Five cases exemplify the ways in which Montagnard health experts have worked to get positive results.
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CASE 1
Family reunification of refugee and immigrant families is regarded as a celebratory occasion. LG exemplifies the stress and health problems triggered by family reunification and how whole neighborhoods can be mobilized to support good health outcomes.
LG
LG came to the US as an immigrant with her children to rejoin her husband. She is in her late thirties, never attended school and does not read or write. In Vietnam, she was a farmer. During her first several months in Greensboro, LG would remain in her small home, rise early to cook, see the kids off when the school bus came, clean and scrub the house, and wait for them to return in the afternoon. Later, her husband would return from work.
LI, a Montagnard Community Health Worker (CHW) and a neighbor, was concerned that LG was deeply isolated and possibly depressed. She sought to encourage LG to venture out. LI, who was a village health worker in Vietnam who regularly counseled families, believed LG had become pregnant but had not seen a doctor. When she and another CHW, Kwol Ksa, sought to speak with LG in her husband’s presence, they were angrily chased away. After the Women’s Learning Group was funded in April 2010, LI was able to persuade LG to walk five minutes to the language and health class that met at a neighbor’s house. Soon LG was a regular member, socializing, laughing, and learning English. Because the class was organized around women’s interests, LG enjoyed the company of mothers and grandmothers. We also used the class to help with other needs — food stamps, Orange Card, Medicaid and other needs — but LG’s husband refused to allow her to bring documents to class for our inspection.
One day LG stopped coming to class. Later we heard she had lost the baby. The CHWs were concerned about depression. Eventually LG returned to class. LG shared with the mothers and grandmothers in the class that she had abdominal pain and bleeding. Immediately, all of them urged her to seek medical help. The class CHWs were also joined by H Wier Siu, a former medical doctor, who also encouraged her to act. But LG was afraid that a return to the doctor’s office would only incur more bills her husband could not pay.
Follow Up
Faced with a crisis, the Montagnard CHWs, Dr Siu and I developed a plan. Acting as a neutral intermediary, I would approach the husband and offer to assist in refiling for food stamps. I would use the opportunity to talk about his wife’s health problems and explain the urgency of action. When the husband understood that his wife was covered by Medicaid, he agreed to allow Dr Siu and the CHWs to directly assist LG.
Later Dr Siu made the appointments for LG’s care, transported her to the hospital, acted as language and cultural interpreter, and oversaw LG’s progress. She took additional steps to avert another family crisis by arranging for a counselor at Planned Parenthood to talk to LG in a safe, calm environment when it seemed LG would risk another pregnancy rather than endure the disagreeable side effects of her birth control medication.
Big Picture
Our consistent approach to Montagnard health has been based on a cultural appreciation of the community, family and individual, as well as the history of the community in Vietnam and its complicated interaction with American institutions such as the Triad’s health systems. In LG’s case, we took the cues from LI that LG was isolated, possibly depressed, and that her husband was uninformed about inexpensive services that could relieve his wife’s suffering. Dr. Siu’s medical expertise allowed her to speak with encouragement and authority to LG. The neighborhood-based class allowed her to make friends and speak about her personal problems, giving us opportunities to help stabilize the family by talking to school officials about her children’s progress, resubmitting their food stamps application to increase the allowance, and obtaining reductions in health bills. Outside class, she could meet supportive neighbors like CHW LI in the nearby park where they went for daily walks. By understanding how the family’s larger problems were linked to LG’s medical needs and by taking time to meet and build trust with the family, we were able to come up with a plan of action with important roles for neighborhood women and our Montagnard health experts. Working with LG has been a positive learning experience for everyone. And in the future, we will be on steadier ground when we communicate with LG and her family.
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CASE 2
Montagnard mothers and wives can be so overwhelmed by family survival that they are not able to care for themselves.
BO
BO is a refugee farmer in her late forties with a husband and three children. She is not employed, has little education but her English is passable. By nature she is good-humored. Her husband’s English is poor. The Great Recession has made it difficult for him to find regular work. Money is a regular problem. At least one son is working but the family seems disorganized and unable to make progress.
BO has been diagnosed with high blood pressure. She has had great difficulty staying on her medications from month to month although she qualified for the Orange Card. Typically we’ve helped her obtain her prescription for 30 days, dutifully she takes her medication but at the end of the month she does not renew it, despite our instructions. After weeks or months, she suffers from severe headaches and other problems and then seeks help. She will work and do small tasks but the pay we give her from the Women’s Learning Group account does not go for her medications. Instead they probably go for family needs. She seems resigned to suffering and bad health as a price for being here in the US. When she feels very sick she misses classes and stays home.
Follow up
After failed attempts to keep her on her medications, we decided to simplify her responsibilities. We decided she must come to us for help and agree to focus on her own needs. This approach is consistent with the message we have impressed on all Montagnard families: “If the mother is strong, then the family is strong”. Such a message gives them permission to put their health needs ahead of the tough problems refugee families face. Without such a clear message, women and wive’s health needs go unmet.
Big Picture
BO’s family situation and prospects are similar to many families we’ve visited. The mothers and wives are highly vulnerable and lack the resources and support to do more than cook, clean, and mind the house. Given the chance, some like BO might be able to make progress and improve their health, but the cultural and economic barriers are significant.
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CASE 3
Montagnard health experts like former MDs can analyze where, when and how patient treatment goes wrong. They have the cultural competence to explain health information and choices to Montagnard families.
BO
BO complained about lower abdominal pain. She was too ill to leave her house but in the first few days she remained cheery and laughing on the phone, giving Dr Siu the impression she was managing. Dr Siu explained to her that it was probably a urinary infection suggested drinking cranberry juice. As the pain and fever increased, BO called me. We arranged for a neighbor who speaks very good English and her husband to meet me at Moses Cone Urgent Care. After about an hour she was seen by medical personnel, got prescriptions for antibiotic and pain reliever, and went home. A neighbor helped pick up the prescription. Because she had an Orange Card, her visit cost $10. Her medications cost $22 and would have been cheaper had they arranged to buy it through the Healthserve pharmacy.
Follow Up
Dr Siu called BO the next day and heard she was feeling much better. Later I met with her and other former Montagnard MDs to discuss BO’s family’s uncertainty about the location of Moses Cone Urgent Care, even though BO had been there before — a mere 5 minute drive from their house. The family did not understand the difference between Urgent Care and the ER.
We discussed the likelihood that BO was underestimating her pain level to Dr Siu and that we needed to teach community members not to understate their discomfort to American health providers. We agreed women needed to know more about causes and prevention of urinary tract infection, especially post-menopausal women. The MDs said there was no equivalent to cranberry juice in Vietnam, but that a warm source of heat applied to the abdominal area would ease pain and induce urination. This also led to a discussion about general knowledge about proper sanitary measures by some refugee wives and families, especially the care and cleaning of enclosed apartment spaces. The MDs stated this could be a difficult subject to raise; they had past experiences of being told to mind their own business. We discussed other, non-critical approaches. We discussed the need for patients to complete their course of antibiotics. The MDs discussed how Montagnard patients routinely stopped taking an antibiotic after a few doses and saved the remainder.
Big Picture
Health access and avoiding trips to the ER are only pieces of the entire refugee health experience used by community members to calculate their decisions. Some families are within walking distance to health and social service facilities but practically speaking they might as well be in Vietnam. Montagnard MDs are able to educate and inform community members on a continuous basis with a cultural awareness and understanding of family and individual decision-making. If American health providers want good patient outcomes in this population, they will need Montagnard expertise.
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CASE 4
If Montagnard refugees and immigrants cannot receive proper treatment for mental illness, they risk entering a harsh legal system with few options.
UT
UT is in his late 40s and is well known in the community for his erratic behavior. He came to our attention because he knew where I regularly met with out CHW team. One day he knocked on the door and explained he desperately needed help. CHW Kwol Ksa and I went to his address to hear his story. He could not sleep or concentrate. He had been unable to hold a job. He had a record of minor charges against him all seemingly related to his mental illness. Last year he had a dramatic run-in with the police which involved tasering and violent restraint resulting in injuries he complains of today. It is clear that he is a naturally sweet tempered man undergoing extreme internal suffering. UT was estranged from his wife and children but the community had made sure he had a place to stay.
Attempts to work with UT proved difficult. As women, the CHWs and Dr Siu did not feel socially comfortable with UT. Coordinating appointments and communications were hard. His housemates would be out or UT would be wandering. Finally, I met HH, a neighborhood store owner who speaks excellent English and who has helped UT in the past. He agreed to leave his shop for a day, accompany us to Winston-Salem and act as interpreter at UT’s medical appointment, a 2-hour interview to evaluate his Medicaid eligibility.
Follow Up
During the Fall of 2011, UT qualified for Medicaid assistance. We also learned through subsequent interviews that UT had been institutionalized before. A month later, he had a panic attack. At Behavioral Health he was diagnosed with schizophrenia and began a treatment of antipsychotic drugs. His follow up treatment seems to have stabilized him. During his appointments Dr Y Bhim Nie, a former Montagnard MD, serves as his interpreter. Since he is a medical and cultural expert, I shared UT’s medical history as soon as we met, empowering him with information he could use to better advocate for UT. In this case, my role was to explain to CHW team and other Montagnard MDs the problems working with mentally ill patients in America, the need to fully inform and involve UT’s children about the illness, and explain how they could support their father and keep their fragile family intact. This family- and community-involvement model seemed to work well when UT suddenly disappeared, leaving the kids in a panic. The police picked him up and jailed him for several days on old charges that were eventually dismissed. Quick response by the family and help from GG stopped the legal process before it became overwhelming and reversed our progress. Even so, UT went many days without medication, unable to communicate his medical condition to the police or his jailers. Today, UT continues to make good progress. His family members say he is happier and more stable.
Big Picture
UT’s problems are medical not legal, but because of his mental illness he has had frightening encounters with the police and judicial system that actually threatened his recovery. If mental illness is tough to tackle for Americans, for UT, a refugee, it is twice as hard. Dr Nie believes mental illness in his community is far more widespread than Americans believe, if they ever consider the matter at all.
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CASE 5
A Montagnard mother chose to bleed for years and risk death rather than weigh her family with more medical bills. A consortium of Montagnard community health experts changed the course of her life.
IC
IC has been in the country as an immigrant for more than 5 years. She lives with her husband and children. Her husband is regularly employed. IC came to our attention while our CHW team was asking for families to participate in a university research project conducted by Dr Jigna Dharod. CHW LI knew one neighbor was very sick but had avoided medical treatment because of the fear of incurring medical bills. She learned IC had been in pain for three years, bleeding ever since giving birth. When she had sought to return to the doctor’s office she was told she was fine. At another trip she was told to go home. Upon meeting her, the researcher and CHW Kwol Ksa were alarmed at the IC’s appearance. Dr Dharod said she appeared to have scarcely any blood in her veins. By then she could hardly move, slept often, and she could not prepare meals for her family. The researcher and Kwol brought her into the doctor’s office. During this time IC was angered by the CHWs’ visits. Kwol Ksa persisted, knocking on her door until she opened it, enduring insults and curses, and firmly urging her to seek help. IC was resigned to suffer or die rather than incur more unpayable medical bills, even though her husband welcomed these visits and wanted his wife to get better. Later, CNNC lay health adviser Snow Rahlan, Congregational Nurse Carolyn O’Brien and Dr H Wier Siu intervened.
Follow up
IC eventually received surgery to stop the bleeding. Dr Siu assisted her at appointments. We helped obtain relief from old outstanding bills. Dr Siu also helped her address other secondary health needs. The husband was very thankful. When IC appeared at the Women’s Learning Group she was almost unrecognizable by her healthy complexion and smile. She said she felt so good that she wanted to return to work.
Big Picture
It took deliberate, persistent effort that went against all Montagnard cultural and social norms before IC would finally agree to receive medical help. Because she has lived in the US for nearly 20 years, CHW Kwol Ksa had the life experience and knowledge of the Montagnard-American family to understand IC’s thinking and how to overcome her resistance. As a mother and grandmother herself, she could speak with authority even though she herself has no formal schooling and cannot read or write. Once we had IC’s agreement, we could move quickly to act. But without courageous on-the-ground advocates like Kwol, IC would have never gotten the help she needed.
