“My first life ended when I landed at JFK... I had to learn how to shake hands, how to look at people in the eye... I am a man of two lives.” — Omar Bah
Omar Bah ran through the Gambian night. Echoes of soldier’s shouting and dog’s barking came from every direction. The memory of every kick and bruise that his battered body had sustained over the last months pulsed through him, speeding him on. He had dared to write about corruption in his government and now he was fleeing his country forever, leaving behind his young bride.
After an arduous journey that took him through Ghana, Omar arrived in Rhode Island in 2007. On his first day, he visited Rhode Island Hospital for his required medical assessment, which included a Hepatitis B test. He had been tested twice before. Both times the results had been negative, though he knew that he was at risk of exposure since 8% of Gambians are Hepatitis B positive.
After a grueling day of tests, his doctor sat him down and informed him of the results: they had come back positive. Omar couldn’t believe that as he had been preparing to start a new life, he could die before it even began.
It was two weeks until his next doctor’s appointment. He spent that entire time alone, mostly weeping in his apartment. He would close his eyes to go to sleep but wake up screaming. He said, “[The doctor] immensely traumatized me because at that time I was also battling PTSD. I was isolated because I was the only refugee from Gambia. I didn’t know anybody.”
At his next appointment, in response to all of Omar’s questions, the doctor could only respond, “Well, the test says that you are immune, which means that you have it in your system.”
The test was positive, which could mean one of two things: either that he had been inoculated against the virus, or that he had come into contact with it. Omar questioned the doctor’s inability to tell him definitively whether or not he had the virus. The doctor stumbled through a reply.
Despite the deep foreignness of his surroundings and his extreme sense of isolation, Omar could not accept the diagnosis. He asked to speak to the doctor’s supervisor. He asks, “Imagine this happening to people who don’t even read or write English: people who are not empowered to speak for themselves?”
This was the worst possible scenario of a healthcare interaction: a distressing experience with a doctor who was not aware that being a refugee often means that the person left his or her home with nothing, let alone medical records, and that he or she most likely comes from a traumatic past.
What if somebody was with Omar the entire time he was going through his initial medical visits? “Things would have been different,” he says. He would never have been with a doctor unfamiliar with treating refugees. He would have been able to talk to somebody who could have advocated for him as well.
As a new influx of Syrian refugees arrives in the United States, they will face a host of challenges. “In the current U.S. political climate,” Omar says, “refugee equates to terrorism. Refugee equals illegal. Refugee means everything that is bad. This is wrong.” Healthcare partners state-wide are looking at innovative ways to minimize the impact of these stresses as they pertain to healthcare.
Since Omar’s arrival in 2007, health professionals and state employees across Rhode Island are working hard to make R.I. “the most welcoming and tolerant state in the country.” In the healthcare context, doctors Elizabeth Toll and Carol Lewis, Director of the Refugee Clinic at Hasbro Children’s Hospital, are spearheading the medical home model, which aims to provide comprehensive and continuous care in order to maximize health outcomes.
This becomes difficult in particular when government support through resettlement agencies ends three-six months after a refugee’s arrival. Though clinics work to provide ongoing primary care, refugees face many barriers when it comes to healthcare access and literacy. Omar’s story points to disillusionment and disempowerment in refugee populations stemming from isolation, inability to communicate, previous trauma and structural barriers that needs to be addressed not just in healthcare but also in the many other aspects of their new lives.
The room in Dorcas is one of many occupied classrooms arranged in a maze-like intersection of corridors. It holds five people: two current and three future healthcare professionals. Fadya is a family doctor leading the session on family planning, along with a nurse practitioner. A beautiful woman in a hijab, a man wearing a baseball cap and another man with striking eyes and an ever-present smile are the Community Health Workers (CHWs) in training. As they are writing their names on Hello tags, Fadya makes conversation. “So there are many Syrian refugees coming in?” she asks. The third man, Burqan, who is from Iraq, agrees, saying that Iraqi and Syrian cultures are similar and that he looks forward to being able to help the new refugees.
Burqan is one of the eight individuals who are being trained in a pilot program organized by The Rhode Island Department of Health, Dorcas and the Refugee Clinic at the Hasbro Children’s Hospital. They are collaborating to train leaders within refugee communities to become CHWs who can advocate for and guide other refugees from their communities. This program will be the first of its kind in Rhode Island.
The pilot focuses on the three largest refugee populations in Rhode Island, which are Congolese, Somalian and Iraqi. This is the third in a series of trainings; Burkan and his colleagues have already completed a 30-hour course and will be assigned their first families soon.
Burkan described his reasons for wanting to become a CHW. “Based on our experience first time in the United States, we noticed that the new refugees [were] facing problems with issues mainly with medical appointments, such as how to deal with the medical provider. So, we think that if we can help in this field, they can deal better than us before.”
Perry Gast, the Refugee Health Coordinator at the Rhode Island Department of Health, explained further. “This would go beyond just helping. [CHWs] would stay with the families until they are more independent. There are caseworkers that help with that for the first three months, but this program is not just focused on health literacy: it addresses other, more basic needs that impact overall health outcomes.”
CHWs can address these needs by, among other things, helping families with transportation, making doctor’s appointments and training families how to independently perform these tasks. In fact, this program could help address many of the issues that interpreters, another group of healthcare professionals largely composed of former refugees, face by formalizing training and reimbursement.
Currently, interpreters are only paid for the time they spend in the doctor’s office. As we sat in the waiting room of Hasbro, Marie, an interpreter from Congo, described the work she had done for a patient sitting next to us. She was a refugee in Uganda for eight years, where she became familiar with another eight. “It’s just a talent,” she says. “In my family we are six. But it’s only me who speaks all these languages.”
She began by going to the patient’s home and transporting him to the hospital. She was waiting to interpret for him during the appointment, which would most likely start late, affecting her ability to reach her next patient on time. After the meeting, she would go to the pharmacy as necessary to interpret and pick up the medication before transporting him home. For all this time, she would only be reimbursed for the time she spent with her patient in the doctor’s office. The rest was all as a volunteer; work through which she found great meaning but which resulted in stress given her financial situation. She explained, “Whatever I do, I do by compassion, by love. No one is forcing me. And I know I’m doing it correctly because those are the languages I love. So I feel happy.”
The new program will hopefully help interpreters, since CHWs would take over many parts of the work for which interpreters are not currently paid. To this end, the Department of Health is working with the Rhode Island Certification Board to create a CHW certification. With it, CHWs would be reimbursed through Medicaid for all the work they do for their patients, just like other healthcare professionals.
Omar, in the new doctor’s office, asked for another test. The same results came out again: confusing and difficult to explain. But this doctor took the time to sit with him. She didn’t ask for medical records. She told him, “I will explain it to you as simply as possible. To start with, you don’t have Hepatitis B.” He jumped up and hugged her for a long time. After many moments of disbelief, she explained that she believed he had been immunized against Hepatitis B as a child, but had no record or memory of it.
After Omar escaped the diagnosis of a life-threatening illness, he went on to found an organization instrumental to refugees based on his own experience with the healthcare system. Teddi Jallow, his wife, joined him two years after he arrived in the United States. Together they founded the Refugee Dream Center in 2015, a post-resettlement agency.
Omar described his work at the Refugee Dream Center as the same work that Dorcas does, such as referrals, skill development and cultural orientation. Teddi explained, “They are left alone. I went through the same thing too. We just pull what we went through to help others.”
It is a lot of work: a typical day at the center might have Teddi organizing a clothes and games drive and preparing for an adult English and health promotion class in the afternoon.
Omar has also become certified in trauma-based therapy by the Harvard Program in Refugee Trauma. Both his therapy, his organization and his consultations with healthcare professionals are based on the value of helping newly resettled refugees from experience. He sees the community health workers program in a similar light. He wishes that when he was undergoing his ordeal, he could have had someone with experience advocating for him like he is advocating today for others.
Teddi described refugees’ broken dreams when they first arrive in America. Many cannot speak English, have difficulty finding a job and must adapt to new and potentially dangerous living conditions, to name a few challenges. This program, she hopes, will offer the support new refugees need to take their first steps to empowerment after a past over which they had little control.
“Maybe we will get there someday,” she finishes, smiling.