A Walk over the Bridge: Discussions on Immigrant Health

I just finished an excellent book called, The Spirit Catches You and You Fall Down, by Anne Fadiman. It offers great insight into the clash between cultural beliefs and the Western medical system. Here is an excerpt of a review written by Mai Na M. Lee:

Around the struggle of the Lees and the American doctors, Fadiman weaves in Hmong history, culture, spiritual beliefs, and moral ethics. The Lees experiences during the secret war in Laos, as refugees in Thailand, and as immigrants in the United States become the focal point of the larger Hmong struggle to understand, and to be understood in the context of world history. Fadiman's richly charismatic and eloquent style brings out the smallest details. She uses personal recollections, folk stories, beliefs, and religious and medicinal practices to intimately reveal the Hmong to the reader. Those who are Hmong will find themselves laughing as their own eccentricities are revealed, and crying when they realize how these seemingly endearing qualities conceal their very humanity from outsiders. Often portrayed as primitive and oddly out of place in this highly technological nation, the Hmong present an ironic challenge to modern American society, and force us to re-evaluate our concept of progress.

Fadiman definitely tells the story of the Lees from a Western perspective, which should be kept in mind when reading her portrayals of the Hmong culture. Nonetheless, I feel that this book should be a required reading for anyone serving or interacting with immigrants and refugees.

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During my last blog, I discussed the impact of the economic crisis on housing for immigrants. I thought it would be interesting to learn more about how a specific community finds housing in Minnesota.

Born in Mogadishu, Somalia, Anisa Esse is an emerging public health leader in the twin cities and an advocate for the Somali community. She is a facilitator for a parenting support group at the Center for Victims of Torture while pursuing a master’s degree in public health at the University of Minnesota.

Esse discusses her families’ experience relocating to the United States 13 years ago.

“In 1995 I was 10 years old. My whole family came; I am one of nine, plus my parents. We first came to California and my uncle found us a house there. It was difficult to find a place for 11. It had 4 bedrooms, but rent was expensive,� she said.

Luckily, Esse said, her father had an established trucking business in Somalia and found a trucking job within a few weeks after arriving in California.

For other Somali families, finding housing is not that easy.

“Usually the family that sponsors you [for your visa] gets a stipend to find housing. The government pays the down payment, and you pay the first month off. The family then goes through the legal process. For three months a sponsoring organization takes care of expenses, like housing, food, health care, all these things,� she said.

Esse said that three months is not long enough to find a job and learn the language. Though families are able to access federal housing like Section 8, some have to wait on application lists for years, she said.

However, Esse said that Somalis are resourceful and are experts at exchanging information.

Somalis will call everyone they know to teach them about a housing application or an event happening, and they will all carpool together, she said.

Esse also said that the media provides incorrect information about the numbers of Somalis living together under one house.

“We have not gotten so desperate that we are living like 30 together. But we are more willing to take others in; more than the average American. Our hospitality keeps people while there is a need,� she said.

Though the initial housing transition may be challenging, Esse said that the Somali community has a really good reputation with housing agencies for paying rent on time and being good tenants.

And like Esse’s family, Somalis’ resourcefulness often pays off.

Esse said, “Seven years ago, we bought a home in North Minneapolis. We were fortunate enough to find something big enough that didn’t cost a lot of money. It’s the American dream.�

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On a given night in Minnesota, at least 9,200 people are homeless. With the economy in a recession, these numbers are only predicted to climb.

Every three years, the Wilder Research Center conducts a survey to count the number of homeless and to better understand its root causes. June Heineman, a research associate at Wilder was involved with the most recent survey conducted in 2006, and is preparing the next survey for 2009.

I asked her about how the trends in homelessness are affected by the current economic conditions.

“One major thing on the horizon are mortgage foreclosures. People who once owned their homes are going to be using the rental market. This makes it harder for people in transitional housing services to find places for rent,� she said.

Just fewer than 2 percent of adults and slightly over 3 percent of youth homeless in the 2006 survey were African immigrants. However, Heineman said that the Wilder Research study focuses mostly on shelters and homeless outreach programs, which limits how effectively they can measure the impact on immigrants.

“A lot of homeless immigrants are doubled up with friends and families, so it doesn’t hit the radar screen we are in. Everyone knows it’s there, but being able to get a handle on it is more difficult,� she said.

Of the African immigrants surveyed, they primary barriers identified were lack of jobs and income and affordable housing. Almost half reported a mental illness—a proportion equal to that of the native born homeless, a trend that has been increasing for the last 12 years. Almost one-third of African immigrants homeless had a physical, mental or condition that limited the amount or type of work they could perform.
“With the lower vacancy rates, it is much more difficult to find a place to live, especially for people with bad credit history, previous evictions, chemical, and mental health disorders. People who are not dealing with those issues, they are going to be a much more attractive,� Heineman said.

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A New York Times article provides both sides of the debate of female circumcision. (See my last posting for an introduction to the issue). The writer includes the voice of Dr. Ahmadu, a woman from Sierra Leone who is one of the few outspoken female voices supporting female circumcision in the U.S. Here is an introduction of Dr. Ahmadu and and excerpt of her writing from the NY Times article:

Dr. Ahmadu, a post-doctoral fellow at the University of Chicago, was raised in America and then went back to Sierra Leone as an adult to undergo the procedure along with fellow members of the Kono ethnic group. She has argued that the critics of the procedure exaggerate the medical dangers, misunderstand the effect on sexual pleasure, and mistakenly view the removal of parts of the clitoris as a practice that oppresses women. She has lamented that her Westernized “feminist sisters insist on denying us this critical aspect of becoming a woman in accordance with our unique and powerful cultural heritage.� In another essay, she writes:

It is difficult for me — considering the number of ceremonies I have observed, including my own — to accept that what appears to be expressions of joy and ecstatic celebrations of womanhood in actuality disguise hidden experiences of coercion and subjugation. Indeed, I offer that the bulk of Kono women who uphold these rituals do so because they want to — they relish the supernatural powers of their ritual leaders over against men in society, and they embrace the legitimacy of female authority and particularly the authority of their mothers and grandmothers.

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In immigrant health, there are a number of cultural practices that elicit conflicting ethical debates. One such practice is female circumcision—often called female genital mutilation— is a procedure in which parts or all of the external female genitalia are removed for non-medical purposes. It is prevalent in eastern, western and northeastern regions in Africa, in some countries in the Middle East, Asia and among certain immigrants in North America and Europe. This practice especially grabs attention in Minnesota due to its high numbers of Somali residents, many who have had the procedure done in their home country. Female circumcision is currently illegal in the U.S.

I recently read an excerpt from the book, Do They Hear You When Your Cry, written by Fauziya Kassindja. Kassindja, born in Togo, writes about her experience as an asylum seeker in the U.S. after feeing her home country from a forced circumcision. Preparing for her to get married, her aunt and caretaker at the time wanted her to undergo this procedure because circumcision is often believed to assure premarital virginity and marital fidelity.

Here is an excerpt from the book, where she discusses looking at her wedding photograph, preparing to use it as evidence in her trial:

My wedding photograph. There I was, all dressed up in my wedding clothes, all dressed up and made up, my hair wrapped in a headscarf, my hands and feet covered with laylay designs, sitting on the bed in the bedroom I’d once shared with my sisters, surrounded by my so-called husband’s other wives. I was looking down in the photograph, my gaze lowered. My expression was composed, resigned, withdrawn. I looked exactly the way I’d felt when that photograph had been taken. I looked like a beautiful young woman who was preparing herself to be ritually sacrificed. I looked like a young woman preparing to meet her death.

According to the WHO, female genital mutilation is internationally recognized as a human rights violation. A number of health risks are associated with the practice, including severe bleeding, problems urinating, and later, potential problems with childbirth.

I believe that this issue is complex, and that it is important to view this practice from a cultural perspective, as well as the view of someone like Kassindja, who feels it is a human rights violation. I encourage readers to keep an open mind and critically try to understand both sides. I will be posting a second posting showing the opposing perspective of this issue.

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In previous blog postings, I have discussed the role of interpreters in immigrant health care, including how patients are affected when they have an interpreter sitting next to them in a visit.

I was interested to read an essay by Nataly Kelly, an interpreter who provides language interpreting for Spanish speaking patients. Surprisingly, Kelly does this not through physical support as one might expect, but communicates for patients through the telephone.

It sounds simple: just translate phrase by phrase what the patient and provider are saying over the phone. However, Kelly discusses the challenges that phone interpreting present: the beeping and buzzing background noises, the difficulty of translating terms such as “HMO,� “coverage� and “copay,� and overcoming barriers of patients not being able to speak—or read—English words and numbers.

Kelly writes in her essay, ‘I hear them; I speak for them; I speak on others’ behalf.’

Without the use of nonverbal communication, Kelly relies on tone of voice and inflections to relay messages apart from simply her choice of words. She includes stories about translating, “Push! Push! Push!� to a patient giving birth, as well as telling a patients’ loved ones about a fatal car accident.

This essay offers insight relevant to not only immigrants and their providers but also anyone who communicates—discussing how to not just speak—but to connect with others.

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I recently attended a lecture given by Priscilla Flynn, DrPH who is the Coordinator for the Office of Women’s Health in Rochester, MN and who speaks nationally about Somali women’s health issues. She discussed a recent study she had conducted about birth outcomes in Somali refugees.

The study reveals important health and policy implications for this population. Though researchers have found that Somali women tend to have better birth outcomes—as measured through the incidence of preterm and low-birth weight babies— than other U.S. women, this protective effect has been dissipating. Flynn studied the changes from 1992-1999 to 2000-2006, and found significant differences in birth outcomes within these time periods.

What is exactly causing these health changes? Though clinicians may automatically assume that an increase in Somali women seeking prenatal care would help the situation—which it could—reports are inclusive. It was found that despite Somali women traditionally having less prenatal care visits— especially as new immigrants, they were still having better birth outcomes.

Focus groups with Somalis revealed important cultural insight into the issue. Many Somalis reported that they did not like the idea of a doctor giving them a due date, as they saw that this practice went against their belief that Allah, or god should decide when the baby will be born. In addition, they viewed the birthing process as natural, and therefore providing no reason to see a doctor unless they experienced complications.

It is hypothesized that other areas around acculturation could account for some of these changes. As I had written in an earlier blog, many immigrants take on unhealthy behaviors modeled by other Americans, which causes otherwise good health to decline with increased stay in the U.S.

As America continues to become a melting pot of people from different cultures, it is important to continue to explore reasons for health changes among specific communities. Though we may assume that a stricter adaptation to our Western medical system can simply provide the cure, we may have to look deeper into a greater, ecological approach to health and wellness that includes cultural beliefs and treatments.

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Since September 11, 2001, Americans’ fear for terrorism has seeped from personal perceptions to public policies— causing innocent people to be labeled as “terrorists.�

An article this week in the Village Voice—an online New York news source—discusses the catch -22 occurring in the U.S. immigration system in which legal immigrants are denied green cards for the same reasons they were granted asylum or refugee status in the first place.

Many refugees come to the U.S. after taking up U.S. supported struggles, such as the overthrow of the Castro regime in Cuba, the opposition to the dictatorship in Sudan, and the fight for independence of Bangladesh from Pakistan.

However, after 9/11, congress passed the Patriot Act, widening the definition of a terrorist. The act defines terrorists as those associated with not only well-known groups such as the Al Qaeda and the FARC in Columbia, but also “undesignated groups� that Homeland Security can deem terrorist organizations at their discretion. These undesignated groups can include less-known organizations that are fighting for independence from dictatorships, or can include individuals who have had forced or very minimal association with a terrorist organizations, such as a nurse who was taken hostage and forced to provide medical services to FARC or a Sri Lankan man who was forced at gun point to give ransom—and therefore financial assistance— to the Tamil Tigers.

The policy is causing law-abiding immigrants—many who have fought hand in hand with the U.S. or for legitimate causes in their home countries— to be denied legal resident status in the U.S., even some of them having lived in the U.S. for years. It is apparent that it will take Americans time before perceptions and fears about “terrorists� return to pre-9/11 views. But do we really lack the ability to differentiate between law-abiding immigrants and those that are the real “bad-guys�? Or is this just an excuse for the U.S. to limit its foreign residency? I encourage others to read the article and create their own opinion.

Posted by oles0045 at 2:10 PM | Permalink | Comments (0)

It’s no secret that there are gaps in America’s health care system. If you are anything like me, you can’t help but worry about what would happen in the case of a serious accident. How would you pay for coverage? Who would take care of you? What if you don’t have insurance at the time?

If you are an immigrant, and you don’t have an answer to one of those questions, you could be forced back to your home country.

A recent article in the New York Times discussed the horrific accounts of hospitals repatriating—or sending back immigrants to their home countries— because they aren’t able to pay for hospital bills.

The article features the story of Antonio Torres, a legal Mexican immigrant who worked in the alfalfa fields of Arizona. His life took a turn for the worse when he got into a tragic car accident, suffering a severe traumatic brain injury. But after being put onto a ventilator at the nearby hospital, his family was told that there was little hope for him and without insurance, the hospital could not keep him. They were advised to pull the plug. The parents refused, and the hospital arranged for Torres’ repatriation.

Torres was sent back to Mexico while suffering a coma and a severe case of pneumonia. It was only until a public hospital in California agreed to see him, that Torres was finally able to be receive the care he needed. He survived, recovered, and is now thriving.

The article demonstrates worse case scenarios in health care. What is important to recognize is that we are not even discussing the health care coverage of undocumented immigrants—Torres was a working, legal resident. Hospitals are making desperate cuts so that they can financially survive, and immigrants are often the first in line to be cut. Once immigrants are truly recognized as part of the American community and Americans recognize health care as a right for all its members, hopefully we will no longer have to hear stories about the Torres family, struggling for their basic human rights.

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You only have to step into a waiting room at Fairview Hospital in Minneapolis to see the incredible need for language interpreters—approximately 25 percent of Fairview’s patients require them. I spent a morning with Mohamed Warsame, the supervisor of interpreting services for Fairview to learn more about the interpreters’ role in health care. What I received was a greater insight into not only their professional roles as interpreters, but also their conflicting identities as cultural brokers.

Mohamed recalls a time when he was translating between a Somali woman and a psychiatrist.

She thought the psychiatrist was from the CIA, Mohamed said. She told me, “What if he has a file on me?� The doctor asked me what she said, and I explained, exactly. I told the woman, “I’m not siding with you, I’m siding with him, I’m a bridge. Watch your language, I have to say it.�

Mohamed is no stranger to bridging communication between Africans and people from other nations. Born in Mogadishu, Somalia, Mohamed grew up in Italy while his father was an ambassador in Rome. He too followed his father’s footsteps, joining the national service and serving as a diplomat in Asia, Africa and America. After completing a master’s in human resources in the U.S., Mohamed combined his people skills with his experience in administration and linguistics to serve in his current position.

When I walked with Mohamed to his office at Fairview, just about every staff member we passed greeted him. Mohamed often responded with “Bonjourno,� his Italian demonstrating only one of eight languages that he speaks fluently.

Hayat Hirsi, an Arabic and Somali interpreter at Fairview believes that Mohamed’s background contributes to him serving as a great role model.

“He tries to reach out and connect with people. Our patients especially respect that,� she said.

Mohamed told me about some of the joys and challenges of interpreting. He discussed how he did his job because of the people, and that he also enjoyed learning about diseases—especially its human aspect. However, he reported that translating cross-culturally in medicine is not easy, as many diseases and technologies do not have a synonymous word in Somali.

“Once, I was with another Somali interpreter, shadowing. The doctor asked the patient about a disease— it deals with mood swings. The doctor asked, do you feel depressed? The interpreter asked the Somali women if she felt sad. The woman said yes. I said, Stop! We don’t have a word for depression—but it wasn’t the right way to say it. Everyone in Somalia knows a few words in Italian, so I asked if she had depreciones? She said no, no, no! The patient would have ended up having depression medicine which would have made her feel depressed in the long run,� Mohamed said.

Mohamed discussed with me how language barriers play a role in not only verbal communication, but also peoples’ perceptions.

“People think that if you have an accent, your brain has an accent. They treat you like a child. Even though I have an accent, I think like you,� he said.

He also discussed how providers have misperceptions of the roles of translators, and they don’t always understand cultural barriers.

“Sometimes they ask depressed people, do you feel like having sex? I cannot ask this straight to a Somali person, it’s taboo. You can’t talk to a woman like that, she would slap me,� said Mohamed.

I asked Mohamed how patients feel with an interpreter there.

“Some people get used to it, but they are always nervous. As long as you are there, they feel ok; they feel protected. When the nurse leaves, I have to leave. They ask you why you leave, they say, stay here,� said Mohamed.

Hayat discussed how sometimes patients feel so comfortable with their interpreters that they want them to help make decisions, like whether or not to have surgery. She said that they believe that if you are from the same background, you won’t tell them something that is going to harm them.

“We always tell them that they are in good hands, but it is their decision,� Hayat said.

Mohamed is intentional about not only his verbal but also his nonverbal communication with his clients.

He said, “I avoid any extra interaction, to avoid them viewing me as their friend. It’s difficult. It’s my community. They expect loyalty. That’s the main challenge. It is not possible.�

Posted by oles0045 at 3:10 PM | Permalink | Comments (0)

Health varies drastically among different immigrant groups. It made me wonder, who is fairing on top? According to the 2000 U.S. Census, Asian Indians are the highest earning and most educated immigrant group in the U.S. Sixty-four percent of South Asian Indians have a bachelor’s degree or higher, compared to the total population’s average of 24 percent. Median household income levels may be as high as $20,000 higher than U.S. median household levels, though because Indians often live with them, possibly skewing the data. Business Week has even called Asian Indians, “model immigrants� because of their success in the workforce, serving as leaders in U.S. business, technology, real estate, journalism and literature.

However, not all immigrant groups come without their own set of health challenges. Asian Americans (without disaggregating Asian Indians) may have better overall health than their U.S. counterparts, but they may be less likely to access health care. A study conducted in Boston found that Asian Indian women may be at higher risk for intimate partner violence. A number of Asian Indians are still practicing influences of traditional Indian medicine, which may be an avenue for health care providers to bridge the gap between western and complementary health practices.

When looking at specific ethnic immigrant groups, rather than labeling any group as a model or low-faring group, health care providers should took an ecological approach to understanding health, looking at how culture, education, employment and social behaviors influence a community. It is clear that no group has members that act the same, though culture does tell us important information about beliefs and behaves. Maybe we should look at "model behaviors" more than just "model immigrants."

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Art is a reflection of the culture and politics of society. I recently viewed A View from the Bridge, a play by Arthur Miller staged at the Guthrie Theatre in Minneapolis.
Set in the docks of New York City during the mid-20th century, this play reveals a tale that is still real today—the story of immigrants’ lives in the U.S.

Here’s the lead for the play:

Written by quintessential American dramatist Arthur Miller, A View from the Bridge is as timeless as the Greek tragedies on which it is modeled and as contemporary as today's headlines. Ethan McSweeny (Six Degrees of Separation, Romeo and Juliet, A Body of Water) directs this first-ever staging of Miller's acclaimed play at the Guthrie.

Longshoreman Eddie Carbone lives in the Red Hook section of Brooklyn with his wife Beatrice and her orphaned niece Catherine, whom they have brought up as their own daughter. Into the household come two of Beatrice's cousins from Italy who enter the country illegally to find work on the waterfront. Eddie's love for his niece turns to obsession when the younger of the Italian brothers, Rodolpho, and Catherine strike up a friendship that blooms into romance. Soon Eddie's conflicted feelings lead him to betray his family's trust and take action that ends in violence.

What I lived about A View from the Bridge was the way the audience could feel the conflicting struggles that immigrants have to face: how to fit in, how to make ends meet in the U.S. while sending money home, the fear of living undocumented, the fear of becoming too close, and the struggle to maintain honor.

The final performances happen this week, and I definitely recommend viewing this well- performed play while it is in town. Not only is it entertaining, but it also elicits the emotional, human side of immigration.

Posted by oles0045 at 8:59 PM | Permalink | Comments (0)

November 4 is closely approaching and the elections are on the minds of both native-born and foreign-born American citizens. But how might the immigrant vote play into the election this year?

In 2006, Minnesota’s foreign-born population accounted for 6.6 percent of the state population, with foreign-born citizens eligible to vote increasing by 67.8 percent from 2000 to 2006. These statistics suggest that more than ever, the foreign-born population will have a greater effect on voting outcomes.

However, in 2004 foreign-born citizens in Minnesota voted less than their native-born counterparts— 64 percent compared to 80 percent, respectively.

Latinos are a particularly sought after vote. Their numbers may not seem all that great—they make up 15 percent of the U.S. population but only 9 percent of eligible voters. But it is the placement of Latino populations that make them important, as a number of swing states—Florida, Colorado, New Mexico and Nevada have high Latino numbers.

Regardless, the immigrant vote is going to continue to be of importance as long as migration continues to increase in the U.S. By 2050, Latinos alone will comprise of 29 percent of the U.S. population. Immigration to the U.S. can no longer be viewed as just an “issue� on the ballot, but a significant portion of U.S. citizens—and therefore voting members—who may be able to swing a vote, from one side to the other.

Immigrants and Voting, 2008 Election Profile and Hispanic Voter Attitudes in the 2008 US Election by the Migration Policy Institute contributed to this article.

Posted by oles0045 at 3:02 PM | Permalink | Comments (0)

America is known as the “land of opportunities.� So doesn’t that mean that immigrants coming to the U.S. should expect wonderful outcomes—including better health?

This is exactly opposite to reality. The phenomenon is known as the “Healthy Migrant Effect,� which shows that new immigrants are actually healthier than native U.S. citizens, but that their health decreases with time when in the U.S. I recently read about it in “Immigrant Medicine,� edited by Patricia Walker and Elizabeth Barnett (Chapter 3). It goes against many stereotypes that Americans have about immigrants as well as their perceptions about health in their own country.

Immigrants who come to the U.S. may be healthier than individuals from their native country. A number of factors can account for why their health decreases with time.

Immigrants face barriers with accessing stable housing, due to lack of credit history, over-representation in low-wage jobs, and housing discrimination. The housing market is tough for everyone these days; now add to it a language barrier and a culture that is drastically different to what you are used to. Instable housing leads to higher stress and mental health challenges, barriers to health care and education, increased spread of certain diseases like tuberculosis, and physical problems from unsafe living conditions.

Like lack of affordable housing, acculturating to a new environment may cause stress and mental health issues. Language barriers, difficulties with employment, isolation, and loneliness are only a few challenges new immigrants may face. Deterioration of mental health along with acculturation may also lead to increased use of drugs and alcohol.

As immigrants continue to live in American society, they will often develop American eating habits. You don’t have to be a nutritionist to know that Americans are eating unhealthy diets, leading to chronic diseases that are not seen in such high numbers across the world.

Finally, when immigrants face issues of poverty, they add to the group of Americans who have less access to health care. Because a number of policies discriminate against immigrants in their abilities to sign up for certain public service plans, low-income immigrants are even more likely to be uninsured than low-income native residents.

The healthy migrant effect may dispel a number of stereotypes and cause us to re-evaluate the lifestyle of America. What are the real outcomes associated with the land of opportunities?

Posted by oles0045 at 2:44 PM | Permalink | Comments (0)

To gain some insight into the process that immigrants go through to attain social service support, I spent an hour observing at a department of human services office this past Friday.

I would estimate that around 40 percent of all clients in the lobby were foreign-born, including equal portions of those of African and Asian descent. The other sixty percent was made up of mostly African Americans as well as whites and Latinos.

When I walked into the main entrance of the building, I was welcomed by the “May Peace Prevail on Earth� sign, which is seen across the twin cities and is translated into a number of other world languages. The building had a directory of services translated into the major languages spoken in St. Paul, but as I stepped into the lobby— the first room ahead when you first walk in— I was surprised to see all signs written in English.

I was impressed with the diversity of staff, there were at least two Latino staff, three Asian, and five black/African American staff, including at least two or three who appeared to be foreign-born. I couldn’t always tell how often other languages were being spoken between staff and clients, though there also seemed to be at least some translators there if needed.

Navigation of the social service system is difficult for anyone, whether foreign-born or whether you have lived in the U.S. all your life. A few images from the observation stuck out to me:

When I sat down, I noticed a few gentlemen of Asian descent—an elderly man and another in his thirties—waiting with a bored, dazed look on their face. A young man was matched up with them to translate for a worker—he must have been fifty years younger than the elderly gentleman being helped. Fifty minutes later they were able to finally leave, which doesn’t include how long they were waiting before I came.

A young Somali woman discussed some paper work to one of the staff members in a very loud, distraught tone. She wasn’t exactly yelling, but others could sense her frustration. She was instructed to sit down. I watched her eyes constantly looking around the room, and shuffling through her papers; she seemed to not understand what these papers meant in this strange place.

A large family shuffled into the lobby and got in line in front of the first staff window. Two young children ran around the room, playing tag and knocking over the rails that hold together the ropes to separate the lines. The mom looked tired and unwilling to deal with the kids, and so did the staff.

I couldn’t imagine how overwhelming it would be to be a new immigrant or have a language barrier trying to navigate access to social programs. My experience couldn’t even capture the amount of time it would take some people to arrive here by bus; I could easily hop over by car. The overall tone between the clients and workers was reflective of the general health care system, especially in regards to services for minority groups and immigrants. There are limited resources, and people are tired and frustrated with the process.

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