Doctors face dilemmas treating immigrant patients

Dr. Elliot DeHaan. Photo by Simon McCormack

Dr. Elliot DeHaan thought he knew what he was signing up for when he accepted an infectious-disease fellowship at Bellevue Hospital Center.

During his two years at Bellevue, DeHaan has diagnosed patients from Ecuador with neurocysticercosis — a parasitic infestation that attacks the brain — and patients from Latin America and the Caribbean with echinococcus — a disease caused by tapeworms that can produce cysts in the liver, spleen, kidney and bones.

One of DeHaan’s colleagues treated a patient from Argentina for Chagas disease, a parasitic infection caused by the feces of reduviid bugs. The infection is so rare in America, DeHaan said, tests for the disease had to be conducted at the Center for Disease Control and Prevention instead of through Bellevue’s in-house lab.

It’s not every day DeHaan encounters a patient with these ailments, but he said he regularly sees people with tuberculosis and malaria, which native-born patients rarely have.

These are diseases doctors don’t get much exposure to in other American hospitals — and that’s why DeHaan signed up.

He wanted to treat patients from all over the world and get experience of diagnosing and treating diseases uncommon among native-born Americans. Because Bellevue, on First Avenue near 27th Street, serves a large immigrant population, DeHaan said it was the perfect place to get a feel for the diseases that dot the globe.

But serving patients from a broad swath of countries presents two major obstacles, according to DeHaan. Doctors at Bellevue must overcome language barriers and gain the trust of unauthorized immigrants worried about being deported.

“There are specific challenges associated with treating immigrant patients,” DeHaan said. “Bellevue is one of the best places to learn about them.”

Bellevue doesn’t keep statistics on how many immigrant patients come through its doors, according to the hospital’s spokesman, Steve Bohlen. That’s because Bellevue doesn’t want to discourage illegal immigrants from visiting.

“We want them to come, so we don’t keep track of their documentation status or where they’re from,” Bohlen said. “We try to make sure no one is afraid to get treatment.”

DeHaan estimates that between 35 to 45 percent of his patients are immigrants. They hail primarily from Eastern Europe, Southeast and Central Asia, West Africa and Latin America.

While he takes a patient’s birthplace into account when attempting to diagnose their illness, DeHaan said it’s never the only factor he considers.

“It’s not just the particular country they’re from,” DeHaan said. “You want to go deeper.”

DeHaan explained how he might diagnose neurocysticercosis using the information about the patient’s symptoms and homeland.

“If you have a person who’s coming in with first-time seizures and he comes from a country where the disease is endemic, then you would want to do an MRI to check for neurocysticercosis,” DeHaan said. “But you don’t want to just assume that everyone who comes from a certain place has this certain disease.”

While a person’s birthplace can be helpful in determining their diagnosis, DeHaan said undocumented patients might not tell him where they’re from.

“Patients are going to be suspicious about whether the doctors are going to treat them, or if after they’re treated, they’re going to be deported,” DeHaan said. “The fact that you’re undocumented is going to affect your relationship with the medical-care provider.”

NYU Professor Robert Holzman co-authored a study that suggests undocumented patients may avoid hospital care because they’re afraid of being deported. His research found that, when compared to documented immigrants and native-born patients, undocumented immigrants at Bellevue endured symptoms of tuberculosis for a longer period of time before going to the hospital.

“We have no direct evidence on what the cause is,” Holzman said. “Our speculation is that people may have delayed seeking care because they feared revealing their undocumented status and that that might lead to deportation or other interactions with immigration officials.”

Holzman said doctors at Bellevue do not report patients’ immigration status to law enforcement. The Health and Hospitals Corporation, which runs Bellevue, has launched campaigns to let immigrant patients know their information is kept private. But, Holzman said, his study suggests greater outreach is needed to make the point clear.

“Finding this kind of a pattern in the people who get care suggests that maybe that information could be presented to the relevant communities in a more effective way than it has been,” Holzman said.

DeHaan said he must work especially hard to gain the confidence of undocumented patients.

“You have to assure them that anything they say is not going to be used against them,” he said. “You have to be aware that they may not be forthcoming.”

A Colombian undocumented worker who did not want to give his name was surprised to hear that Bellevue treats patients without asking for documentation. He works as a hot dog and pretzel street vendor in Williamsburg and moved to America three years ago. He said he is working on getting legal status, but he came to America illegally.

“That’s good to hear,” he said when told Bellevue doesn’t turn patients away. “I hope that’s true.”

He said he’s had no major health issues since venturing to the States, but he’s avoided seeing the doctor a couple times because he’d rather not risk being reported.

“If I had an emergency, I would go to the hospital no matter what,” he said. “But for smaller things, I would not want to get in trouble.”

While some immigrant patients struggle with issues of trust, DeHaan said others come up against a language barrier. Doctors at Bellevue rely on a 24-hour translation line to help them communicate with their patients.

“You always lose something when someone is translating for you,” DeHaan said. “But it’s obviously better than nothing, and it’s the best you can do in a lot of situations.”

While completing his residency in Boston, DeHaan said he experienced the pitfalls of relying on translation. The word “dizzy” in Cantonese is very similar sounding to the word for “sick,” DeHaan explained. As a result, some patients were unnecessarily prescribed medication for dizziness because they said they felt sick.

“You have to ask them (whether) the room (is) spinning,” DeHaan said. “You have to be more specific in your discussion with them and not just use terms that can be easily misconstrued.”

Holzman said doctors at Bellevue must also be aware of their patients’ cultural backgrounds when determining what they’re trying to communicate.

“Sometimes it’s difficult to interpret what people say without having some knowledge of the place where they’re from,” Holzman said. “You have to be alert to things that people say that will convey information that, if you didn’t have that alertness, would be meaningless to you.”