Beyond Borders:

Providence's Refugee Health Crisis and the People Responding to It

by Ishita Khurana

Fleeing the Democratic Republic of the Congo, Aline Bingyungu thought she was leaving her life’s work behind. But in Providence, Rhode Island, thousands of miles away from home, Binyungu finds herself in the same career that forced her out of her home.

“I was working back home to help women understand their rights, teach them how to defend themselves and stand up for themselves,” she says. Now executive director of the Women’s Refugee Care Center in Providence, Bingyungu works to lower barriers between refugees and healthcare providers in the city. From medical interpretation services to health education events, her nonprofit aims to empower women refugees to advocate for their healthcare needs. “I left the country because when you speak up against the government, when you want to engage everybody, to support, to help, you are not welcome. I left because it wasn’t safe.”

More than 3 million refugees like Binyungu have resettled in the U.S. since 1975, as per statistics from the UN Refugee Agency. Refugee resettlement in the U.S. has historically been available only to the most at-risk individuals, such as women, children, seniors, survivors of violence and torture, and those with acute medical needs.

While many people are able to obtain refugee status through the UN Refugee Agency or a governmental entity prior to reaching a country of destination, others must apply for refugee status after arriving at or crossing the border into their country of destination. The International Rescue Committee defines these individuals as asylum seekers, those who have fled immediate danger of murder, kidnapping or otherwise extreme violence.

Obtaining refugee status is a rigorous process. Once a refugee is recommended for resettlement in the US—which can take several years in itself—they are thoroughly vetted over 1 to 2 years. According to The UN Refugee Agency, each individual is screened through 8 federal government agencies, 6 security checks against federal databases, a medical evaluation, and 3 interviews through the Department of Homeland Security.

“I left the country because when you speak up against the government, when you want to engage everybody, to support, to help, you are not welcome. I left because it wasn’t safe.”

Binyungu was an asylum seeker who obtained refugee status. Resettling in the U.S. saved her and her family’s lives. Still, their futures remain tenuous. “There are many hardships,” she says. “You have to learn the language, the culture—everything is new.”

For refugees traumatized by forced displacement, navigating an unfamiliar environment is often an additional burden on their health. Long and dangerous migration experiences can leave refugees susceptible to communicable diseases such as measles, accidental injuries, and pregnancy complications, among other health troubles, according to the World Health Organization. The COVID-19 pandemic disproportionately harmed refugee populations. Mental health conditions such as depression, anxiety, and post-traumatic stress disorder (PTSD) are more common among refugee populations compared to host populations. Refugees’ frequent exposure to stressors such as violent conflict, natural disasters, environmental degradation, and economic crisis further diminishes their mental health.

Despite poor mental and physical health conditions, refugees are often unable or reluctant to seek healthcare in the U.S. due to personal and social barriers. These barriers range from differences in language and culture between patients and providers to financial and mental health issues that disproportionately impact refugees. Refugee organizations in Providence are working to address these barriers by bridging the gaps between refugees and healthcare providers.

Amal Clinic is one such organization. Recently restarted after its closure due to the Covid-19 pandemic, the clinic serves under- and uninsured South Asian, Middle Eastern, and North African populations in Providence, RI.

Samer Wahood, medical student at Amal Clinic, at the entrance of the dermatology clinic at a refugee camp in Jordan

Source: Samer Wahood

In February 2024 Samer Wahood, a medical student at Brown University, volunteered at a free clinic in Providence. The clinic, which catered primarily to under- and uninsured individuals from Arab, Desi, and African backgrounds, saw over fifty patients within just the three hours it operated. This turnout made it clear to Wahood that these populations needed a more permanent clinic.

Wahood and Dr. Abrar Qureshi, his mentor and the chief of the dermatology department at Rhode Island Hospital, reached out to administrators at Clinica

Esperanza about opening its doors to Amal Clinic during its non-operating hours. Clinica is an existing free clinic for uninsured adults in Rhode Island, primarily those who are Spanish-speaking. With the cooperation of Dr. Morgan Leonard and Dr. Anne De Groot, the respective executive director and founder of Clinica, Amal Clinic began to operate as a clinic within a clinic.

“It has been incredible, the journey we’ve had since,” Wahood says. “We’ve recruited physicians from over 20 different specialties and over 100 volunteers.” Currently, Amal Clnic operates twice a month, each session running for a few hours after Clinica Esperanza has closed for the night. At every session so far, providers at Amal Clinic have seen over 30 patients who would not otherwise have received healthcare.

Wahood recently encountered Alia, a Syrian patient who had previously been diagnosed with familial mediterranean fever: a rare genetic disorder that causes severe, persistent rashes and fevers. She had been struggling with this condition on and off for ten years. “Every day, she had an urge to itch and scratch and wasn’t able to be comfortable in her own skin,” Wahood said. At the Amal Clinic, Alia was seen by Dr. Qureshi, a leading expert in the fields of dermatology and rheumatology—branches of medicine that deal with skin and inflammatory conditions. “In just an instant, we were able to book her an appointment,” Wahood said, at Qureshi’s clinic.

“The dream,” Wahood says, is to run the clinic “twenty-four-seven. To have people physically in that building seeing patients who need to be seen. It’s clear that our list of patients is more than the spots that we have available every night, so we’re booked out months in advance. But we’re hopeful to see our clinic operating more often.”

According to the 2023 data report from the National Association of Free and Charitable Clinics (NAFC), free medical clinics across the United States saw over 5.8 million patient visits in 2022. Clinica Esperanza alone has served over 30,000 patients since its establishment in 2007. However, there are debilitating limitations to the healthcare that these clinics can provide.

Dr. Lamyae Elansari, an internal medicine physician who volunteers at Amal Clinic, says that language is the most tangible barrier to refugee care in a clinical setting. Adults with limited English proficiency (LEP) not only report worse health statuses, but lower levels of trust in healthcare providers as per the KFF Survey on Racism, Discrimination, and Health.

To counter language barriers, Amal Clinic relies on volunteer interpreters who speak a range of languages including Spanish, Urdu, Bengali, Pashto, and Arabic. Omar Atia interprets for

Dr. Lamyae Elansari, internal medicine physician at Amal Clinic

Source: Lamyae Elansari

Arabic-speaking patients at the clinic. In this work, “your purpose is to function,” he says, as a “bridge between the doctor and the patient.”

Atia recalls working with Khalid, a patient experiencing chronic obstructive pulmonary disease (COPD): a lung disease that makes it difficult to breathe. The patient suffered from a host of other physical and mental health conditions, including high blood pressure, acid reflux, and depression. “Because of the language barrier, whenever I would speak to him, he would tell me, ‘oh yeah, everything’s okay, I’m good, I’m good,” Atia said. “Just because he couldn’t express what’s going on” in English. But once he spoke with an Arabic-speaking interpreter, he felt much more comfortable, Atia said. “Just having someone there that understands him, he was able to get to a place where he was comfortable sharing.” Since then, Khalid has returned to the clinic several times, and has successfully signed up for free healthcare insurance through Amal Clinic.

“That’s the blessing of being an interpreter: the work feels very, very fulfilling,” Atia says.

But interpretation has its drawbacks. Elansari believes that interpretation is necessary and helpful when the patient and provider cannot communicate in the same language. But she says that her experience as a provider “is always different when you have an interpreter in the room. I feel like it’s not the same level of connection."

Omar Atia, medical interpreter at Amal Clinic

Source: Omar Atia

This disconnect, Elansari says, is largely due to interpreters’ lack of medical education. To become a certified medical interpreter in Rhode Island, an individual must simply demonstrate fluency and knowledge of basic medical terminology in both English and the target language. Interpreters are not trained to engage with more complex medical terminology, nor are they trained to navigate patient encounters. So interpreters sometimes miss or mistranslate details essential to a patient’s diagnosis or treatment, Elansari says.

Sometimes patients feel more comfortable communicating with their interpreter than their physicians. “So that’s where there’s a big kind of responsibility [for the interpreter],” Atia says. “You want to make sure that you’re not saying much more than what the doctor is saying, or trying to fill in gaps.”

Despite these complications, in-person interpreters are critical for the operation of free clinics like Amal. According to an article in the Journal of Migration and Health, in-person professional interpreters improve the quality of patient care in terms of communication, satisfaction, and even clinical outcomes. “None of these clinics could run without the interpreters,” Wahood says. “It’s such a crucial role. You can’t provide healthcare without having someone who can break the barrier between languages.”

“None of these clinics could run without the interpreters,” Wahood says. “It’s such a crucial role. You can’t provide healthcare without having someone who can break the barrier between languages.”

Language barriers are exacerbated by cultural barriers. Differences in cultural beliefs are particularly prominent in conversations regarding mental health, which is highly stigmatized in many cultures. For some individuals, “it’s very hard to open up about their mental health,” Elansari says, “because maybe in their culture, it’s a sign of weakness.” Recently Elansari treated Youssef, a refugee who had been forced to leave his entire family behind in Syria. He was struggling with severe depression, “but he was not ready to talk about it,” Elansari says. Rather than asking him if he could be experiencing depression outright, she was careful to approach the topic indirectly, speaking to him in Arabic, before suggesting that he take a questionnaire to confirm the diagnosis.

Elansari’s approach to Youssef’s diagnosis and treatment demonstrates what she calls “culturally sensitive care:” healthcare that responds and adapts to the specific needs of a patient’s particular cultural background. She believes culturally sensitive care is an essential component in improving refugee access to medicine. Refugees, she says, need to see themselves represented in the world of medicine; patients “have more trust when they see someone treating them who looks like them.” Elansari also says that refugees need to feel heard: “Many patients are happy just to feel like someone is hearing out their problems.”

Studies show that cultural sensitivity training for medical students improves patient outcomes. But US medical curricula have no formal, standardized requirement, according to the Accreditation Council for Graduate Medical Education. “When you don’t have training, you can make mistakes,” Elansari says.

As a patient herself, Elansari has experienced the repercussions of these mistakes. “When I went with my husband to the doctor, the doctor assumed I don’t speak English,” she said, laughing. Although her husband has lived in the US longer, Elansari speaks English just as fluently; she also speaks French and Arabic. As the provider explained Elansari’s diagnosis, “she was looking at my husband. Not me, and I was literally the patient. I felt like I was not recognized.”

“When I went with my husband to the doctor, the doctor assumed I don’t speak English,” she said, laughing. Although her husband has lived in the US longer, Elansari speaks English just as fluently; she also speaks French and Arabic. As the provider explained Elansari’s diagnosis, “she was looking at my husband. Not me, and I was literally the patient. I felt like I was not recognized.”

Linguistic and cultural differences are often complicated by medical mistrust, particularly among refugees of color. Bingyungu, a Black refugee herself, refers to what she calls an “adage:” “The white people want to kill us, exterminate us.” Such mistrust is grounded in centuries of marginalization and mistreatment of people of color at the hands of white Europeans and Americans.

The Tuskegee study, conducted by the United States Public Health Service Commissioned Corps in collaboration with the Tuskegee Institute, is perhaps the most widely recognized display of medical racism within the last century. According to the Centers for Disease Control and Prevention, the study monitored 399 Black men with syphilis, a common sexually transmitted disease, over a period of 40 years without consent. Since their goal to observe the long-term progression of the disease, the researchers left these men untreated as they died or otherwise experienced severe health issues, even as penicillin surfaced as a treatment roughly 15 years into the experiment.

The Tuskegee study is certainly not the only example of medical racism in the United States. From the practice of eugenics and forced sterilization in 1970s to the current disparity in maternal mortality between white women and women of color, medical mistrust among people of color is just as rooted in reality as it is difficult to dismantle. “It’s hard to convince them,” Binyungu says, to seek procedures and vaccinations necessary for their health and even survival.

Others may be uncomfortable seeking care because of previous traumatic experiences with healthcare. Some women don’t want a male doctor to treat them, Binyungu says. They may have been sexually assaulted by a male doctor, or experienced domestic violence. “If you have that experience, if you know about that experience, you are worried,” she says. The long-term psychological consequences of such abuse may result in patients’ avoidance of or hesitance within clinical settings that can prevent them from receiving proper care. “That’s the problem,” says Binyungu. “That can affect their health.”

Even when refugees seek healthcare, many are faced with financial limitations. According to Wahood, “When you’re underinsured or uninsured it’s very difficult to access the best medications you can for the treatments that you need. It’s sort of like you’re set back 30 years in the past.” Despite the availability of new medications that can help manage, if not cure, more medical conditions now than ever before, they are only available to those with more robust insurance.

Wahood recently saw a patient at Amal Clinic presenting with hydradenitis suppurativa, a skin condition that causes painful lumps in areas such as the groin and armpits. Sometimes, like in the case of Wahood’s patient, these bumps grow large and break open, leaking pus. “We have treatments, biological drugs that can help with this. But the patient is uninsured,” he said. “We scrambled to find an option for her.” Staff at Amal Clinic filled out an application to the pharmaceutical company that makes a curative drug for free care. “That was the best we could offer at that time,” Wahood said, sighing. “We have no choice but to offer the patient inferior treatment.”

When Elansari first immigrated to the U. S., she was shocked by the cost of healthcare. “Seeing important members of our community not having access to healthcare because they don’t have insurance,” she says, “I was so sad. Nobody deserves to compromise on their health because of financial reasons.”

Insurance is far from the only financial consideration when it comes to healthcare. Amine, a refugee from Sudan, arrived in the U.S. just 8 months ago. She speaks very little English, and in the absence of a translator she communicated her experiences through broken sentences and an online Arabic-to-English translator.

“I was working here,” she said, pointing to her office door on the second floor of the Women’s Refugee Care Center, Binyungu’s nonprofit. “My office.” But one morning, during her commute to work, her bus met with an accident. Jerking forward, Amine hit her head and wrist on the chair in front of her, sustaining serious injuries. An ambulance was called, and she was seen by a physician.

Fortunately, Amine has medical insurance and was not burdened with hospital bills after her accident. She was also satisfied with the quality of care she was provided by her doctors, reiterating that her “doctor is working good” throughout our conversation. “But when I have accident, I need help,” she says.

Amine is the sole breadwinner in her family of 6, providing for her father, her husband, and her three children. “Before I have the accident, I work here, I take the money, I pay the rent,” she says. “When I have the accident, I can’t work. So I need help in this situation. Who can help me?”

Returning to work is not only implausible because of the physical consequences of her injury, but because of the endless appointments she must attend to receive healthcare as well. “How can I work when I go to hospital?”

I met Amine one month after her accident, and noticed that her wrist was still covered by a large rectangular bandage. Neither she nor her doctor are sure if she will be able to return to work in the near future—if she will be able to pay her rent.

Staff group photo from Amal Clinic's first session

Source: Samer Wahood

Evidently, free clinics are not a perfect solution to the health crisis faced by under and uninsured refugee populations. As a physician, Elansari is often frustrated by the limitations of the care she can provide. Coming to what is supposedly “the most powerful country” in the world, she was shocked to see patients “literally suffering because they cannot get proper help.”

“We think about free clinics as a sort of band aid,” Wahood says. “We need to have better solutions for these patients that are not just reliant on individual donations from people and donations.”

But Elansari is also hopeful about the future of free clinics like Amal. “Sometimes you cannot do a lot, but at least you can relieve their pain. It’s very rewarding, knowing that you are able to provide help for populations who maybe would not have ever gotten any care if not for a free clinic.”

Free clinics are a part of the U. S. healthcare system that are here to stay. The question remains: how can we best serve these populations within the constraints of the system?

Reflection:

The topic of refugees has become increasingly contentious with the rise of anti-migration and xenophobic rhetoric in social and political spheres. Correspondingly, refugee support services such as community-based nonprofits and free clinics are increasingly undervalued. My goal in writing this piece was to present the issue of refugee health in Providence through a nuanced and multidimensional lens: one that reflects the significantly improved reality of refugees fleeing dangerous environments while addressing the persisting issues that prevent them from living healthy, sustainable lives in the U.S.

I found my interviewees quite easily, as I have worked extensively with refugee populations in the past. I drew on my connections as a volunteer ESL teacher and medical interpreter, and was fortunate to find people who were incredibly passionate and knowledgeable about refugee health. Scheduling and responsiveness, however, were major issues due to the nature of medical and nonprofit sector work. Some of my interviews were even cut short, and my interviewees at times did not reply for weeks at a time. In fact, I am still waiting to hear back from Aline Binyungu regarding pictures and more details about her experience as a refugee and work at the Women’s Refugee Care Center.

However, this process has been incredibly rewarding. As a Comparative Literature major, writing in a journalistic and direct as opposed to analytical and academic style has been both a challenge and a pleasure. As a pre-medical student with an interest in global health, learning more about the realities faced by refugees in a medical setting has been enlightening.

I am looking forward to polishing this piece even further.

Audio:

Khurana Healthcare Journalism Audio.mp4

Sources:

Interviews:

Aline Binyungu 10/03/2024

Samer Wahood 10/11/2024

Lamyae Elansari 10/16/2024

Anonymous Refugees 11/01/2024

Omar Atia 11/14/2024

Documents:

ACGME Home, https://www.acgme.org/. Accessed 15 December 2024.

“Eugenics and Scientific Racism.” National Human Genome Research Institute, 18 May 2022, https://www.genome.gov/about- genomics/fact-sheets/Eugenics-and-Scientific-Racism.

“Familial Mediterranean Fever - Symptoms, Causes, Treatment | NORD.” National Organization for Rare Disorders, https://rarediseases.org/rare-diseases/familial-mediterranean-fever/. Accessed 15 December 2024.

“Free and Charitable Clinics Served 5.8 million People in 2022.” The National Association of Free and Charitable Clinics, 26 April 2023, https://nafcclinics.org/free-and-charitable-clinics-served-5-8-million-people-in-2022/.

Gonzalez-Barrera, Ana, et al. “Language Barriers in Health Care: Findings from the KFF Survey on Racism, Discrimination, and Health.” KFF, 16 May 2024, https://www.kff.org/racial-equity-and-health-policy/poll-finding/language-barriers-in-health-care-findings-from-the-kff-survey-on-racism-discrimination-and-health/.

Heath, Morten, et al. “Interpreter services and effect on healthcare - a systematic review of the impact of different types of interpreters on patient outcome.” Journal of Migration and Health, vol. 7, no. 100162, 2023. National Library of Medicine, https://pmc.ncbi.nlm.nih.gov/articles/PMC9932446/.

“Hidradenitis suppurativa - Symptoms and causes.” Mayo Clinic, 21 June 2024, https://www.mayoclinic.org/diseases-conditions/hidradenitis-suppurativa/symptoms-causes/syc-20352306. Accessed 15 December 2024.

Majumdar, Basanti, et al. “Effects of cultural sensitivity training on health care provider attitudes and patient outcomes.” National Library of Medicine, 2004, https://pubmed.ncbi.nlm.nih.gov/15227764/.

“Refugee and migrant health.” World Health Organization (WHO), 2 May 2022, https://www.who.int/news-room/fact-sheets/detail/refugee-and-migrant-health. Accessed 15 December 2024.

“Refugee Statistics.” USA for UNHCR, https://www.unrefugees.org/refugee-facts/statistics/. Accessed 15 December 2024.

“The Untreated Syphilis Study at Tuskegee Timeline | The U.S. Public Health Service Untreated Syphilis Study at Tuskegee.” CDS, 4 September 2024, https://www.cdc.gov/tuskegee/about/timeline.html.

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