Not Just Doctors: Reflections on refugee health care issues from a medical provider

Caring for refugee patients is a complex problem that challenges many aspects of our health systems and governmental agencies. As medical student at Brown University, I have spent the last few years attempting to address the barriers to care, at the level of the physician, by focusing on treatment for the health problems that are specific to refugee patients. In addition to providers’ illiteracy about the medical issues that are specific to refugees, other key barriers to the provision of care include language, cross-cultural differences, and structural issues such as transportation to health facilities, telephone access, and financial constraints. In Rhode Island, multiple programs and organizations provide services focusing on these individual barriers to care, but the overarching health system problem in providing for refugee children’s health care is the long-term integration of providers and social services.

Many public and private agencies, governmental organizations, social workers, voluntary resettlement agencies, and clinicians provide services for a single refugee family in Rhode Island. All are involved in receiving refugees, home placements, securing employment and benefits, school enrollment for children, ESL classes, interpreter services, citizenship preparation, and, of course, medical care – from making doctor appointments (as well as providing transportation or accompaniment to appointments), to providing low-literacy health education materials, to helping patients finance medical care. While any one group, the International Institute of Rhode Island for example, may provide many resources for refugees, they often refer out to other groups or are themselves naturally fragmented to deliver multiple services.

Consider, for example, the many requirements of the initial intake of new patients at the Rhode Island pediatric refugee clinic at Hasbro Hospital. A nurse sees each new patient on the Friday before his or her Monday clinical visit with a physician. The purpose of this visit is to collect any medical paperwork, screen for tuberculosis, get urine samples and blood tests, check height and weight, and give stool collection kits for the patient to return the following Monday when they are seen by a physician at the monthly refugee clinic4. For these two initial visits to be successful, multiple integrated services are required: a service provider must coordinate these two appointments with both the clinic and the family (via interpreter); a social worker or volunteer must accompany the family to and from the hospital because of unfamiliarity with the neighborhood or inexperience with public transportation; a translator must be available for both visits; the patient’s family must be informed of the necessary migration and medical documents to bring; the procedure for collecting three stool samples outside of the doctor’s office must be explained, and so forth. Providing effective care for refugee patients thus involves much more than what transpires in the clinical interaction between a patient and physician.

The treatment of lead poisoning is an excellent clinical example of these barriers to care. Lead poisoning is a common problem among refugee children that often goes undetected by clinicians until many months into caring for these patients. The physical health requirement of preventing lead poisoning is complicated by the need to obtain adequate housing that is lead-free, requiring assistance from housing agencies or social workers outside of the hospital staff. Additionally, the ability to secure stable and safe housing is directly related to income and employment, requiring the assistance of another agency to procure employment. Finally, the patients and their parents are unlikely to be familiar with the concept of lead poisoning and the cultural practices that may be contributing to lead exposure . This adds the ever-present dimension of language and cultural barriers that require a third, fourth, or even fifth party’s assistance.

I have seen this complex problem first hand as a volunteer helping to resettle a new refugee family from Eritrea. On all my visits to this family’s home, the single interpreter in Rhode Island who speaks their language (a refugee himself who was trained by the hospital) has either been unavailable, late, or misunderstood the meeting time. The integration of these services is challenging and frustrating, but is required before a patient can even see a provider and face the difficulties of the clinical interaction itself. At that point, a whole new host of problems arises – language, cross-cultural differences, financial issues, referrals for new services, awareness of the most relevant clinical problems to the patient’s ethnic group, etc. - that require additional coordination of resources for the patient. For example, Refugee Medical Assistance no longer covers patients eight months after the date of US entry, but it can take more than a year for many refugees to find gainful employment that provides health coverage . The medical provider and her staff must coordinate with the various organizations involved in securing care as well as employment agencies and interpreters to ensure that no patients are lost to follow up and that patients maintain their ability to afford health care.

The discourse on treating refugee patients tends to focus on the cultural competency of the individual clinician or medical staff - professionally trained medical interpreters, bilingual and bicultural staff, and expertise in refugee health issues on the part of the physician. While these features in clinic services are essential for adequate care, systematic linkages between specific providers, resettlement agencies, health departments, immigration services, and other governmental organizations on both the local and national level are necessary and are far more complex to coordinate. Addressing this health system failure is difficult because obvious solutions are not available; the most effective methods of delivering comprehensive services for refugees are unknown, as this population tends to be underrepresented in medical and social science research and neglected in health care policy. From a medical standpoint, my mentor Dr. Carol Lewis at Hasbro Children’s Hospital and I are attempting to address the particular health needs of refugee children that may go unrecognized by current standards of care. We have created a standardized protocol of care that facilitates more effective medical service for this complex group of patients. The goal of truly comprehensive and high quality care for refugees, however, necessitates a highly integrated system of cooperative work and communication between the many organizations and individuals who provide services for these patients, a requirement that begins before and extends far beyond the doctor-patient interaction at the examination table.