular commitment to Real Rent Duwamish

The transcript ends here.


Rahel SchwartzProfile Photo

Rahel Schwartz

Rahel was born in Addis Ababa, Ethiopia, and moved to Nairobi, Kenya, when she was 15 years old with her family. After completing high school, she moved to Searcy, Arkansas to attend college and graduated from Harding University in 1993 with a BA in Biology and Chemistry.

She moved to Seattle, WA, in 1994 to pursue a graduate degree in Clinical Research.

In 2001, she opened her own real estate/relocation company and worked as a rental agent until 2011. In October 2011, she joined the University Family YMCA teaching Zumba and kids hip hop classes. In 2013, she went back to school to complete her Masters degree in Public Health, specializing in Health Education and Promotion, and got involved with the YMCA's Chronic Disease Prevention Program at Meredith Mathews working as a community outreach personnel while completing her internship. She was promoted to Program Executive for Health Equity in 2015 and is currently on multiple boards including African American Health Board, Bishop Blanchet High School, Ethiopian Community Center, and Somali Health Board.