Dr. Ishmael Togamae spends a lot longer with some of his patients than most primary care doctors. He runs the weekly refugee clinic at the Mid County Health Center. Lately, that has meant long conversations with patients through a phone translation service. It also means seeing patients who have been through a great deal before they were able to make it to the U.S. Dr. Togamae joins us to talk about how he and his colleagues are preparing for an influx of refugees from Afghanistan.
This transcript was created by a computer and edited by a volunteer.
Dave Miller: From the Gert Boyle Studio at OPB, this is Think Out Loud. I’m Dave Miller. More than a thousand refugees from Afghanistan could be coming to Oregon in the next few months. No matter where they come from, every refugee who arrives in the US has to get a mandatory health screening. In Multnomah County those happen at the Mid County Health Center in outer southeast Portland. Dr. Ishmael Togamae is the Lead Provider for the refugee clinic. He joins us now to talk about his work. Welcome to TOL.
Ishmael Togamae: Thank you Dave, for having us on a show for this refugee clinic.
Miller: Can you tell us what happens in general at these required health screenings? This is something that the federal government says you have to do. What happens?
Togamae: Our goal here in the refugee clinic is to integrate these new folks into our system, address the health issues. Not only that, but to keep the general or local population against, you know, infectious disease that they might come with. That’s the overall goal that we have in this clinic. With that in mind, we do have systems in place. When the patients or when these clients come in, they go through these systems that we have in place.
Miller: What kinds of health issues do you see most often?
Togamae: The majority of the time with our African refugee population, we see these individuals primarily with behavioral issues, like post-traumatic stress disorder, anxiety. Some of them, they’re coming in from [a] war-torn country. They also have depression, having difficulty with sleeping. In addition to that, they also have other medical conditions, chronic medical conditions like high blood pressure. Some of them have diabetes and all that.
Miller: But as you led with PTSD, with anxiety, with depression, with behavioral health issues, are there services you can connect them to for mental health needs in addition to physical ones?
Togamae: Having the refugees in here, we are so thankful that there’s a whole team out there, not only here in the refugee clinic. We have all these resettlement agencies like Lutheran Community Services, Catholic Charities. We also have the insurance folks to take care of the insurance for us. We also have, within the clinic itself, so many other individuals including like the front desk, management of the county in general, small clinics that we have in here, health administrative offices. All these individuals, the nurses, the doctors, we all help together to address all these issues that these clients are coming with. Not only that, but we also have a specialist that also assists us. We always have the OHSU health system, Providence, also Legacy, and all those. Those are the places that we easily access if there is any more complicated issues that our clients come in with.
Miller: How much of your time with patients are you actually focused on medical issues as opposed to so many other issues that might be connected to a newly arrived refugee?
Togamae: Our refugees, when they come into the clinic, they initially are screened for blood tests, and all that, and then they’re subsequently seen by the provider. In each of these consultations, there is usually a whole family, the family maybe consisting of up to six or seven individuals altogether.
Miller: And you might see the whole family at the same time?
Togamae: At the same time, that’s right. We see them all at once and that takes a lot of time. Most of the time it’s done through telephonic interpretation. It’s a challenging process.
Miller: Can you explain how that works, what it means to see one or six patients via telephonic translation? What’s happening?
Togamae: So we have this language service that we have access to. We dial them up and ask them if we can have the language which the clients speak. When we have the interpreter on the other end of the line, then we speak to them and that’s how we get the information from the clients. We speak to the telephonic interpreter. Then it goes to the client. The client goes back to the telephonic interpreter and then comes back to the provider.
Miller: So you would be in the same room as your clients or your patients. But there’s a speaker phone essentially between you that’s enabling the communication from English to Pashtun or whatever, and back.
Togamae: Right, right. That’s exactly correct. It’s a speaker phone. Sometimes we have the iPad video phone. So we have those services in place. During the whole process we do that. The reason why we have the whole family in one place is because you know, a majority of these clients, in a situation where you know they are scared in a place where they are hearing guns, bombs and all that. The kids, when you leave them alone is kind of bad for them. We try to do that as much as possible, to be very friendly, to be culturally oriented to them. That way most of the clients say ‘okay, this is a friendly place’. That’s what we try to put up right in front when we see the clients. We go through each patient. If there are sensitive issues, especially for adults, then we easily separate the client from the rest of the family members. We have that option also.
Miller: Questions about reproductive health or other issues where it may be better if there’s more privacy. I should remind folks if you are tuning in, we’re talking right now with Dr Ishmael Togamaei. He is a family medicine doctor. He’s a lead provider for Multnomah County’s refugee clinic. Have refugees who left Afghanistan post-US withdrawal, meaning just in the last couple weeks, have they already started arriving at your clinic?
Togamae: Yes. We have not received anyone yet since they started the evacuation, but there are a few that traveled out prior to that. But we’re expecting in the coming weeks. and probably months, probably up to like 150 refugees or something like that to be resettled here in Oregon.
Miller: Do you have a sense for the kinds of issues, medical or mental health or whatever, that you’re likely to encounter when that influx starts?
Togamae: Yes. There are some concerns [about] illnesses like measles and diphtheria, and all that. Those [are] prevalent in Afghanistan. We are very much aware of that. Our providers are well versed with symptoms of measles and all that. In addition to all these other behavioral health issues, we also screen for highly infectious diseases like TB for example, or measles, for example. Those ones we will do best with. We are ready and prepared for that.
Miller: What has the pandemic meant in terms of your ability to see patients in person?
Togamae: That is an issue where our management provides, our clinic director here is a very much aware of, and we try our best to practice social distancing, health hygiene and all that. As much as possible. In certain situations we achieve that. Because most of them come with large families, so we try our best to just have them in one spot as much as possible.
Miller: How did you gravitate to this particular practice of medicine where you’re focusing not every day, but often, on this very specific and in some ways vulnerable population?
Togamae: So my background, I was trained in physical medicine in Fiji and I did my graduate studies in Public health at Tulane University in New Orleans, especially in neglected diseases in tropical medicine. That’s where I did my graduate studies. This is followed by family medicine residency with the University of Hawaii. My interest has been on the tropical side of medicine, but then also on traveling medicine. When I completed my residency in 2013, I decided to look for a job here in Portland, Oregon. I moved here in 2013. It so happens that Mid County Clinic that houses the refugee clinic, I presume, is the only refugee clinic in the whole of state of Oregon. That’s where I ended up getting involved with the refugee clinic, seeing our very vulnerable populations, and found the clinic in 2013.
Miller: What’s it like to try to build a rapport with patients who you’ve never met before and who may be anxious, as you noted, just to be in the US in general, or to be talking with a doctor, when you don’t even speak the same language?
Togamae: It’s extremely humbling and it’s a very challenging situation because most of our refugee clients, they come with very broken path. They stay in refugee [camps]. There’s no home. they literally have no country. They come with very broken backgrounds basically. Trying to get them settled down in the US, it takes a lot of effort. There are so many barriers that these individuals go through. That in itself is quite traumatic for these clients. Many of these barriers, like I think we discussed earlier on about language, language barriers, have cultural barriers. Many other barriers like housing, transportation systems in general. Our clients don’t understand that we use insurance, and money is involved. Most of these clients really have no health care at all. They come in expecting things to be done quite fast. Sometimes we do achieve that, sometimes we don’t. They get frustrated with navigating the health system itself, already quite difficult for many locals, and for an individual who doesn’t speak english, it’s even harder for them to do that. Part of the challenge that we face here at Mid County at least once every day is trying to get these folks to settle into the US enough [in a] smooth manner that they can actually assimilate well into the local population.
Miller: Ishmael Togamae, thanks very much for joining us today.
Togamae: Thank you so much for having us.
Miller: Dr. Ishmael Togamae is the Lead Provider for the refugee clinic at Multnomah County’s Mid County Health Center.
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