Navigating Health Care Can Often Leave Refugees Lost in Translation

By the time the federally funded Squirrel Hill Health Center’s Mobile Unit opens its doors in the Pittsburgh community of Prospect Park, people are already lined up, looking for help.

A few times a month, the mobile unit sets up in this neighborhood full of refugees. On board is a doctor and a medical assistant who is an Arabic-speaking Iraqi refugee. Also on board the bus is Praves Wagley, an ethnically Nepali, Bhutanese refugee who serves as a translator for many of the people who come for care. Of all the refugee communities in the area, at an estimated 4,000, the Bhutanese are the largest.

Trying to access health care without English language skills can often leave refugees in Pittsburgh lost in translation.

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Terapeuta Julanne Bibro-Ruch trabaja con Adu Sit, un refugiado birmano, en el Centro de Salud de Squirrel Hill. Un intérprete participa por teléfono. 

(Erika Beras/Reporting on Health Collaborative)

People with all kinds of ailments and other problems stop by the mobile clinic. On a recent afternoon, Meunka Tamang, a 21-year-old Medicaid recipient, arrived. She had been in the ER earlier in the week with abdominal pain and was supposed to follow up with a primary care provider. She came holding a bag full of prescription pills asking someone to translate what the labels said, confused about the time of day to take them and what their effects would be. She had questions about post-treatment symptoms, and she needed a letter from a doctor excusing her from her housekeeping job for the week.

Many of the patients who knocked on the clinic's door had similar concerns. While some were there for doctor’s appointments, others came clutching letters from hospitals, state agencies, insurance companies, or even utility companies. They needed a translation.

In some ways, the clinic is breaking new ground. It has been a long time since physicians in Pittsburgh have had to deal with large populations of non-English speaking patients. And the clinic is one of the few places in this city where when they access health care, they can be ensured of interpreter services. This is true even though by law health care providers that receive federal funds are supposed to offer interpreters.

Pittsburgh was once an immigrant foothold. European and Middle Eastern immigrants and black migrants from the American South built the city into what it is. But when industry began to shutter in the 1970s, people started moving away in large numbers. And for a long time, people did not move in.

It's only been in the last few years that census numbers have ticked upward. Some of that is young people moving to Pittsburgh from other cities, but it's also refugees. Several thousand have been resettled here in the last few years by four resettlement agencies, and others move here after being resettled elsewhere.

In some ways it’s a perfect fit: There is ample employment and affordable housing stock. But in some critical ways, it’s not a good fit at all.

"Pittsburgh is about 20 years behind the rest of the country when it comes to immigrants," said Barbara Murock, the Immigrants and International Initiative Manager for Allegheny County’s Department of Human Services. "We’re still learning and we’re at a tipping point in terms of having enough immigrants that we need to start developing systems and programs and pathways for people to obtain services that they need." 

Those services include everything from having interpreters in a slew of languages in the courts and schools and drug and alcohol treatment centers. 

However, making services available is more than just language. For refugees, a lot of what they don’t understand is cultural.

When Jean Elomba was resettled here from the Congo, he spoke Kinyamulenge and struggled with everything from navigating public transportation to grocery store aisles.

"Coming here from the Congo is like you pretty much go to a different planet," he said. 

And those were just basic needs. The barriers are magnified when it comes to accessing health care, particularly mental health care.

In some languages and cultures, there aren’t words that are the equivalent of depression or trauma, bipolar or autism. When mental health is understood, it often comes with a stigma attached.

Marco Gemignani teaches psychology at Duquesne University. As a younger man, he worked in refugee camps in Bosnia. Now, his students work with newly arrived refugees at Catholic Charities in Pittsburgh.

He said seeking out mental health care may be frowned upon in many cultures.

"Patients who come from more collective societies, seeking out individual therapy is seen as an act of selfishness because they are taking care of themselves more than they are taking care of their larger family or the community they come from," he said. 

Those who work in the field say refugees don’t usually come in to clinics searching for mental health care. Instead, they come in with physical symptoms that are indicators of other problems, symptoms like headaches or stomachaches or trouble sleeping.

Such was the case for Adu Sit, a Burmese refugee who went to Pittsburgh’s Squirrel Hill Health Center because he was having trouble sleeping. He was referred to therapist Julanne Bibro-Ruch who has an office at the center. Doctors say it is less stigmatizing to send a patient to someone else in the same center than to send them to another clinic altogether.

In a small office, the two faced each other, over a telephone that was set to speaker. On the line was a Burmese translator from Pacific Interpreters, a company on the West Coast. As the patient and therapist spoke in their native language, they watched each other closely and carefully — looking into each other’s eyes, watching each others hands and body movements. 

Sit, 38, had been in Pittsburgh for two years and was experiencing some situational depression. He was going through a breakup with his wife. He doesn’t speak English and Bibro-Ruch doesn’t speak Burmese. But they’ve previously met, and Sit said he now trusts her as if she is family.

"Last time I feel more depressed and really sad, but this time I can open more I can really talk about my family conditions," he said. 

Translation services are expensive and not always easily accessible. The cost of an interpreter, even on the phone, can be high. The translation services the center uses averages $5,000 a month. They also use in-person interpreters, staff who speak a variety of languages. 

And while using translators such as Praves Wagley on the mobile clinic is helpful, there are also concerns of privacy and information spread in insular communities. There may be thousands of Congolese in a community, but the group that speaks Kinyamulenge is different than the one that speaks Swahili and the one that speaks Lingala and those who speak French.

At last count, the University of Pittsburgh Medical Center provided interpreter services in more than 200 languages. That number is only expected to grow as the refugees community grows and changes.