by James Tobin • photos by Martin Vloet

Calligraphy of the names Takeru and Seiya by Kazuo Aoki

At 4 p.m. on Saturday, August 13, 2005, Ayuko Ando — 38 years old, mother of a three-year-old son, 6,400 miles from her home in the Chiba prefecture of Japan — felt the first stirrings of labor pain.

She was hosting a barbecue at the house in Novi, Michigan, where she and her husband, Bunto, are living during his seven-year sojourn in the U.S. for his Japanese employer. Mrs. Ando said a few words to her husband and excused herself. The guests said their goodbyes. At 5 o’clock, Mr. Ando called the Women’s Hospital Birthing Center at the University of Michigan, and at 5:30, the Andos got into their car for the short trip to Ann Arbor.

Twenty-nine miles away, in a small office just west of the hospital, Mrs. Ando’s doctor was stealing the end of a weekend afternoon to catch up on some desk work.

Ayuko Ando with her son Seiya

Amazingly fluent in the Japanese language — the result of three years’ study in Japan — Michael Fetters, M.D., associate professor of family medicine, is director of the Japanese Family Health Program (JFHP), which he founded in 1994 as an initiative of the Department of Family Medicine. The JFHP is a prime example of the U-M’s commitment to treating the whole patient — that is, to approaching a patient not as a mere collection of symptoms but as an individual comprising elements of personal history, ethnicity, gender, socioeconomic status and cultural background, including language.

But treating the whole patient is no easy matter. As the experience of the Japanese Family Health Program shows, it requires sustained attention to the intricate details that make up any human culture — details that can mean the difference between wellness and illness, even between life and death.

“All of this is about subtleties,” Fetters says. “It’s about these multiple, tiny things that combine into a totality that can be really overwhelming for someone who’s vulnerable.”

The dire case often cited by the JFHP staff is that of Itsumi Koga, a Japanese woman suffering from severe postpartum depression whose baby was found dead in a frigid pond in Farmington Hills in 1995. Exactly what happened remains uncertain, but medical professionals took stock, scrutinizing the needs of an overlooked population of several thousand Japanese living temporarily in southeast Michigan, most of them tied to the auto industry. As a group they were well educated and well off, but badly in need of what is now called “culturally competent” health care.

Takeru Ando keeps a watchful eye on Michael Fetters, who is examining his 9-day-old brother, Seiya

“They were receiving very poor medical care,” says Thomas L. Schwenk (M.D. 1975), professor and chair of Family Medicine. “It was very fragmented. They were wandering around southeast Michigan and couldn’t really find a home. They were very isolated for cultural and linguistic reasons.” Schwenk and other key players at the U-M supported Fetters’ plan for a comprehensive clinic to serve the growing population of Japanese families living in the Midwest, most of whom stay for three to five years while the husband puts in time abroad for his Japanese employer.

Now the Japanese Family Health Program staff numbers three physicians — Fetters, Masahito Jimbo, M.D., Ph.D., clinical assistant professor, and Kiyoshi Sano, M.D., assistant professor of family medicine — two nurses (including Haruko Osaki-Wurtz, who frequently troubleshoots patients’ cultural confusion over the phone) and seven support staff. Logging more than 6,200 patient visits in 2004-05, the program will move to new, larger quarters in the Domino’s Farms complex in 2006, from its current location at the East Ann Arbor Health Center.

“In my mind, this is part of a much larger commitment that we have to a whole variety of underserved populations, and they’re underserved in all kinds of ways,” Schwenk says. “This is not fundamentally different from the volunteer work we do at the migrant farm-worker clinic in Manchester. We have an extremely strong commitment to cross-cultural care and competency. So, in a certain regard, this is what we do naturally.”

Michael Fetters with Bunto,Takeru, Ayuko and Seiya Ando and Kiyoko Funato

The health benefits are large. In a comprehensive literature review, Seonae Yeo, Ph.D., an associate professor of family medicine and of nursing, and a nurse practitioner in the Japanese Family Health Program, found that language barriers alone contribute substantially to health disparities among ethnic and racial minority groups in the U.S., including fewer clinic visits, poorer understanding of physicians’ explanations, more emergency room visits, and less follow-up care.

“Medicine is really a social science, and, for that matter, nursing is as well,” says Yeo. “So if you really want to make a product that can be used by someone in need, culturally competent care is a very natural form. Without this, providers think they are providing care, but they never get there because there is a huge barrier called language and culture. You may think you’re giving them medication, but if they don’t understand you, they throw it away when they walk out.”

Yeo joined the JFHP shortly after the death of Koga’s baby in 1995. “When I learned about that,” she says, “I just felt I couldn’t say, ‘I can’t do it because I have to make tenure.’ You have to find something you can do.”

On the car ride to the hospital, the main thing on Mrs. Ando’s mind — apart from counting the minutes between her contractions — was her little boy, Takeru. She had left him at home in the care of her mother, Kiyoko Funato, who had come from Japan to help her daughter. In Japan, tradition prescribes that pregnant women return to their parents to give birth. So some expatriates go home to deliver their babies, and others have their mothers come to the U.S. for several weeks.

For all our talk of “family values,” Americans could learn much about the subject from the Japanese, whose devotion to the proper rearing of children is profound. That devotion is symbolized in the painstaking selection of a child’s name. Various factors are considered — the choice of pictographs that make up the name, each of which has its own meaning; the number of strokes that make up the name; and the overall meaning of the name. In fact, many names have multiple meanings. “Takeru,” for example, means “healthy,” “strong,” “always running” and “liberty.”

Little Takeru Ando is, in fact, all of those things. But Mrs. Ando worried because this was the first night he would spend apart from her. Her mother visited the U.S. for Takeru’s birth three years ago, too. Then, the two women sparred a bit about precautions. Japanese women, for example, often advise their daughters to avoid any form of cold just after giving birth — ice, cold drinks, even sitting in a wind — fearing a link to ill health later in life. There was disagreement about such things in the Ando house. Funato urged her daughter not to read too much or to watch too much television. But this time, Funato said through an interpreter, “Everyone is relaxed.”

With or without such support, many young Japanese wives find life in the U.S. difficult. Japanese corporations press young executives to marry before working in the U.S. In such cases, courtship can be speedy. Some marriages are even arranged. So young newlyweds often arrive here not knowing each other very well, and once they’re here, they encounter social pressure to have children soon. Spoken English is seldom well taught in Japan, so even a well-educated woman may find the language barrier insurmountable. Driving at high speeds in the spaghetti of U.S. expressways is daunting. Husbands work punishing hours, frequently staying at the office very late to participate in teleconferences on Japan time.

As a result of all this, young wives often find themselves in virtual isolation. Enclaves of Japanese families have developed in Novi, West Bloomfield, and Canton Township. But even there, says Veronica Ichikawa (Ph.D. 1988), a clinical psychologist affiliated with the JFHP who has a large practice among the Japanese of southeast Michigan, social circles are small and tight, and women fear that if they complain, word will quickly reach their husbands’ corporate superiors.

So for some, life in America is a very tight vise, and depression is a not infrequent result, especially among pregnant women and young mothers. But in Japan, any psychological illness still carries a powerful stigma. Denial is strong. It’s clear that Bunto and Ayuko Ando enjoy good health, a happy adjustment to the U.S., and a strong marriage. But for other Japanese families living in the U.S., untreated depression can lead to long-term trouble, often between mother and children, especially when the family returns to Japan. For an American doctor unfamiliar with Japanese culture, the progression from bad to worse can be hard to prevent. A subtle code exists between Japanese patients and doctors. A woman complaining of a problem with a child may be saying her marriage is in trouble. A patient who describes a “stiff shoulder” may be saying she feels depressed. In the U.S., only a physician as well schooled in the intricacies of Japanese culture as Michael Fetters can read such signs and respond accordingly.

Mrs. Ando has had no such problems. Apart from prolonged morning sickness, her pregnancy proceeded smoothly, and she enjoyed a comfortable relationship with Fetters. He had delivered Takeru — in fact, he treated Mrs. Ando’s mother when she fainted in the delivery room, saving her a trip to the emergency room — and she appreciated his friendliness to her growing son. In Japan, most physicians remain stern, paternalistic figures. Many patients welcome the collegial approach of family physicians in the U.S.

“Dr. Fetters is a very kind and sympathetic doctor, very conscientious, I think,” Mrs. Ando said through an interpreter. “And maybe because he has children of his own, he is very kind and gentle toward Takeru and toward children in general.”

The U.S. and Japan both enjoy highly advanced medical systems. But the differences between them, and between cultural beliefs about health, are profound. In maternity care, for example, Japanese often resist the frequent prescription of vitamins, preferring to manage nutrition through diet alone. In Japan, ultrasound examinations occur at every prenatal visit; in the U.S. they’re much less frequent. In Japan, fathers seldom attend the birth, a practice now expected in the U.S. The Samurai/ Bushido code of ethics — emphasizing self-denial and courage in the face of pain — encourages Japanese women to bear the pain of childbirth without painkillers, including the epidural injections common in the U.S. An episiotomy (the incision made in a mother’s perineum) is normally avoided when possible in the U.S., but standard in Japan. American physicians want their patients to be active participants in their health care, while Japanese doctors are offended by a request for a second opinion.

Fetters and his colleagues point out that they are not seeking to practice Japanese medicine. Rather, they’re practicing the medicine they think best with patients accustomed to a different system — a system patients may believe to be superior to Western medicine. So it’s no easy matter for American doctors and Japanese patients to reach accord. But it’s much easier in a clinic like the Japanese Family Health Program, where the entire staff is not only bilingual — several are Japanese-born — but deeply aware of Japanese values and attitudes.

“Because of the clinic,” Mrs. Ando said, “I didn’t have any problems with my prior pregnancy, and so far with this pregnancy, I haven’t had any problem. So it’s very beneficial. Some friends of mine who were here decided to go back to Japan to have their deliveries, but in my case, I had no problem deciding to stay for delivery here.”

Upon learning the Andos were on their way, the Birthing Center staff called not Mike Fetters — still at work in his office on Fuller Street and unaware of the Andos’ approach — but Jeanette (Sordyl) Kibler, who lives on the south side of Ann Arbor. Given the long hours that labor usually takes, the staff could wait a bit to notify the doctor. But the interpreter was needed right away.

“I do this job to be with people in crisis or times of need, when communication is really important. My only experience in the hospital was in Japan, and I understand how it feels to need help during times of illness or crisis.” —Jeanette Kibler

Raised in the small town of Mount Morris, Michigan, near Flint, Kibler went to Japan in 1976 to work for a Japanese Christian student organization. In all, she spent an extraordinary 18 years there (13 as a single person, and five years with her husband who works in the automotive industry) — two stints surrounding master’s training in Japanese literature at the U-M. Returning to Ann Arbor with her husband in 2000, she hoped to volunteer as an interpreter at the hospital. Instead she was offered a job with the U-M Health System’s Interpreter Services Program, which interprets for patients and staff in 39 languages.

“I do this job to be with people in crisis or times of need, when communication is really important,” Kibler says. “The satisfaction is being able to be present with people and to help them without being intrusive. My only experience in the hospital was in Japan, and I understand how it feels to need help during times of illness or crisis. I’m very grateful that I’m able to be of some help to Japanese living in my country.”

Often, interpreters help foreign patients through the bureaucratic maze of the U.S. medical system. Japan has national health insurance and no system of referring physicians — thus the bewilderment many Japanese feel upon first encountering HMOs, PPOs, and strict rulebooks about referrals. But when Jeanette Kibler arrived at C.S. Mott Children’s Hospital, she found the Andos already settling into a corner birthing room on floor Four West. The Japanese Family Health Program guides their patients through the maze in advance, and prepares a birth packet with essential consent and educational documents — an unheralded but critical service — so Kibler could attend directly to Mrs. Ando’s medical needs.

As Mrs. Ando’s labor proceeded, Kibler began to speak with her and Mr. Ando about what was happening. She interpreted for the nurse as questions were asked about previous births, health history, and any complications during this pregnancy. Kibler learned Mrs. Ando had decided against an epidural injection (JFHP staff offer advance consent for epidural discussions), and they were beginning to discuss pain control when the contractions accelerated. Suddenly Bunto Ando realized he’d left his camera in the car. He asked Kibler: Was there time to get it? Kibler listened to the doctor and nurses as they measured the dilation of Mrs. Ando’s cervix. Forget the camera, she told Mr. Ando.

The baby was coming extremely quickly. Naomi Pearsall (M.D. 2003), the resident physician, assessed the likely timetable and sent a quick message to Mike Fetters’ pager.

As Mrs. Ando began to push, Jeanette Kibler attended closely. Sometimes the words exchanged at this point are very simple — a matter of counting, or a quick instruction to the mother to turn her body or hold her breath.

But understanding is essential. Communicating across the barriers of language and culture is difficult in the most mundane settings — at a gas station, in a restaurant. It’s that much harder, and far more important, in the most intimate moment in a family’s life. Many of the JFHP’s patients speak English well. But at such times, interpreters remain crucial even for the most fluent English speakers. Fetters has helped at least two delivering mothers avoid cesarean sections simply through clear communication and support in Japanese about the need to push just a little longer.

“If they have a serious problem,” he says, “I want them only to have to think about what the problem means for them, in terms of their medical decision-making. I don’t want them to worry about whether what they’re interpreting from English is accurate. That’s where there’s a very central role for interpreters.

“It’s absolutely essential for any cultural group that they be understood in order to get the best possible care.”

At 8:11 p.m., Fetters’ pager went off. He looked down at the message: “Patient Ando is here and is delivering very quickly. Come if you can.”

A moment later he was behind the wheel of his Toyota Sequoia. (The license plate reads: “Genki” — Japanese for “Are you well?”) He gunned it up the hospital hill, grabbed a space in the parking structure, dashed up to Four East, the usual place when a mother is delivering quickly. No, the nurses told him — the Andos were on Four West. He ran. Another nurse pointed to the right room. Fifteen feet from the door, he heard the sharp first cry of a newborn. He burst into the room.

Smiling, tired faces turned to greet him.

“I didn’t make it in time,” he panted, “but I’m here.”

Internally, he recalled later, “My heart sank, because I wanted to make the delivery for her. If you go that far, you want to be there for the delivery. You rush up there, your heart’s racing. There’s kind of a high to rushing into delivery.

“The funny part of it was, everybody in the room was all happy — and I was thinking, ‘Aw, crud.’”

He settled for chatting with the happy father. Yet only a physician as well versed in Japanese culture as Fetters could know just the right question to ask of a Japanese father: What would the baby boy’s name be, and what did that name mean?

The answer: Seiya — “to manage a country,” “moderate,” “graceful” and “strong leadership.” All with a healthy beginning at the University of Michigan, 6,400 miles from home.