|Oregon State Bar Bulletin JULY 2012|
The first time I walked into the waiting room of IRCO, the Immigrant and Refugee Community Organization, I thought I had stepped into another country — or several other countries. People of all different nationalities and colors filled the room, talking in their native languages. The noise level was overwhelming, and my gray suit felt out of place among the brightly colored clothing that many of the Somali and Bhutanese refugees wore.
IRCO’s waiting room illustrates Oregon’s burgeoning diversity. When I moved to Portland from Washington D.C., in 1986, I was surprised by the homogeneity of Oregon’s population. But Portland’s foreign-born population more than doubled in the decade between 1990 and 2000. By 2005, people from other countries accounted for 13 percent of Portland’s population, and that number continues to grow. This change, however, has come more quickly than our adaptation to the needs of our newest residents.
In November 2010, the Oregon State Bar Bulletin examined cultural competence in Oregon. “Culture of Awareness,” OSB Bulletin, November 2010. The article highlighted the reversal of a wrongful conviction of a Mexican immigrant who spoke no Spanish but was nevertheless given a Spanish interpreter for his murder trial. The case of Santiago Ventura Morales, spearheaded by now-Chief Justice Paul DeMuniz, led to the passage of a law in Oregon requiring testing and certification of interpreters who work in the courts, ORS 45.291.While the new law responded to a lack of cultural understanding, it addressed only a specific problem with the legal process. Meanwhile, the diversity of Oregon’s international population continues to grow and the issues created by misunderstandings of cultural differences extend well beyond the translation of testimony in court.
Many recent arrivals come from countries unfamiliar to most Oregonians and bring their own circumstances, customs and languages. The cases Oregon attorneys will handle for these new arrivals demand that we expand our understanding of a wider range of cultures and cultural differences. This article will focus on how attorneys can learn what they need in order to represent some of our newest arrivals.
Many Oregonians may be accustomed to Spanish-speaking immigrants, but Somali, Iraqi and Bhutanese refugees are still relatively rare for most Oregon lawyers to encounter. For refugees from Asia and Africa, the hurdles that delay or prevent assimilation into a population that does not understand their culture include not merely language differences but also differences in attitudes about work, health, and family. As refugees admitted to the United States under special humanitarian dispensation, they arrive with histories of war, famine and mental and physical trauma that are unfamiliar and often unimaginable to Oregonians.
According to the United Nations High Commissioner for Refugees, there are an estimated 10.5 million refugees worldwide. The majority of these refugees receive temporary support in the country to which they have fled, until they can return safely to their home country. Fewer than one percent of those refugees will be resettled permanently in a third country such as the United States, and the United States welcomes more than half of those. Oregon takes in approximately two percent of the U.S. total each year.
Although their experiences vary, most refugees have experienced some combination of loss of family members and homes, seeing loved ones killed, a prolonged stay in refugee camps or interim countries, extreme harassment or torture, brutality, malnourishment or starvation, and rape. These circumstances may be associated with specific physical and psychological health issues that need to be addressed in the host country, sometimes over a period of years.
Tom Kinzie, Health Services Coordinator at IRCO who has worked with refugees for more than a decade, has seen firsthand the fundamental barriers that some refugees must overcome to fit into our society. He describes a visit to the home of an African woman who spoke no English, a single mother with four children:
After gesturing around for a while I realized that I needed to call one of my colleagues who spoke her language. As I was calling my colleague I realized that four children were sitting around a cooking pot and they were trying to divide up some raw vegetables to eat. No one had shown their mother how to use the stove or perhaps she did not understand the training she had been given. She lacked an understanding of basic information that we take for granted.
As a Social Security disability attorney who represents many refugees, I’ve been visiting IRCO every six weeks for two years now, carrying my lawyer’s briefcase — the equivalent of the black medical bag my dad, a doctor, used to carry on house calls. Before I arrive, many folks have already signed up to meet with me to talk about whether they can obtain Social Security disability benefits. In my bag I bring informational brochures, applications and advice for everything from getting good lay witness statements to the importance of medical evidence in disability cases. When I arrive, people are already lined up waiting to meet with me. Sometimes entire families crowd into the small room that IRCO provides for us. Often, children or teenagers act as interpreters for their parents.
Sometimes I have to give them bad news. If they’ve lived in the U.S. for seven years, they are likely no longer eligible for disability benefits. The disability that an individual wants to talk to me about may not be documented in any medical records and in a Social Security disability case the medical evidence is usually dispositive. I have to tell refugees that missing an arm or an eye often isn’t sufficient to win them benefits, and that the horrors of their experiences in their native countries and in refugee camps are not, by themselves, sufficient reason to get benefits.
More often, the challenge is simply to understand the meaning behind the words that the interpreters tell me on their behalf. As Tom Kinzie describes:
A Somali man reported to his health care provider that he had tremendous pain in his chest. But his physician could not find any objective medical evidence for the pain. It was also clear that this refugee had symptoms very much like depression and Post-Traumatic Stress Disorder. It was only after we were able to refer him to the Intercultural Psychiatric Program at OHSU, which specializes in mental health treatment of refugees and others who have experienced war trauma, dislocation and torture, that we discovered the true significance of his chest pain. While in Somalia a group of armed men came to his village and ordered his whole family outside. One of the armed men pointed a rifle at this man. His son jumped in front of him and took a fatal bullet in the chest that was meant for the father. The word “heart” took on a whole shade of new meaning when I first heard this story.
Such stories of failure to communicate with medical personnel are not unusual. A 30-year-old woman from Somalia whom I represented was denied disability benefits because an examining psychologist for the Social Security Administration found her responses to his questions flippant and sarcastic. When he asked her what she would do if a neighbor’s house caught fire, she answered simply “run.” The examining psychologist, failing to consider that her entire village had been burned to the ground, branded her response “inappropriate.” From her point of view, that response was normal and accurate, hardly sarcastic or flippant.
Another Somali client suffered recurrent nightmares but focused instead on his concerns about his physical health. His physical complaints were unlikely to qualify him for disability benefits, in contrast to his mental health limitations, which were severe. After talking with IRCO and researching Somali culture, I learned that many Somali refugees suffer from post-traumatic stress disorder but do not attribute their nightmares or hyper vigilance to psychological factors. Instead, Somalis are more likely to report symptoms or complaints related to disrupted sleep, lack of energy, headaches, abdominal pain, gastrointestinal problems, gross body aches, arthritis and back pain.
A Somali refugee’s descriptions of pain may also be different from what we are used to — at times, more extreme and pervasive. Somali refugees may use pressured speech and make physical gestures to communicate a sense of urgency and frustration, e.g., making cutting motions toward their arms as a means of communicating their experience of pain. A patient may use dramatic speech, e.g., “I can’t even touch my head,” when referring to the experience of headaches. A Somali patient might say, “I’m hurting head to toe, in each and every vein and hair,” or “a very hot wind is blowing through every nerve.” If relying only on literal translation, a medical provider might misunderstand the patient’s meaning or find the patient’s account exaggerated.
An older man from Iraq whom we represented had owned a store in Baghdad. When the store was bombed, he suffered both physical injury to his spine and trauma during an escape. Once in the United States, he experienced depression and post-traumatic stress disorder, thinking not only about what had happened but also about those he had left behind, including a brother who had died in the attack. But he had great difficulty acknowledging these mental health limits on his functioning. In fact, Iraqi refugees have the highest rate of both PTSD and physical injury of any group resettled in our area in recent history. Yet his hesitation was understandable once you know that the pre-war mental health system in Iraq consisted primarily of psychiatric hospitals where individuals with chronic and severe mental illness like schizophrenia were confined. In Iraq, having such a mental illness is still highly stigmatized, as it is in many countries. Some Iraqis worry that psychiatric hospitals are where political dissidents are sent.
Thus when working with my Iraqi client, it was important for me and for his healthcare providers to avoid using terms related to mental health and instead focus on his symptoms, such as his difficulty sleeping through the night or his tearfulness. Instead of using terms like “depression” or “post-traumatic stress disorder,” we used examples: “You have bad nightmares and think about what happened to you all the time.”
Iraqi refugees are different from many other refugees in another important way.
Unlike refugees from Somalia or Bhutan, most recent Iraqi refugees have never lived in refugee camps. In 2008, there was a large increase in the number of Iraqis arriving in the U.S., primarily due to the passage of the Refugee Crisis in Iraq Act, which provides up to 5,000 special immigrant visas yearly for Iraqis who worked with U.S. forces in Iraq. They came to the United States with relatively more education than adults from refugee camp backgrounds; many were well educated and well-paid professionals in Iraq before our 2003 invasion.
Approaches to Educating Ourselves
Through our work with these clients, we’ve learned a few approaches to educating ourselves about cultural differences so that we can more successfully represent clients from international communities. These approaches include:
Ensure that assigned interpreters speak the client’s first or preferred language. Whenever possible, request an interpreter whose gender or language won’t cause additional trauma for a client. For example, a recent female client spoke only one dialect (S’ghaw Karen) but was assigned an interpreter who spoke Burmese. The Karen are indigenous to the Thailand-Burma border region in Southeast Asia and are one of many ethnic groups in Burma. Each year in the Karen state, usually during the dry season, the Burmese military attacks Karen villages, setting fire to homes and destroying rice stocks and supplies that enable a community to survive. Thus a Karen refugee is unlikely to trust an interpreter speaking Burmese, and such an interpreter should be used only as a last resort.
Identify and consult with community leaders. Every refugee community develops leaders, formal or informal, and members of the community know who they are. Often they are the members of the community who speak English well and who have stepped up to help newcomers. These unofficial leaders are a good source of information about cultural norms, specific facts about a particular family or individual, and about recent arrivals from their native country. They are also important sources of information for their community, helping new arrivals understand the criteria for disability and enlightening those who won’t qualify so that they don’t waste their time waiting for benefits that aren’t likely to be awarded.
Educate other participants in the case — particularly healthcare providers — as to the cultural factors at play. Our refugee clients rely on public health care. Their treating doctors are invaluable allies in obtaining disability benefits, just as they are in workers’ compensation and personal injury cases. They are also likely to have some information about different cultural norms and responses. But they may also lack cultural information, which attorneys can supply. It is critical to alert treating doctors that a patient from a particular cultural background may be unwilling to complain or share symptoms while another may consider it normal to describe physical symptoms in dramatic or symbolic ways. For example, many Karen value not imposing on others, being quiet or less talkative. Doctors have high social status in their culture so patients may not be comfortable questioning them or expressing dissatisfaction with their treatment. Because the Karen people are mostly from rural, culturally traditional areas, they may be ashamed, embarrassed and hesitant to tell information to their health care providers, and this may be true especially for female patients. The patient-provider interaction may benefit from having a Karen caseworker, when possible, consult with the patient to clarify issues or discuss issues in preparation for appointments.
Consult Local Refugee and Immigrant
Refugee and immigrant organizations employ international staff as well as translators, who understand and work with diverse communities. Excellent local sources of information include
IRCO. IRCO, the Immigrant and Refugee Community Organization, is a community-based, nonprofit founded in 1975 that assists refugees and immigrants through the various stages of integration into U.S. society. IRCO’s clients represent many countries and regions throughout the world, including Vietnam, Laos, Cambodia, China, Pakistan, Samoa, Tibet, Burma, Bhutan, Iraq, Iran, Somalia and Cuba. IRCO’s mission — to promote the integration of refugees, immigrants and the community at large into a self-sufficient, healthy and inclusive multiethnic society — is implemented through a host of programs. These include translation and interpretation (IRCO helped translate our firm’s informational brochures on Social Security disability into Arabic, Russian, Burmese and Somali). They also include programs for newly arrived immigrants and refugees on employment training and placement, acculturation and support services. Through its programs, IRCO has developed many in-house experts who understand the diverse communities it serves. (www.irco.org)
The Center for Intercultural Organizing (CIO). Founded by Portland-area immigrants and refugees, the CIO was originally established to combat widespread anti-Muslim sentiment after 9/11. The CIO is an advocacy organization for immigrants and refugees. (www.interculturalorganizing. org)
The Intercultural Psychiatry Program at OHSU (IPP). The IPP serves individuals and families from Afghanistan, Bosnia, Cambodia, Congo, Central and South America, Ethiopia, Iraq, Iran, Laos, Liberia, Myanmar, Rwanda, the former Soviet Union, Sierra Leone, Sudan, Somalia, Vietnam and other countries in Asia, Africa, the Middle East and South America. The IPP staff and physicians offer services in more than 15 languages. (www.ohsu.edu/xd/health/services/clinics/InterculturalPsychiatricProgramIPP.cfm)
Causa. Causa is Oregon’s statewide Latino immigrant rights organization. Their programs include civic participation, community education, leadership development, public communications and policy advocacy. (www.causaoregon.org)
Lutheran Community Services for Refugees and Immigrants. These serviceshelp refugees and immigrants access resources and gain skills to successfully transition to their new communities (www.lcsnw.org/services.html).
Catholic Charities. In addition to immigration legal services, Catholic Charitiesof Oregon offers a variety of special programs aimed at Spanish-speaking communities. They also assist newly arrived immigrants and refugees from a wide variety of countries in successfully transitioning to life in the United States. (www.catholiccharitiesoregon.org)
EthnoMed is an excellent online source of information about cultures particularly represented in the refugee population in the Pacific Northwest. The website is maintained by the Harborview Medical Center of the University of Washington and directed by clinical faculty in the Department of General Internal Medicine’s Refugee and Immigrant Health Promotion Program at Harborview. The EthnoMed team works with caseworker cultural mediators, medical interpreters, health care providers and ethnic community leaders who serve as authors and advisers. (http://ethnomed.org/culture)
Oregon has made progress, but as we look to a future when the demographics of our state will be drastically altered by new arrivals, we need to continue to be aware of cultural differences as they affect fair access to legal services and benefits. Given the number and variety of cultural communities in Oregon, no attorney could hope to be an expert in every cultural norm. Still, by remaining sensitive to differences and making use of the resources and approaches outlined here, we can begin to prepare our legal system – and our own legal practices – for the changing face of Oregon.
ABOUT THE AUTHOR
Portland lawyer Cheryl Coon practices Social Security disability law with Swanson, Thomas, Coon & Newton and represents claimants for both SSDI and SSI benefits at all stages of the process. James Coon, a partner at the firm, whose practice has included workers’ compensation, personal injury and appellate law, contributed to this article, as did the firm’s Nicole Bockelman, who practices workers’ compensation law with a focus on Spanish-speaking clients.
© 2012 Cheryl Coon