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On the Path to Migrant Health: Refugee Care with Elena Diller

[Editor’s Note: As part of our ongoing series On the Path to Migrant Health, we present guest blog posts by future migrant clinicians. Today’s guest blogger, Elena Diller, is a junior at Washington and Lee University. She is a Sociology major on the pre-med track, with minors in both Poverty and Human Capability Studies and Women and Gender Studies. She will pursue an MD/ MPH dual degree after graduation. She explores her first encounter with MCN as an intern at New American Pathways, where she assisted refugees.

Elena Diller“But this won’t cut my food stamps, right?” asked the Iraqi man sitting behind me. I looked over his pay stubs that I had just uploaded to Compass, the Georgia online system to apply for governmental benefits. Staring at my feet, I answered, “I hope not, but maybe…” He grew more persistent, glancing at his wife who sat by him and the two children in their laps. “I need the money -- I’m working so hard, but it is to help my friend out.” I nodded my head and expressed my sympathy for his situation, but explained that I could only help him apply, not change the government-determined amount. After thanking me profusely, the refugee family left and I marched to my case manager’s office. I voiced my concerns about his budget being cut. She told me that his 20 hours of overtime a week at a local tire shop would indeed lower his family’s monthly Supplemental Nutrition Assistance Program (SNAP) benefits.  “But that isn’t fair. He isn’t using the money for more groceries for his family.” She sighed disappointedly, suggesting that we direct the family to food pantries in the area. 

As a summer health intern at New American Pathways (NAP), a refugee resettlement service in Atlanta, I was privileged to hear the stories, and often the hardships, of rebuilding life in the United States. To be honest, most of the eight week internship consisted of paperwork, and lots of it. Phone in one hand, I would set up medical appointments for one client while filling out Medicaid renewal paperwork for someone else. Some days, I would tag along to doctor’s offices and assist refugees with filling out stacks of never-ending forms. It was through these seemingly mundane tasks, however, that I gained insight into the life of refugees in the United States. The aforementioned anecdote, for example, demonstrates how the American welfare system lacks flexibility in its accommodation for personal circumstances. Previously resettled refugees, such as the Iraqi family, often help incoming refugees because of cultural responsibility and a knowingness of the limited funds and numerable barriers when restarting life in a new country. 

Balancing state government with cultural differences makes refugee resettlement, and in particular the management of refugee health care, a daunting task. Most of NAP’s clients speak little English and read even less. Thus, the doctor’s office is a place of anxiety for many refugees because of language barriers. Though Medicaid stipulates that their providers must provide interpretation when necessary, many health care centers do not set up interpretation. Part of my internship was then calling Medicaid to set up interpretation on behalf of the client or convincing one of NAP’s multilingual staff members to accompany the client. Though not all interpreters are necessarily of the same culture as the refugee, many are. This cultural translation, in addition to linguistic translation, is crucial for successful patient-doctor decision-making. For example, Somalians may refuse to take Tylenol because death is listed as a possible side effect. Americans understand that, when taken correctly, death by Tylenol is almost impossible. Yet, this is not contextualized on the label. Medical providers must be aware of cultural nuances as they often act as determinants of health behavior.

It wasn’t until I was sent a Migrant Clinicians Network webinar by my case manager that I realized NAP’s clients are not the only group facing these difficulties. Many of the barriers to meaningful health care, such as transportation and language, are similar for other types of migrants as well, like farmworkers. I watched Deliana Garcia’s webinar entitled Trauma Informed Care: Behavioral Health in the Primary Care Setting, which provides insight into how clinicians can act as resources to patients who have experienced trauma. A patient, for example, may present with a rash, but have experienced a trauma in the past. Many migrants including refugees face unimaginable hardship in their journey to and settlement in the United States. These appointments are then an opportunity to assist patients with underlying mental health issues stemming from their migration. Primary care providers can address immediate needs to an extent and then direct clients to accessible resources for more care if need be. Yet, integrating mental health awareness into a primary care setting is a challenging task. How does a clinician address mental health issues, particularly if such issues are not considered “valid” within the client’s culture, while still addressing the presented ailments? 

One way, Ms. Garcia suggests, is to ask specific medical history questions that may indicate trauma. Questions referring to sleep and social support are open ended and reserve judgment of the patient, yet provide insight to the examining clinician. This is a similar approach to how case managers at NAP gauge the mental and emotional well-being of refugees. In most of the refugee communities, there is a stigma against mental health problems, yet people will discuss trauma with a trusted friend. Case managers for refugees, clinicians for migrant farmworkers, and others working with mobile populations can then be the stepping stones to achieving holistic health. The work of Migrant Clinicians Network and its applicability to refugee health care is a sign of the improving inclusivity of diverse communities within the current health field. 

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