by Alli Straubhar
An Iraqi woman presented for evaluation of her diffuse body pain. As she told her story in broken English, it was apparent that she had suffered indescribable abuse and seen unfathomable terrors. Her wounds had long since healed, her bruises can no longer be seen, and her broken bones had mended. What lasted were her visions of what she experienced that were imprinted forever in her memory. As she recanted what she endured, the scenes flashed before her eyes making all those wounds real and present again. Healing her pain would not solely rely upon the management of pain generated from nerve damage or improperly mended bone. Extensive mental health therapy and social support would be incorporated into her care.
This woman was a recent immigrant from Jordan where she lived for two years since she fled Iraq. She came to America with her three children. Her estranged husband came as well and lives here in Salt Lake. The majority of the abuse she described was at the hands of her husband. Living here in America allowed her the freedom to be separated from him. She had her own home where she lived with her children. The Salt Lake City Iraqi refugee community is a small community, but a growing one during the last decade given the turmoil from the Iraqi war. Although the woman spoke broken English and had some understanding of the language, she preferred to not use a translator during her exam. Due to the small size of the Iraqi community and the limited number of translators here, she was concerned about having a local Iraqi translator. HIPPA as an American law does not always transcend cultural lines. She could not be certain that what she said would be kept confidential and she feared for her safety. She broke down, sobbing, stating she was terrified to leave her home and she constantly looked over her shoulder to check if her husband was following her. She felt that the risk of having a miscommunication about her health was smaller than the risk she took in having a person of her community present during the exam and hearing her stories.
This story illustrates some important issues. It is easy to take for granted the right we have in America for privacy of our health information. We also have the luxury of speaking the dominant language and understanding healthcare in a biomedical fashion (as opposed to Eastern medicine or shaman medicine). One of the biggest obstacles in providing access to healthcare is providing it in the native-language of the people one is treating.
According to US laws, in order to obtain adequate informed consent, the patient must be given information about their care in a manner that they can understand it. In most cases with the refugee population, this means obtaining a translator. In a systematic literature review, it was found that use of professional interpreters was associated with improved clinical care over the use of ad hoc interpreters. The use of professional interpreters seemed to raise the quality of clinical care for patients with limited English proficiency to approach or equal that for patients without language barriers. While all healthcare systems that receive Medicare funding are required to provide interpreters and aids to facilitate patient understanding, there is little funding for this. Often there are too many patients and too few resources to assist in every patient understanding all aspects of their care. The staff relies upon the patient, their family, friends or other healthcare professionals to provide interpretation, and this can be detrimental to the care of the patient.
Providing translational services to these clients is paramount to providing effective, safe and complete healthcare, but this comes at a price. An entire infrastructure is required to provide translators and this is expensive.
There are many barriers that refugees face as they begin to acculturate and assimilate to the American lifestyle and become incorporated in our society. Language plays a pivotal role in this. If healthcare professionals are aware of these challenges and try to help overcome them, better care can be provided to the patient.
At the end of the interview, the patient stated she was grateful to be in America, that her children were safe, and they were away from the destruction of war. Albeit she was terrified of her husband and had experienced significant violence at his hands, she was grateful to be getting help here. She was excited about the possibility of moving on with her life. Someday she hoped to have a job and work outside the home. She seemed so have some optimism despite the current misery she was feeling. Hopefully we can improve our health care infrastructure to support that optimism.
Alli Strauber is a 4th year medical student at the University of Utah who is going into Family Medicine.