By Megha Satyanarayana
Special to The Washington Post
Tuesday, February 5, 2008

Several years ago, shortly after arriving in the United States, Lyubov Belyayeva suffered a massive heart attack. She had left Russia to be with her daughter in Silver Spring, and she spoke no English.

In her mid-60s at the time, she'd had high blood pressure but no inkling of a heart attack. "There is no history of heart disease in my family," she said in Russian. "I think stress brought on the heart attack."

The American health-care system was a mystery to Belyayeva. She was used to no-cost, centralized health care, where seeking second opinions for simple ailments was acceptable, even expected. What's more, she had no insurance and needed her daughter to translate the complex information her U.S. doctors conveyed.

But many of the potential pitfalls in Belyayeva's experience were mitigated by a program in which health educators, including foreign-educated doctors, help recent immigrants.

A few weeks before her heart attack, Belyayeva had sat through a Holy Cross Hospital seminar in Russian, in which she had learned how to access health care and even received information about heart health. She had enrolled in the Silver Spring hospital's financial assistance program and ended up paying virtually nothing for her care.

The health education program, she said, may have saved her life.

* * *

Immigrants are the new face of Montgomery County. In a 2003 United States Census update from the Montgomery County Planning Department, 30 percent of county homes had a foreign-born head of household or a foreign-born spouse.

This change in the population calls for adjustments in delivering care, said internist Irene Dankwa-Mullan, program director of public health services in the county health department. The concept of going to a doctor for checkups is novel to many minorities and immigrants, she said.

Dankwa-Mullan's department, along with local hospitals, have therefore created education programs that focus on minority and immigrant populations. Their goal? To save costly emergency room admissions.

The program in which Belyayeva participated, the Holy Cross Hospital Ethnic Health Promotion Program, uses community leaders and laymen to teach prevention in the immigrants' languages and in the context of their various cultures. Sometimes the topic is prenatal care or breast health; other times, it's quitting smoking and heart health. The program started in 2001 and is run by the hospital's director of community health, Wendy Friar.

Friar is enthusiastic about developing one particular source of help: foreign-trained doctors who cannot practice medicine in the United States. Who better to overcome the many challenges immigrants face, Friar thought, than a doctor who not only speaks the language but understands the system his participants come from?

"It popped into my head one day, after hearing stories of doctors working as nurses' aides, in housekeeping, hotels and restaurants," Friar said. "If I could get more, I'd bring them on in a second."

* * *

Belyayeva's seminars were taught by Lev Nora, a former internist who fled Ukraine in 2000. Now in Rockville, he is one of three medical graduates who have worked with Friar as health educators. The other two, both Latinos, have since relocated.

Nora, 49, had been the chief of the department of internal disease at the Municipal Hospital of Odessa. His salary was low, and because the government was in turmoil, he worried that his position was not stable. "I could lose my job at any time," he said.

Soon after he and his family arrived in Maryland, Nora studied for the U.S. Medical Licensing Exam. The part-written, part-clinical exam was the first step toward practicing medicine in the United States. He also had to complete residency training, a multi-year ordeal.

"It was like finishing medical school again," he said.

When Nora's wife had a complicated pregnancy, he had to abandon the residency before getting his license. After a chance meeting with Friar, Nora became involved in the health educator program, which is funded through state and local grants. Nora sets up shop in community centers, apartment complexes and sometimes coffeehouses, sharing his new cultural competence with members of the burgeoning Russian community.

He teaches mostly heart-health and tobacco-cessation programs but discusses anything with his participants, he said. If they need aid, he helps them with the paperwork. If they ask, he'll volunteer to go with them to their doctor.

In Russia, Nora explained, it is common to give the family more information about the patient's status than the patient receives, he said; it protects the patient's will to live. For immigrants, the American process is confusing, and misunderstandings occur even in the presence of translators, he said. Some of his clients have been here for years and have never seen a doctor.

Nora's comments are borne out by Belyayeva's experience. Not only was the new system a challenge for her, but the hospital was intimidating, with a big emergency room and an intensive care unit where everything was new and high-tech, and the doctors asked a barrage of questions. Her daughter was there to help, but meeting Nora, she said, was a stroke of good fortune -- and a relief.

Nora estimates that half his participants act on what they've learned in the seminars, whether it's through lifestyle changes, getting screened for cancer or forming a doctor-patient relationship.

After a short stint in the intensive care unit, Belyayeva went home. She controls her blood pressure and cholesterol with medicine, and aside from a painful dental filling, she said, she feels good.

* * *

Every culture has its own way of interacting with health-care professionals, said internist Elise Riley, director of the Holy Cross Hospital Health Center at Montgomery College.

The humble plantain, she said, is a great example of cultural confusion. To nutritionists advising their West Indies clients to eat more vegetables and fewer carbohydrates, the starchy, banana-like food is mostly a taboo. But in the Caribbean, many consider the plantain a vegetable, so "eat more vegetables" means "eat more plantains."

And for non-English speakers relying on friends and family members, some of them children, translation may miss important information from doctors and pharmacists.

"Being able to communicate directly with patients is so important. We must be able to communicate in the appropriate language but use the appropriate terminology, too," Riley said. Immigrant patients often wait until things are unbearable, she said. Many emergencies are advanced illnesses, such as diabetes, that could have been well controlled in office visits. Sometimes her patients don't know their illness is treatable here, because it would not have been at home.

This is where a health educator like Nora is so valuable, Riley said: He translates, he understands medical jargon and people trust him. He finds the right word when a direct translation doesn't exist. He makes life easier for doctors.

And for patients like Belyayeva, what she learned from Nora about health care in the United States will help her stay strong as she explores her new home. ¿

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