Immigrants and Health Care: Newcomers, New Challenges
Bridging The Gaps
Mobile Clinic Delivers Care to Immigrants, but Challenges Are Daunting
Tuesday, January 22, 2008; Page HE01
A42-year-old political refugee from Sierra Leone, trained as a chemist in France, recently showed up -- desperate -- at the mobile health clinic in Silver Spring where I work as a nurse practitioner. He had lost his health insurance, he explained in fluent English, after his hours had been cut at the university cafeteria where he was working as a cook and dishwasher. By the time I saw him, he had been without his diabetes medication for several months, his blood sugar was dangerously high and he was suffering from kidney damage. I got him back on his drugs, but not before sharing his frustration that his insurer could just drop him.
Stories like this are all too common among the immigrant patients I see at the nonprofit community clinic. All are uninsured. Most have had limited preventive care, and many suffer from chronic diseases including asthma, high blood pressure and diabetes.
Another patient, a squat middle-aged woman from Guatemala, came in wearing a food-stained apron and clutching a drug ad -- the Latin press is saturated with them -- for Botox. Did we offer this treatment? she asked, pointing to a fit young woman in the beauty magazine. I tried to break it to her gently that, for us, life-and-death needs take precedence over cosmetic procedures. But I was glad her worries about wrinkles had brought her in: She had severe high blood pressure. She left with skin lotion -- and medication and education to prevent a stroke or heart disease.
Medical problems like these are complicated by tenuous living arrangements, limited English skills and differing cultural values. No wonder frustration and burnout are high among people who try to help. But if we don't provide care, the incidence of preventable diseases will go up -- along with the costs.
Here, based on what I've seen, are some of the challenges we face:
¿ It's hard to get immigrants to take advantage of available services.
Patients I see at "Moby," as we call our van, are often wary of clinicians like me because of language barriers, fears about their immigration status and confusion about the health system. They worry about long waits that could jeopardize their jobs.
At the clinic, we try to build trust by hiring people fluent in Spanish (my second language), Farsi, Creole, Korean, Amharic and others, and partnering with trusted community groups. Patients learn, generally by word of mouth, that we provide care and medications on a sliding fee scale, in a language they understand and, when possible, from a medical provider from their country.
¿ Medication issues can complicate care.
We all know about over-the-counter drugs; many immigrants use what I call "under-the-counter" medications. Small local grocery stores, or bodegas, sell everything from tetracycline and other antibiotics to oral contraceptives. Patients often take tetracycline for whatever ails them, and many of my female patients are taking birth control pills that they acquire without a prescription. Then they show up with symptoms that may be tied to these drugs or a variety of herbs but are hesitant to admit what they are taking until they know they can trust me.
One young Salvadoran patient of mine who thought she had an ulcer -- but may just have had heartburn -- was taking misoprostol sent from her country. She didn't know that this ulcer-preventing drug is a component of the RU-486 regimen for medical abortions. Since she was considering having a baby, I took her off it. This is a very strong drug, I told her -- probably too strong for what she had. (She tested negative for the bacteria that cause stomach ulcers.) I gave her an over-the-counter medication and told her to stay away from spicy foods and coffee, and to sleep with lots of pillows (to reduce reflux).
¿ Language barriers take many forms.
Consider mistranslation. A young Peruvian woman, being evaluated for chronic urinary tract infections, was sent to a local hospital for a "clean-catch" urine specimen. But when the written instructions, translated badly into Spanish, directed her to "pee on the bed," she left the lab without leaving a specimen. After I explained what she was supposed to do, she was so grateful that she brought me a hand-knitted cap.
While trained medical interpreters are increasingly available, many clinics still rely on family members instead. I have seen a school-age child asked to interpret for a parent being checked for a sexually transmitted disease or to relay a cancer diagnosis to a grandparent. The law requires any organization receiving federal funds to provide interpretation to people who speak limited English. Still, clinics don't have enough bilingual staff, and many don't know that companies such as AT&T provide county-subsidized phone interpretation services.
Even when the same language is spoken, cultural descriptions of ailments and symptoms can stump clinicians. "A fire deep inside" (code for heartburn or arthritis) or "air stuck in the back" (meaning a muscle spasm) requires us to expand our thinking.
Even telling a patient to take a drug "twice a day" isn't straightforward. It took me a while to realize that some patients were taking their medication upon waking, and their second pill with breakfast.
Most educated health consumers can provide a basic medical history, estimate the date of their last tetanus shot or report whether their grandmother died of stomach or colon cancer. For many immigrants, though, family history is unknown because their relatives died suddenly, and there was no system to analyze the cause of death. My Dominican patients often state that a family member died of "patatu" -- it means an unknown cause.
¿ The poor health of many immigrant patients is aggravated by poverty.
With the rise of obesity and its related problems, including heart disease and diabetes, I encourage my patients to maintain a low-fat, plant-based diet. Many come from countries where fresh fruit and vegetables are cheap, and processed and fast foods are expensive. When they arrive here, the situation flips and their diets often worsen.
They sometimes tell me that eight packs of ramen noodles (high in fat and sodium) cost $1, but they cannot buy enough vegetables for a salad for that price.
¿ Immigrants need access to mental health, dental health and specialty services.
Wait lists for these services are long, transportation is difficult, and appointments often conflict with work and child-care needs.
To get prenatal care or eye exams, patients must first get a referral from us, then have their eligibility verified in another office and then wait for services elsewhere.
One patient of mine fled Nicaragua during the Contra war and suffers from post-traumatic stress disorder, compounded by her concern for her teenage son, who is stationed in Iraq. So far, she has been unable to find mental health services in Spanish.
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I do what I can to help patients and their families understand their options and achieve goals we set together. But the fragmentation of the health system that frustrates English speakers with health insurance is worse for immigrants. Finding a balance between teaching them to advocate for themselves and negotiating the system for them is hard. Positive reinforcement -- perhaps a quick phone call to remind them about an appointment or congratulate them on lifestyle changes evident in lab results -- goes a long way. Recognizing that someone cares is often enough to make people start caring more for themselves.
Recently I saw a patient who had had high blood pressure, cholesterol and blood sugar. She heeded my advice, and six months later, her readings were normal. She'd also lost more than 10 pounds by cutting back on soda, eating more fruit and vegetables and walking daily. We celebrated her victory with dancing and singing. That's one fewer uninsured patient likely to need space at an emergency room. ¿
Lois Wessel is a family nurse practitioner with Mobile Medical Care Inc. and the associate director for programs with the Association of Clinicians for the Underserved. She also teaches nursing at Georgetown University School of Nursing and Health Studies. Comments:firstname.lastname@example.org.