Is there an interpreter in the house? Addressing health in refugees and asylum seekers.

A personal perspective written by Ms Maria Nguyen, Final Medical Student Volunteer

At some point during medical school, students will be taken through the obligatory themes of cultural sensitivity and vulnerable patient groups. Refugee health was one such topic, briefly occupying the limelight during our ‘Professional Attitudes & Cultural Education Studies’ component of our General Practice training. Tutorial role-plays invariably steered towards the clinical. Refugee, are you? Better check hepatitis B and C, HIV, malaria. Active tuberculosis. Anaemia. Vitamin D. Immunisations? Diet? Dental health? Mental health? The list goes on.

Like good holistic medical students, we jotted down points on cultural awareness and sensitivity. Check what language the patient speaks. Book an interpreter, preferably “on-site”. Arrange seating to enable direct communication between the interpreter and patient. Speak directly to the patient. Speak in a clear voice. Use pictures and diagrams. Use printed material in the patient’s language. Remember different attitudes to death and dying. Cultural taboos. Body language. Eye contact, unless it’s perceived as insensitive. DO NOT BE INSENSITIVE.

On the ward, my brief experiences with refugee health consisted less of perfect triangles of clear doctor-interpreter-patient communication, and instead typically involved a doctor spotting my surname on my ID badge and enquiring whether I could consent a patient for an angiography in Vietnamese. As my cardiovascular Vietnamese vocabulary didn’t extend beyond ‘chest pain’ and ‘heart’, my response was always a polite no.

The lessons learnt from those earlier tutorials tumbled back into relevance when I joined The Water Well Project as a volunteer. I was allocated to address a young men’s soccer team, predominantly from Afghanistan, on navigating health care in Australia. What healthcare services are refugees and asylum seekers entitled to again? What cultural taboos should I be aware of? My frantic Google searches did little to dispel the butterflies, and neither did a quick review of my scant tutorial notes.

Of course, my nervousness was unwarranted. The group of young men, after understanding what we were there to discuss, listened in, asked questions, translated for each other when needed, laughed at our jokes (thankfully), and willingly shared some of their own experiences. I soon signed up to more sessions, and found that each new encounter with a different group always brought fresh insights, and different challenges.

I quickly appreciated the range of languages and dialects that exist within cultures. The Afghan diaspora, for instance, included migrants who could speak Dari/Hazaragi, Pashto, Uzbek, Turkmen, Urdu and some 30 other minority languages. Having an interpreter, who was often fluent in more than one language/dialect other than English, was a blessing for the participants but did mean the session moved at half the speed.

Subtle and not-so-subtle cultural differences also emerged with some frequency. I remember speaking to a large group of women from an assortment of refugee backgrounds about sexual health. When the topic of contraception arose, one woman proclaimed that condoms made sexual intercourse less pleasant, which was why she didn’t often use one. I sat back, bewildered and bemused, as half the room tittered in agreement. Another lady asked me why knowing about STIs was important, since she’ll only ever have intercourse with her husband. Not surprisingly, that particular session went overtime, carried by intense conversations mostly regarding sexual responsibility. My pre-organised notes on ten different types of STIs stayed in their folder, untouched.

I was thrilled every time I could connect with a new group of participants, and as time went along and my pre-session jitters gave way to earnest anticipation, I learnt probably my most important lesson when it comes to addressing health in refugees and asylum seekers: as different as we may be in terms of culture, language and life experiences, the things that dictate our attitudes to our health and accessing healthcare are still one and the same – our ability to be autonomous, to make informed choices, to be heard, understood and personally supported. Mary Belfrage nails it in her perspective on “culturally safe” health care: "People need to feel like themselves and believe that the health care is connected to their lives, that they are involved and have choices, that it’s not primarily someone else’s agenda. It’s often not so much about empowering people as not disempowering" (ref1).

The migrants, refugees and asylum seekers we encounter will, I hope and believe, walk away a bit more empowered (or perhaps a bit less disempowered) to make life-affirming choices. Such is the aim of the Water Well Project. And at the end of the day, I leave these sessions more enriched, marvelling at the similarities and differences between human beings around the world, and wondering whether med school tutorials could have ever truly prepared me for these complex and rewarding interactions I’ve been honoured to experience.


1- Belfrage M. Why “culturally safe” health care? Med J Aust 2007; 186 (10): 537-538.