By Sarah Ruth Bates
and Kate Connors
What are the health care consequences of fearing deportation? In 2018, as immigration status becomes less certain for many, physicians are finding out. “I’ve realized what a loaded question ‘How long have you been in this country?’ is,” says Elise M. Henricks, MD, medical director of Upham’s Corner Health Center in Dorchester, Boston, and a family medicine physician. “It used to be a standard social history question.”
Elise M. Henricks, MD
Physicians caring for immigrants in Massachusetts are recognizing immigration status as a social determinant of health. “Two of my patients have had relatives incarcerated by the INS [Immigration and Naturalization Service], and others feel that they’re at risk, or their family members are. It’s changed the way that I ask people questions,” says Dr. Henricks.
Whole Patient Exemplified
Caring for immigrant patients requires physicians to surmount linguistic, logistical, and cultural barriers — but those difficulties create opportunities to make profound differences in patients’ lives. Supporting patients’ citizenship applications and connecting them with community resources are parts of this broad conceptualization of health care.
Maryanne C. Bombaugh, MD, MBA
“I have incredible joy from helping my patients through the citizenship process,” Dr. Henricks says. “I take pictures of them when they come in with their passports, and I have a photo album of people who’ve come in with their new documentation status paperwork or their passport. It helps me realize that I have an important role in helping people to establish themselves here.”
Gained in Translation
The requirements of a multiethnic patient population start with overcoming language differences. “Language barriers require extra effort on the part of both the patient and the office, or the health care system,” says Maryanne C. Bombaugh, MD, MBA, vice president of the MMS and a physician at the Community Health Centers of Cape Cod. “Language barriers can impact understanding, compliance, quality, and access
to care.”
Upham’s Corner translates materials into four languages and hires bi- or trilingual staff from the community. At Cape Cod, staff and clinicians access live interpreter services online. Conversations that English-speaking patients might have with their physicians through letters or a
patient portal — sharing test results, for example — may necessitate in-person visits for immigrants.
Understanding Cultural Differences
In these ways and more, care delivery requires a cultural shift in patients and providers. “So many layers of my patients’ stories impact how they think about taking their medication, or about time,” Dr. Henricks says. “Appointment times in other cultures can be much more vague; you just show up at the clinic and wait your turn to be seen.”
The health implications of cultural divides are described perhaps most memorably in The Spirit Catches You and You Fall Down: A Hmong Child, Her American Doctors, and the Collision of Two Cultures, by Anne Fadiman (Farrar, Straus and Giroux, 2012). The book, which explores conflicting ways to think about epilepsy, has become a staple of public health and medical education.
Cultural differences require interpretation, just as language differences do. “Vietnamese folks use cupping” — placing a cup on the skin and creating a vacuum or suction — “so women come in with marks that could look like bruises to someone who’s not familiar with the culture,” says Dr. Henricks. Staff from the local community serve as cultural (as well as linguistic) interpreters at Upham’s Corner. “No matter what you learned in medical school, you haven’t learned the cultural practices of all the people you’re going to be working with.”
Global Health Is Local Health
Global health experience may provide similar insights, says Arul Mahadevan, MD, a radiation oncologist. The clinical perspectives Dr. Mahadevan gains on his international medical trips — to countries including India, Bangladesh, and Tanzania — inform his care of patients at Radiation Oncology Associates and Lahey Hospital & Medical Center.
“It is important for us to be culturally sensitive and understand where our patients are coming from,” he says. “A lot of multilingual and multinational people are living here in Massachusetts. People come to this country with all their susceptibilities based on their cultural and habitual causes of cancer. It’s not just clinical medicine: It’s about the social issues and beliefs that patients bring with them.
“How do you relate to them, how you talk to them about treatments and palliative care? That’s very important for people practicing here in Massachusetts. Although we are calling it global health, it’s all local.”
Value for Providers
Given all of those challenges, how do these physicians caring for immigrants avoid burnout? “I’m very proud of the persons who work with me and the teams that care for our patients,” says Dr. Bombaugh. “These are very vulnerable patients, they’re underserved, and community health centers are places where all can truly be cared for.”
Dr. Henricks agrees. “I’m looking at my parking lot right now, and it’s completely packed. So is the waiting room. I’ve been here for 19 years, so I have patients that I’ve known since birth. The relationships with people make all the rest of it possible. And it’s such a group effort. Working with people who have a sense of the larger picture and the greater good keeps me going.”
