Members of New York City’s fast-growing Bangladeshi American community aren’t in obvious need of transportation.
Many male members of the community work as taxi drivers. Their city has one of the best public transit systems in the U.S. Uber, Lyft and other ride-sharing companies are proliferating and claim to have made transportation cheaper, easier and more accessible than ever.
But when New York University Langone Medical Center researcher Nadia Islam first started looking at the Bangladeshi community’s high rates of diabetes, and how to improve them, she found that transportation was the crux of the problem.
Doctor’s visits, just one part of managing the chronic disease, go missed, especially by female members of the community. They often rely on husbands or sons to take them to appointments and, with little or no English, struggle to make the trip on an unfamiliar transit system.
These knotty factors might easily be dismissed as endemic, too difficult to unwind. But for years, NYU Langone’s Islam has led a program that uses the community’s members to make sense of why type 2 diabetes — which is more common in adults and is the most prevalent form of diabetes — goes unmanaged and how to change that.
Trained community health workers bring those with diabetes to medical appointments and teach them how to use the subway. They lead workshops at local community centers about caring for the disease and teach those lessons one-on-one, too.
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These workers are reaching far beyond where the health-care system normally goes. But they’re effective because they speak the same language as the people they work with, developing trust and gaining insight into diabetes’ larger cultural context.
Sharmin Nahar, 35, got gestational diabetes when she was pregnant with her now-3-year-old daughter. For many women, gestational diabetes goes away, but Nahar’s didn’t, and she did little to change her lifestyle in the wake of the diagnosis.
But since she got involved with NYU Langone’s program last year, Nahar has started going to the doctor, eating better, exercising and taking her medicine, she says.
Before, “I thought, ‘I’m too young. I don’t need to go to the doctor. It’ll go away,’ ” Nahar says, young daughter clinging to her legs. “I know now that it isn’t going anywhere.”
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Mamnun Haq, a founding health worker in the NYU Langone program, leads a diabetes workshop in Ozone Park.
What it looks like
In the basement of a Bangladeshi community center in Brooklyn, amid clusters of tables and chairs, 10 men and women, the latter clad in colorful patterned hijabs, are exercising. They’re led through a series of breathing, neck and shoulder exercises, followed by arm rolling and toe touching.
“Look like a turtle,” instructs community health worker Nahar Alam, demonstrating as she hunches her back and shrugs.
This crisp late November day has a bite to it, but the activity is taking place indoors for other reasons, too. The exercises today are excuse-proof by design, the health workers say: possible to do anywhere, without going outside — many predominantly Bangladeshi communities lack walking trails or parks — or paying for a gym membership.
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Participants in an NYU Langone health program go through various exercises described as excuse-proof because they’re designed to be done indoors and without equipment.
The program has also developed a DVD with the workout, narrated in Bengali by a Bangladeshi health worker so participants can better understand and relate to the subject matter.
Over the course of five sessions, participants learn about the different types of diabetes, the symptoms of being pre-diabetic, who is at risk and the ABCs of diabetes — a mnemonic device to help remember blood-sugar, blood-pressure and cholesterol metrics. They go over what doctor’s visits have to be scheduled and how many times a year, and asking about flu and pneumonia shots while at a doctor’s office is recommended.
Shajahan Meah, a 57-year-old cab driver who lives less than two blocks from the community center, has had diabetes for nearly two decades but says he still had a lot to learn from the program. Meah learned about important metrics that go beyond blood-sugar levels, including blood pressure, and has started exercising and eating in new ways.
“I only knew [previously] that if I was feeling bad, I should go to the doctor. Now, I have my own doctor — myself,” Meah says.
How participants respond to the workshops and lessons, which are part of an ongoing research study, could have important implications for how this kind of work is done in the future. But in the process, health workers have learned more about why participants don’t go to the doctor or care for their chronic disease.
A conservative immigrant culture makes it hard for women to leave their homes and have agency in the outside world, health workers say. Many Bangladeshi men work long shifts as taxi drivers or restaurant workers, making it hard to find time for an appointment. And undocumented immigrants have little access to health insurance or care.
Because of this, improved care — a challenge in its own right — isn’t enough if patients simply can’t get to health-care institutions, health workers say. And that’s where they come in: taking patients by subway to their appointments and, en route, teaching them to navigate the transit system.
But challenges are stubborn and sometimes unexpected.
When one woman’s severepain made it impossible to walk even a block, a health worker told her about Access-A-Ride, a service available to many in the community, though few know about it. But when the two of them traveled by taxi to apply for it, the patient forgot her cane, as required. They had to return a second time.
Who health workers are, and why it matters
The program’s success hinges upon the health workers themselves, all of whom come from backgrounds of active community involvement and, often, activism.
Alam first got involved with domestic-violence organizations when she came to the U.S. in 1993. She started a nonprofit called Andolan that advocates for low-income South Asian workers from her kitchen, and she has organized babysitters and housekeepers to fight for their rights at work.
Mamnun Haq, another founding community health worker, co-founded the New York Taxi Workers Alliance. Mursheda Ahmed had volunteered for several community-based organizations. MD Taher is the leader of a local cricket club, a game popular with Bangladeshis that continues to play a significant role in Bangladeshi American life.
Potential participants are identified by city hospitals or community doctors, but health workers often don’t hear back after making calls. So even in an era of unprecedented communication technology, referrals are largely person-to-person.
Nahar got pulled in after health workers brought her sister-in-law, who’d broken a leg, to the hospital. Upon realizing multiple members of the family had diabetes, health workers held a workshop in Nahar’s family’s shared home.
Community health workers MD Taher, Mamnun Haq, Nahar Alam and Mursheda Ahmed.
November’s workshop opens with “Salaam alaikum,” an Arabic greeting. A PowerPoint presentation and lessons are in Bengali, the official language of Bangladesh and one in which the health workers are fluent. The 45-minute session ends with naan wraps, though the health workers say they typically aim to serve something healthier.
Naan may well exemplify the nutritional challenges baked into the culture of Bangladeshi Americans. Traditional food is typically rich, delicious and unhealthy, health workers say.
Nadia Islam, who founded and supervises the program and also serves as deputy director of the NYU Center for the Study of Asian American Health, is a Bangladeshi American herself. With two immigrants parents, she grew up eating traditional food every day.
Like many South Asians, a number of Islam’s family members — her grandfather and grandmother, two aunts and, most recently diagnosed, her father — are diabetics.
“Even though [diabetes] is so common, there’s a lack of awareness about how to manage and prevent it,” she says. There’s a “sense of fatalism,” too, she says: “They say, ‘Everyone in my family has it, so I’m going to get it, too, and there’s nothing we can do about it.’ ”
Resources for diabetes patients are typically one-size-fits-all, she says. A doctor’s pamphlet does little “for a recent immigrant who, one, may not speak English and, two, may not eat things like pasta and bread. There’s a total disconnect.”
Community health workers, because of shared culture, can do a better job, she says.
Workers often advise patients to eat less of their traditional foods. But they also suggest things they’ve tried themselves: mixing brown and white rice to “bring brown rice to eye level,” health workers explain, or serving chickpeas and salad to break the Ramadan fast.
“I did it, I do it myself, and so you can do it,” Alam tells participants.
Of course, it’s not all brown rice and roses. Not everyone is satisfied with the chickpeas and salad. Recommendations can rub up against familial expectations and obligations. What happens if the rest of the family doesn’t want to eat healthier? “You can’t cook one meal for you, one for your husband and one for your child,” Ahmed, another health worker, says, adding that, if it’s the husband who has diabetes, “a wife will be more supportive. Women, they don’t get that kind of help from their families, most of the time.”
Islam is the official religion in Bangladesh, and a majority of the country is Muslim. Household budgets can’t always accommodate healthy food, an added expense on top of the cost of purchasing halal food, which is prepared according to Islamic law. Health workers suggest looking for food on sale, but they allow that healthier halal food can be both harder to find and more expensive.
There’s also a constant need to combat misunderstandings.
Parboiled rice, which is popular in Bangladesh, is often confused with brown rice. Though parboiled rice is better than white rice, brown rice is still the best option.
So, “we send pictures to them,” Ahmed says, advising, “Go to Costco.”
The November workshop came just two weeks after the U.S. presidential election, and, with the president-elect having proposed a Muslim registry and immigration suspension, “Everybody’s scared,” Ahmed says.
The workshop’s stretching section, “for reducing stress in general and election stress,” Ahmed says, goes longer than usual.
At the close of the gathering, Alam talks about what to do in the current political climate. If a stranger harasses you, asking for your green card, don’t hand it over, she says. And “if anything happens, call the police,” Alam advises the assembled group.
Though hate crimes against Muslims in the U.S. reportedly jumped 67% last year, Alam says she’s been telling worried Bangladeshi Americans that leaving the U.S. won’t make them any safer. “If you go to Bangladesh, we have far worse problems there,” she says. Her daughter wanted to move to Canada, but she told her no, she reports.
And this feeling of fear threatens the very nature of community health work. Health workers go out and appear in public by themselves, and safety is paramount to what they do. And, for Alam, that’s under threat. Just the day before, on a public bus, she was yelled at by a stranger who shouted the president-elect’s name, she says.
Referring to a neck brace she was wearing during a postsurgical recovery, the stranger screamed, “We’re going to break all Muslim women’s necks,” she says, still visibly shaken.
Now, she’s wondering if health workers should start going out in pairs. And she says she’s told her ninth-grade daughter she could stop wearing her hijab, but her daughter chose to continue.
The program’s funding, too, could be jeopardized. Grant money from the National Institutes of Health is “everything” to the program, Nadia Islam says, and there’s been speculation that the NIH could face budget cuts under a new administration in Washington.
But the health workers express confidence in the work they’re doing, and the value they provide. ”This is our people,” Alam says. “We’re helping our people, our community.”
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