Andrew: What types of special problems do international students face?

Jean: Language. Communication. Things as simple in their country as going to the hospital to get taken care of for a health-related issue is suddenly different. In most countries other than the U.S. you end up going to a hospital clinic and to be seen there. Here, that's not where we start. We start with a health care provider that is usually located away from a hospital and only end up being hospitalized if absolutely necessary. Well it's a completely different way to access health care for even relatively simple things. They may have known how to do it in their home country, but it's very different here.

Andrew: What types of differences are there between the U.S. and other countries in terms of regulations, immunizations, etc., and what kinds of problems can those present to international students?

Jean: One of the issues they will face are the immunization requirements in the U.S.-they differ greatly from the requirements that [the students] have grown up with. They may assume that they are all immunized for everything that they could possible need, and yet coming to the U.S. they may find that there may be two or three things that the U.S. does differently from their home country. And within the U.S., each state has different requirements, and even with in one state the universities may have differences, even among themselves. So what they really need to know is where they are going, what is required, what they have, and bring a copy of [their records] with them, preferably in English. Even if it's not in English we have some forms to be able to translate what immunizations they have had. So what these students will end up doing, often, is needing additional immunizations to meet university requirements. Most of the universities that have a mandatory policy also will suspend registration or charge additional fees if [the students] are not in compliance. That can be very frustrating for the student because one, they don't understand what they are missing, two, how to get it, and three, [they thought] that everything was taken care of at home. So again, they have to re-enter the health care facility within the U.S. and negotiate that, and it can be a maze even for American-born students, let alone international students, just getting the needed requirements for each school.

Lu: The other thing that they don't understand is that if they come here with a chronic illness, they have to be able to know management. They have a different system of management of chronic illnesses. In fact I rarely see an international student with a chronic illness unless it's something that they developed here. And even if they developed, let's say, diabetes here they will be sent home, oftentimes, because the system of management is so different than it is here.

Andrew: You've talked about the difference in health care systems, does this lead to difficulties with reporting health problems that international students might be facing?

Jean: Yes. There's a problem with reporting as well as just plain accessing it. The other factor is cost. If they go to an emergency room it's three or more times as expensive to treat that illness as it is if they were to go to a private health care provider and only go to the hospital if absolutely necessary. For example, and emergency room visit could be $300 where an office visit could be $60.

Lu: And they don't understand the difference at the time because their type of medical system requires them to seek care in a large facility (i.e. hospital). Here, I'm thinking of one particular student who had a severe ear infection, who was sure he was gong to be hospitalized. I also had Japanese nurse managers this summer who said a patient's average length of stay in a hospital is two to three weeks for things that we do here on an outpatient basis. Their inpatient care is more extended than even ours. So teaching these students home care-"no, you can do this at home: you can take your medicine, do your drops, do your irrigation or your own dressing change and take responsibility for your own care"-that's a whole different approach than it was at home because they don't have managed care at home that charges them for everything. Whereas here, if they did the same things they do at home, the cost would be astronomical.

Andrew: What can international students do to minimize the impact of emotional problems?

Jean: Any time you go cross-culturally, you're going to have some times of isolation and loneliness, and even bonding together with other international students or other students with common backgrounds and common language can help students keep a sense of reality about their own lives.

Lu: Having their churches or religious organizations posted around the campus can help. This is a Christian campus, so we won't have [information about] a Buddhist temple posted on any of our boards, and we assume sometimes that all of our students are Christians, even though some of them might not be. We have very few Jewish students, but we have some. So having their local church, synagogue, or community support group, and even the international club numbers posted on campus, along with information about transportation, is a big help.

Andrew: What can international students do to adjust to the new climates when they come to the U.S.?

Jean: One of the biggest things they can do is dress appropriately. If they've grown up wearing shorts, and it's 40 degrees (5 degrees C) outside, sandals and shorts aren't going to cut it-unless of course you live in Seattle where that's normal even in the winter-but those are people who are acclimatized to that. So it's really about listening to their own bodies: if they're cold, they should put on something to get warm . . .

Lu: If their feet are going to be wet all the time, have enough pairs of shoes that are waterproof, so one can be dry and one can be waiting in the wings drying off. You'd be surprised how we can get foot fungus on kids because they don't realize that