A young Vietnamese mother who doesn't speak English walks into the Community Health Center in Burlington one morning carrying an infant who's been awake all night with a high fever. A nurse conducting a routine examination of the child notices the baby's skin bears suspicious red marks that look like burns or bruises. As a licensed health-care provider, the nurse is required by law to report suspected cases of abuse or neglect. As recently as five years ago, she might have alerted the authorities before realizing her mistake.
Not anymore. Today, medical workers at CHC have learned to recognize the telltale signs of "coining," a traditional home remedy to relieve pain that is practiced in many Asian countries. This gentle procedure involves rubbing the skin with hot oil or warm coins, which leave behind red marks that eventually fade.
"As practitioners, we have a belief in holistic medicine," says Lee Orsky, a physician-assistant at CHC who screens and evaluates all new refugees to the Burlington area for communicable diseases. "So when a young Asian woman comes in with her child who has a fever, I'm not going to assume that the only thing she's using is Tylenol, because I know, culturally, that they are using other things. And I'm not going to be judgmental." Despite its challenges, Orsky notes that treating new foreign-born residents is rewarding. "It's what brings me to work every day," she says. "It sort of feels like a little travel trip for me."
Coining is just one example of the many unfamiliar practices and beliefs that Vermont's health-care workers have had to learn about in the last decade. As the number and diversity of Vermont's foreign-born residents grow, so do the demands on the region's health-care facilities. The challenge for local doctors, nurses, mental-health workers and other providers is not only to communicate with their patients -- who may speak a bewildering assortment of languages and dialects -- but also to understand their unique histories and cultural attitudes. As medical practitioners will tell you, it's almost impossible to diagnose and treat an illness if they literally don't know where the patient is coming from.
Compared to other states with larger and more ethnically diverse populations, Vermont has only just begun its education into the world of culturally appropriate health care. In 1993, the CHC began to see an increasing number of foreign-born patients, the result of a wave of refugees moving into the Old North End. Many of these new residents didn't speak English and had never been exposed to Western medicine. As a result, even routine procedures such as having their blood drawn or getting a gynecological exam could be traumatic experiences. As CHC's Alison Calderara explains, the medical staff soon realized they were lacking an essential diagnostic tool: professional interpreters.
"Equal access to health care doesn't mean the same thing to every person," Calderara says. "And for people who don't speak the language, equal access means that you have to have an interpreter." For years, it was considered acceptable to have a family member, typically a child, translate symptoms, diagnoses and treatment instructions. No more. Under federal law, health-care facilities that receive government funding are now required to provide interpreters for any patient who cannot speak English. In response to this rule, CHC became the first medical institution in the state to hire professional translators. Currently, the clinic employs interpreters who speak Bosnian and Vietnamese, as well as health-care professionals who are conversant in French, German and Spanish. In 2003, of the 8700 or so patients the facility served, more than 5 percent required an interpreter.
"Russian, Czech, Portuguese, Chinese, Tibetan. We get language requests that are just amazing," says Calderara. "Sometimes in a medical environment you can be talking about things that are stressful, and you always want to be sure that you're talking to people in a language that they are comfortable in."
Of course, understanding what a patient is saying isn't the same as knowing what a patient means. As Orsky learned, sometimes even the simplest words and concepts do not translate well from one language to another. "When I first started seeing the Vietnamese population, I would hear from them that they feel hot,'" Orsky recalls. "If you came in and said you feel hot, I would say you have a fever. That's not what the Vietnamese meant. They were having problems with their liver or stomach that was causing them to feel hot.'"
Orsky discovered another cultural difference among her Asian patients. Many of them would immediately agree to whatever treatment option she suggested, then not follow through with it. "Their culture requires that they be very polite, even subservient to you," Orsky explains. "So we have to be very aware of that and make sure we give them plenty of choices."
Among some African refugees, the attitudes toward health and treatment can be quite different. Muderhwa Runesha is director of the Office of Minority Health at the Vermont Department of Health. A native of Congo, Runesha explains that the first contact a medical professional makes with a Congolese patient can be critically important to gaining his or her trust. In his culture, a doctor will take a lot of time greeting patients and asking about their families and friends. Eventually, he says, they get around to discussing the reason for the visit.
Runesha explains that this stems from a pervasive cultural attitude that illnesses are caused by forces outside a person's body, such as a dispute with a family member, friend or someone else in the community. "This holistic approach is very important, to take into consideration the body, mind and spirit," Runesha says. "Because when there is an imbalance in those three, the person gets sick."
Runesha says that once the ailment's cause is identified, the patient and provider will "negotiate" a treatment. "In some cultures, when an African goes to the hospital, when the doctor gives only pills, the patient will say, How come you give me only pills?' They believe an injection is stronger," he says.
Runesha is writing a program on cultural competency for Vermont's medical professionals. It's an involved and time-consuming project, he says, because even within a single country like Congo there are many different cultures and attitudes towards health care, which vary not only by geography but also age, gender, class and education level.
If providing refugees with medical care poses some unique challenges, tackling mental-health issues is even more daunting. Cathy Kelley is the refugee clinician at the Howard Center for Human Services in Burlington. One of the few mental-health professionals in Vermont who sees exclusively foreign-born patients, Kelley points out that the stigma mental illness already carries in American culture can be even stronger in more traditional groups.
She notes, for example, that in Vietnamese there isn't even a word for mental illness. And in some African cultures, a client's interpretation of what is causing a mental illness may be radically different from a westernized interpretation. "We might see someone as being psychotic and they might view themselves as possessed by spirits," Kelley explains. "The challenge there is to keep their perspective in mind while also trying to provide them with the best care we can."
The mental-health needs of some refugees can be formidable for patient and caregiver alike. On the day of our interview, for instance, Kelley had just met with a Bosnian client who had lost 36 members of her family to war. "It's hard to imagine how to give that person some hope that they will be able to overcome this," Kelley admits. "But I think that what you try to do is just find some small ways of supporting them."
With other clients, she says, it can be hard to overcome their inherent fear or distrust of the medical profession in general. Some refugees are afraid that if they are diagnosed with a mental illness, they will be deprived of their basic freedoms or given a label that will haunt them for the rest of their lives. Others, like those from former Soviet republics, may be inherently distrustful of mental-health workers, especially if they or someone they know from their native country was interrogated or tortured by physicians or psychiatrists.
When it comes to receiving treatment, a refugee who has resettled among a very small population of native countrymen may be concerned about protecting his or her privacy. A client may show up for an appointment, only to discover that the interpreter is someone he or she knows. Although interpreters are bound by the same rules of confidentiality as clinicians, the client may still fear that his or her problems will be discussed with friends and neighbors.
But while it's easy to assume that all new refugees are plagued with problems such as severe depression or post-traumatic stress disorder, Kelley points out that their most common complaints aren't too different from those faced by the general population.
"Refugees also have to deal with issues like, How am I going to pay the rent, how do I find a job when I don't speak the language, and what do I do about the fact that my children are more acculturated than I am and they're losing the values that are important to me?'" Kelley says. "These are all pretty complex issues."
Likewise, Orsky at CHC is wary of propagating stereotypes about refugee health. As a physician-assistant who spends about half of her time with foreign-born patients, she says that all too often the things she reads about new populations moving into the community prove to be untrue. Even health-care workers themselves can jump to conclusions about the cause of a patient's ailment and overlook the obvious.
Orsky recalls one case she had several years ago when a young African man who was attending a local high school came in complaining of exhaustion. He was working two jobs, attending school full-time and, like many teens, sometimes didn't eat well. But it was natural to assume that, as an African refugee, he was suffering from depression, difficulty acclimatizing to Vermont's winters or even a tropical disease. Not so, says Orsky. "It turned out the kid had mono."