Serena Zhou-Talbert
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Interview Text and Audio
Abstract
Dr. Serena Zhou-Talbert immigrated to the United States from China when she was three years old. She has MPH and MD degrees and currently works as a resident family medicine physician at the Prospect Hill Community Health Center, a Federally Qualified Health Center (FQHC) that serves a 60 percent Hispanic population. In this interview, she discusses the barriers to accessing healthcare that her patients face, telling stories of particular patients as examples. She also briefly discusses her own identity as an immigrant from China. This interview is part of a GLBL 382 project investigating barriers to accessing healthcare for immigrants in North Carolina. As part of this course, students also travel to Guanajuato, Mexico over Spring break. Anna Silver is also volunteering as an English language tutor with immigrants throughout the semester as part of a service-learning requirement to build relationships with immigrant communities.Themes
Transcript
Anna Silver: So, my name is Anna Silver, and I am here interviewing Dr. Serena Zhou-Talbert about her work with immigrants at the Prospect Hill Community Health Center as a doctor. The date is April 8, and it is 3:05 PM. To start, can you tell me a little bit about your background, kind of where you grew up, and then a little bit of maybe education and work history, and how you came to be working here at Prospect Hill?
[00:00:31] Serena Zhou-Talbert: Okay, so, a brief history. I was born in China—Shanghai, China—came to the United States when I was three. Moved—moved around a bunch of places, so, went from Minnesota to Mississippi, lived there for a year, spent a little bit of time in Arizona, and then moved to Connecticut for high school. Went to college at Johns Hopkins to study behavioral biology there, and then during the interim, when I was in Johns Hopkins, my parents moved to South Carolina, which is where they are now. And then I was also pre-med in Johns Hopkins, that was kind of, wasn’t really sure I wanted to go to med school though, however. Ended up doing an internship, worked with a lot of issues—dealt with issues with racial and ethnic health disparities, and that was kind of how I started getting interested in public health and health disparities and issues like that. And then after that, I spent a little time abroad in, in Shanghai, China, and then, got exposed to alternative types of medicine I think so, that was kind of my first interest in medicine. After college, I spent a year abroad in Ecuador, and I was working—working in community development, so I was in charge of this, the health programs for a nonprofit called Manna Project International, and then I think that’s kind of how I got interested in working with Latino populations, like global health and kind of tied that into healthcare. And then after that I spent, moved to California, where my then boyfriend, now husband was, and then spent a year kind of doing random jobs and then did an MPH, deferred a year for med school to do an MPH in public health, and global health, a focus on global health. And then ended up going to Michigan State University for med school, mainly chose that because of their, their—they have a pretty high emphasis on primary care, strong primary care focus, so went there for medical school. Did a, was under there—there was a leadership for the underserved track that they did, so I was a part of that. And then ended up going into family medicine for a lot of the same issues, or a lot of the same reasons as I mentioned, their emphasis in public health and being able to kind of, being able to have that first point of contact, the first point of relationship for patients, and have that, maintain that kind of continuity, being able to deal with a wide variety of issues, and then, yeah. So chose UNC Family Medicine because there’s really strong primary care in North Carolina, and then, they have this underserved track that I was really interested in, especially the clinic at Prospect Hill. So it was an FQHC, so I wanted to kind of work in an FQHC, and they have 60% Latino patients that we see, so that’s kind of how I ended up here, long story short, yeah. And I’ll be continuing actually working with a similar type of population after I graduate in June, so I’ll be working at Caswell Family Medical Center, which is about twenty minutes north of Prospect Hill, so, a rural clinic there, yeah.
AS: Cool, perfect. You mentioned the Manna Project International in Ecuador, what is that nonprofit, what do they do? And also, is that where you learned Spanish, or did you—
[00:04:22] SZT: Yeah, that’s where I learned Spanish. Yeah, it is, it’s a—so, basically, it’s a community development type of nonprofit organization where they take graduate students from college and kind of have, they, whatever passions that they specifically have, so they kind of can start their own programs. But when we were there, it was actually just the second year, so it was still really early on in its, this was like 2008, so it was started in 2007, and so a lot of it was foundation building and starting new programs. So my focus was on everything health related, so kind of starting any sort of health related programs. A lot of it was kind of, we did a community needs assessment to see what kind of programs the community would be interested in, so, ended up starting a women’s health and an exercise, a nutrition program there, which actually is still running today, which is really exciting. And then, did a lot of work with working with the Ministry of Health, and then trying to connect patients, or trying to connect a lot of the community members with the public health system there. And then doing a lot of, a lot of my work was with networking and then working with these other local clinics to try to expand their clinic. And then we host a bunch of medical students and spring break volunteers and things like that, and, I think those were the main things. We—oh, and we started a, a library, a teen library in the community, which is actually where, it was actually really cool that we did that, because now that kind of is our base now where people can go there for resources, public health type resources, medical resources, so we’re starting kind of expanding there. So, I haven’t been back since then, but I heard it’s doing really really well, so I think those were the main things, but yeah, that’s kind of, so, my niche was health, and then seven other graduates who were there with me—one person was focused on English, another person was focused on art, another one was focused on microfinance, another was agriculture, so it was kind of a little bit of everybody doing their own thing, so kind of things like that.
AS: That’s really cool.
SZT: Yeah so it was kind of cool. And it’s asset-based community development is kind of the things that we were doing.
AS: That’s awesome. [00:06:50] Okay, can you explain to me what an FQHC is, to start, and then, a little bit about the Prospect Hill clinic in particular, like the range of services that you guys offer?
SZT: Sure. So federal—FQHC stands for federally qualified health center, so, the brief explanation of that is basically, there’s—it’s—there’s a lot of different types of safety net clinics in the, in the country, and it’s federally funded so they have to—there’s a bunch of different rules that I won’t go into detail with, but every single clinic has to meet a specific criteria, has to serve a specific amount of underserved, Medicaid underserved patients. But they basically just provide a lot of the services that they, and otherwise other people can’t get. And Prospect Hill has been, is one of several, I forget how many exactly, but there’s—it’s part of the PHS community, the Piedmont Health Services, and so, there’s quite a few in this area, I don’t know, I think five or six, they’re expanding, and Prospect Hill is the largest one in the area. The headquarters are in Carrboro, but, so basically it offers primary care, and dental care, WIC, pharmacy, they have this migrant healthcare program, and they serve mainly, like 60% Latino patients, and the rest of it’s kind of mixed Caucasian, African Americans, and then others. And it is, and I don’t know the exact percentages, but there, majority is uninsured, and then I think—I wanna say like thirty, thirty-something percent or forty-something percent, and then I think after that is like twenty-something percent Medicaid, and then after that Medicare, and then a smaller percentage private insurance. Is there anything specific else that you wanted to know about it?
AS: No, I think that covered everything.
SZT: Yeah, okay. Yeah, they have a pretty wide range of services that they, that they provide for patients and, but yeah, it’s mainly primary care, we do, we do, it’s like, Prospect Hill specifically is run by, is a resident—so it’s a teaching clinic, so residents work there, and our program, two from each—they’re expanding—but in our, in my class, it’s ten total residents, and two of us are in the underserved track, so we work in Prospect Hill. But then, after that, or before, or the classes after us it’s three, three residents, so there’s eleven total and three of them, and then actually next year they’re, we’re expanding to fourteen total, so there will be three residents from, going to Prospect Hill and three residents going to Siler City PHS, yeah, and then the rest of them are in the main family medicine clinic. So it’s kind of neat, so we’re getting more, more people, so yeah.
AS: Do you know—I just thought of this—do you know how long the clinic has been around?
SZT: Oh, man. I’d have to look it up. I don’t want to give you the wrong information.
AS: Yeah, no, that’s fine.
SZT: I feel like seventies, but, I’ll look it up for you.
AS: Yeah, that’s fine. [00:10:21] Okay, we’re gonna move into talking a little bit about the barriers to healthcare that these Latin American immigrant patients are facing. So I know you speak fluent Spanish; how much do you feel that has helped you connect with your patients and work with them?
SZT: Yeah, I think it’s, it’s helped a lot. I wouldn’t say I’m completely fluent, but, you know, enough to, enough to understand people and not cause a lawsuit, but it helps so much because there’s a lot of things that get lost in translation, and, and that’s a reason why there’s so many Latinos that come to our clinic, because, because we have bilingual staff members. And then, and the providers obviously have to be able to speak Spanish because we don’t have interpreters there, but there’s a huge difference when you—because I’ve definitely dealt with patients who speak a different language and, and there’s almost always something that I know is lost in translation. And I speak Mandarin so I know I used to interpret for Mandarin, and there’s many many times where they would speak to, you know the, when the patient would tell me something, and it’s like impossible to translate because there’s just, there’s a lot of cultural implications to it that it’s very difficult to translate into English without those backgrounds, and I think—and I know I’m from a different culture so there’s still probably things that I’m, that I’m not getting completely, but just being able to have the patient communicate you directly and being able to know that you’re at least, you know, in there, speaking their language and trying to understand them and get to their level I think makes a big difference in their relationship and having them, and trying to meet them where they’re at. So, I think it makes a big difference to try to at least get rid of those barriers, because that’s one of the things that they have to deal, another barrier they have to deal with in this, trying to, you know, getting used to being in this country, so.
[00:12:30] AS: Then, aside from language, are there other cultural barriers that you’ve encountered—maybe like differences of opinion on medicine, or any sort of thing like that?
SZT: Yeah, yeah. I think, there’s a lot of subtle things. I’m trying to think of a specific, a specific example. I mean little things, like in a lot of—I’ve noticed in Latino cultures, they’ll take medicines, but they’ll stop taking them as soon as they feel better, and there’s not really an understanding that you have to keep taking this medicine in order for you to get better, like, for instance, antibiotics is an example, they start feeling better and they stop early. Blood pressure medication, any sort of medication really is once they start feeling better, they think they can stop. And this has been a problem that I’ve seen over and over again with medication adherence. With people that come back a lot, you know, keep coming back, and then you realize they, you realize that they, they just stopped their medication. And a lot of this is cultural, but a lot of this is education as well. I can think of one of my patients actually who I just saw and diagnosed him with heart failure, really really really bad heart failure, so, ended up getting him on the right medication and then getting him, getting all these tests and things like that got him to take them and then literally I’ve been seeing him every three to six months—he no shows a lot—but when he does come, it’s the same, we’ve had the same conversation like six times, where he just, he just stopped taking his meds, that he hasn’t filled them for three months because he said he feels fine, he doesn’t need to take them. Doesn’t seem to get it that you have to keep taking them in order to prevent complications. I think we finally got to him, but it took like six or seven visits to finally, to finally have him understand that. And, so that’s one thing, and there’s little things like, I don’t know. I feel like there’s a lot of Hispanic people that I’ve seen who think, who attribute high cholesterol to, I’m trying to think what was it—I think, any time they have sort of, muscle pains or some sort of issues they always attribute it to cholesterol problems. I don’t know, that’s just a random thing I thought of. That’s not really that relevant. So, but those are, I mean that’s one example, but. And they basically, I’ve found that, a big difference in Latino populations and maybe more so, than in comparison to maybe white and African Americans, they’re very respectful, they’re very respectful of your authority, and they listen to everything that you, that you say. And, so, I mean, it makes them really—it’s a really really great population to work with. They, they do, it is, they do, they—I’m trying to think of a way to say it—they’re just, they’re really appreciative, you know, and they don’t take what, they don’t take coming to the doctor all those things for granted, they really do take that for heart, so I think that makes your job easier, even though you deal with very complex patients, complex social issues, things like that, but, I don’t know, they’re just a joy to kind of work with.
AS: Yeah. [00:16:20] What about alternative medicine, do any of them talk about that at all?
SZT: No I personally haven’t, I know that that’s been something, I know a—I always ask but actually I personally haven’t seen that much, which I was actually really surprised about. I saw, I see it a lot more in different types of non-Latino cultures, which actually was really, is really surprising to me. But in this specific clinic, not a lot of people I know have been doing alternative-type medicines. I mean, some people take supplements and things like that, but I actually found that a lot of people who are even poor more, it’s ironic like a lot of people who are more, even more educated or have a, come from affluent backgrounds, do more alternative medicines. But, at least from my experiences in this clinic, not many people do alternative medicines. When you say alternative medicine, do you mean things like herbs, or, you know, like shaman, things like that, or like acupuncture, or…
AS: Yeah. When I talked to Bryan, he mentioned some of the farmworkers talking about going to see hueseros or curanderos.
SZT: Oh yeah, yeah. I haven’t personally dealt with it but I think that’s something that I don’t routinely ask and I should, I know I should be asking, but we generally have so many other things to deal with that I usually don’t end up asking. But that’s actually a good point, I’m sure that some of them do, but, I always recommend, you know, an alternative approach in many different types of things but most people can’t afford it. But, yeah. I, I don’t personally know, at least in my patients, I’ve never had that problem or at least yeah…
AS: So, another thing, I know—[00:18:28] I’ve read things about, with mental health, Latino populations maybe not being as open to talking about that. Have you found that to be accurate or no?
SZT: Yeah, pretty accurate, depending on, yeah, depending on the situation, but what I’ve found is that a lot of times, people will come in with somatic complaints, and there’s usually, when you can’t find a—most of the time—you can’t find a physical cause, and it ends up being, being a, something psychological. So, there’s usually, for example, the other day I saw a guy in his fifties with erectile dysfunction, and after talking to him for a bit, you know, he, finally he opened up a little bit, and it was, I found out it was because his brother was murdered, and about a month ago when all of this stuff happened—when it started happening, so, that’s, you know, that’s an example, where they, and he has been super, you know, going through a lot of acute stress and all of these issues, and then it ends up manifesting in a variety of other physical complaints. So they come to, they come to me for these physical complaints, but then once you explore further you realize there’s, most of the time it’s some sort of something else is going on. I saw this a lot after Trump got elected, actually, and I’m not gonna go into politics a lot, but we saw actually back we saw a lot of people come in with actual physical symptoms, like vomiting, nausea, abdominal pain, which did not have any medical causes, and it all had to do with anxiety and things like that, so Melissa was really busy then—you know Melissa, she’s our behavioral health—so, but yeah. I mean, it’s a big issue. And a lot of people don’t talk about it until, but then if you, once you develop a relationship with them, they’re a lot more open, but almost every single one I would feel like has some sort of manifestation, psychological manifestation from a lot of the stress that they deal with from being in, you know, just living, being an immigrant and not understanding a lot of the, a lot of the policies and things like that, but, yeah.
AS: That is very interesting. And then if something like that happens, if you recommend that they get kind of some mental health treatment, are they normally open to it at that point?
SZT: Yeah, most of them are, and I think once you start, once we identify the issue I think they all, most of them are always open to wanting to try any—something. I think a lot of the problems, I don’t know, this would be—I wish you could talk to Luke Smith, because he’s the psychiatrist, but he, but he sees a lot of, a lot of people with a wide variety of issues, but he actually has had to deliver medicines to their homes because—like literally he would personally take these medicines and drive and go to these peoples’ homes and give them the medicines because they have been, [00:22:04] they have been afraid to come to the clinic, and we’ve seen that happen a lot in the aftermath of the election too, where, I know I’m kind of going on a tangent, but they—
AS: You’re good. It’s relevant.
SZT: They, a lot of times, we—you know, we have, we start people on treatment, or start getting them into behavioral therapy, but then the problem is follow-up and having them come back and then, especially, it’s getting a little better now but there was a period of time where we would see a lot of gaps where people would just stop coming in, for months upon months and months and then a lot of it has to do with fear of being caught, of being, you know, I know that deals with more the undocumented part, but it was a huge issue back at that time. We saw a lot of the first hand consequences of that. But yeah, to the point where people have to go to their house to deliver the medicines because they were afraid, you know, to come to the clinic, so, yeah.
AS: Yeah, I read actually a New York Times article about that, because Bryan mentioned it to me during the interview—
SZT: Oh yeah.
AS: Where they interviewed Dr. Ashkin for it. Yeah, yeah. Okay, is—aside from just fear, [00:23:29] is having the time to come in or being able to get transportation ever an issue for your patients?
SZT: Yeah, yeah. Transportation is a huge issue, and our, we have, we have a pretty—I think our no show rate is about 30ish percentage, and transpor—there’s a lot of barriers, but transportation is one of them. A huge issue, because, you know, we’re, most of these families are single family homes, they have a breadwinner, they usually have one car, and they always have to find a way to get them to the clinic, and then if some—you know, it’s like—or a single mom, or—overall it’s a big issue, a lot of them can’t drive and, so that’s one of the reasons why our no show rate is so high is because they can’t get a way, find a way to get to the clinic. Some people come from really far away. A lot of actually our patients drive all the way from Virginia, or from Greensboro because we’re the closest safety net clinic in their area because it’s a little bit cheaper to go to our clinic than some of the other clinics in their area, so. There’s also just a lack overall of access to clinics in the rural communities overall, especially these types of FQHC clinics, especially nowadays where they’re closing a lot of these community health centers in the area, or at least defunding, not closing, but there’s a lot, there’s a huge problem with defunding these community health centers with this new administration, so—so yeah, people travel for like two hours, up to two hours, I think one of my patients went three, traveled three hours just to get here, so, you know. It’s like, when you find that out, that you know they’re, if they’re late, or they no show, you know, you kind of, it’s like they, they drove really far to get here to see us, so.
AS: That’s pretty crazy. So then, in terms of paying for the appointments, I know obviously the prices are reduced a lot and you have the sliding scale, right, based on income, [00:25:50] but is payment still an issue for some patients?
SZT: Payment is still an issue, especially—I think with the primary care stuff, especially if they don’t have insurance, I think it’s fine, but the problem really is getting specialty care or getting any sort of further diagnostic tests and things like that, and affording medicines and things. But I mean, coming to the visit and all those things, that’s, they usually, you know, will cover it, if you’re uninsured it’s like twenty-five dollars. And if they’re in a sliding scale I’m not really sure I think they don’t have to pay anything. I’m not, I’m not sure the details I’ll have to ask Tashia the exact cost of it, but, but yeah, I mean I think the biggest issue is really just getting full care, because they, you know, we have to be really careful about what labs we order, in case they get charged for it. You know, we have to be very careful about what tests to order. There are times we absolutely need this person to get, this person needs this, needs this CT scan, or needs this MRI scan, and we know they can’t afford it. So, those are always problems that we deal with on a regular basis, where Tashia ends up having to try to get them into either emergency Medicaid, or some sort of charity care, but then, but then there’s problems with trying to, understanding how to apply for that, and all of those problems, but. But yeah, cost is always an issue, we always have to keep that in mind when we’re ordering tests and when we’re putting them into referrals, because we know most of the time they won’t end up going because they—it’s not because they don’t want to, they know, or they can’t, it’s because they can’t, you know, they can’t afford it. They are afraid of, ( ) or they have to, it’s either, you know, they pay for their medicines or they pay for, they feed their family. Or it’s like, you know, they have have to make that choice, so, you know.
AS: Yeah. Okay, let’s see. What about, we talked about—a little bit—about education being an issue. [00:28:13] Is there also a lot of confusion and misinformation, I guess, about how the American healthcare system works? Do your patients have difficulty understanding that? I would imagine, it’s kind of confusing [laughter].
SZT: Yeah, I mean, I don’t get it, I don’t get it. I actually studied it, and I still don’t get it. So, I mean, if I don’t get it, I mean I’m pretty sure somebody with a third grade education who can’t speak English doesn’t get it. It’s so confusing, and I feel like it, it’s just, it keeps changing, and it definitely affects them because most, a lot of the, a lot of immigrants don’t realize—Latino immigrants—don’t realize that they are eligible for, for example Medicaid, or if they’re pregnant they, they are eligible for emergency Medicaid. Most people are uninsured because they don’t know how to, they don’t know how to navigate the system or they don’t have the resources, they don’t have somebody to kind of help them with it. So, they come to our clinic for the first time, even though you realize they, they are eligible, and then, but the paperwork to even get them—even I look at the paperwork and it’s so confusing, and then having to deal with it and trying to get it in Spanish and things like that, and a lot people, we get this all the time, where even some, some, some staff members are like why can’t, you know, if they’ve been in this country for this many years, how come they can’t speak English yet? But it’s, it’s a lot more complicated than that, when, you know, when you, when you only have a, a elementary school education, you know, and coming to this country and then learning a new language as an adult without even that primary education, it’s sometimes nearly impossible to try to learn a new language, so, it’s like—and then a lot of these, a lot of these people are coming from backgrounds where they had to deal with trauma, or they left their country because of trauma, or some other issue, and that has a huge effect, detrimental effect on your cognitive, learning and all of those abilities. And so, it’s not, it’s not that simple to be able to learn a new language and be able to navigate those systems and understand these things. So, I’m really impressed by a lot of, how a lot of the, a lot of these, our patients have been able to navigate the system, like being able to at least deal with kind of assimilate—or not assimilate that’s the wrong word—but being able to kind of adjust to a lot of the cultures here. But, yeah, I mean, it’s very confusing, and, so, coming from a whole different culture, a whole different background—I, I, I’m really impressed that they are able to figure it out because it’s really—with minimal assistance, because they, you know, overall have to, there’s a lot of other things I’m sure that they have to deal with, so. But yeah, that’s a huge barrier, just being able to know if you’re eligible or not, and being able to get all that paperwork filled out, so.
AS: Are there any, I know you mentioned the physical manifestations of mental health issues being pretty common, but [00:31:37] are there any issues that are particularly prevalent among the Latino populations that you serve?
SZT: Like different types of medical conditions or things like that?
AS: Yeah.
SZT: Yeah so, I would say it’s pretty common, pretty similar maybe to the, any sort of, like the general population, but there’s, I think, there’s definitely more disparities that you see in Latino populations, but there’s disproportionately higher numbers of obesity, diabetes, and that kind of comes with heart disease and blood pressure issues—hypertension, depression, and then, the common musculoskeletal things, like back pain, shoulder pains, and, you know, a lot of—depends on their occupation too, but people who work in, you know, farmworkers, they come in with a bunch of different musculoskeletal issues. But, but mainly the biggest things we still see are just diabetes, obesity, hypertension, like the rest of this population, but more, much more so in the Latino population because, because of their lack of access to healthy foods, and their diet in general, it’s a very carb-heavy diet, but yeah, we see that, we see that a lot, and so, yeah.
AS: Yeah.
SZT: Hepatitis ( )
AS: Gotcha. This is somewhat related to that, I’m kind of curious what you think. I was asked in a public health class one time, we were asked to write a paper, the question was do you choose your own health, and they asked us to kind of put a percentage on it, like [00:33:31] how much do you choose your own health, or how much is it affected by other things. You don’t have to necessarily put a percentage on it, but I’m kind of curious what you would think about that question.
SZT: Oh that’s a, yeah, choose your own health—that’s hard. I—there’s so much more to health than just, and obviously we say, you know, you can, we, I feel like our society blames so much on the individual, like you get to choose to be healthy, you get to kind of, you know, choose not to smoke and eat healthy and all of these things, but only if you have a certain amount of money, only if you have a certain amount of support and live in a certain amount of, certain area, it’s—if you’re gonna live in a rural community, where the nearest store is a liquor store or a, you know a ( ), nearest is a Dollar General and, you know, you’re making less than, way less than fifty percent of the federal poverty level, you, you obviously want to choose to be healthy, but you don’t have the resources to be healthy. So, there’s so much more than just—I don’t know how to put it into a percentage—but, you can choose to be healthy if you have the resources to do that. But if you, if you, you know, if you’re one of—I’m trying to think—one of my patients who’s like, who has—okay, I’m just thinking of one patient I just saw. She’s, she has seven children, she’s pregnant with her eighth, who has Down—now we found out that her, has Down Syndrome. And not all of these pregnancies were from the same dad, a lot of them were forced, wasn’t like she was trying to get pregnant, they were forced, like rape, basically. And no access to family planning, so it’s, she wasn’t able to—a lot of this happened in other, I think it was El Salvador, and, she’s by herself, she’s single now, because the dad was abusive, so now they’re out of the picture. Her other kids, literally one time I had a visit with her and six of her children. It was a well child visit that were not well child. Like every single one of their kids has issues because of the trauma that they’ve been through. I mean, I don’t know, and then, obviously she has health, she has a bunch of health issues. She has diabetes, and hypertension, and all this other stuff because she has to, she has to feed her, her family, and she has to, she can’t eat healthy because she doesn’t, it’s too expensive to eat healthy, and so they have to take fast food, or they have to eat, you know, spend whatever little money, food stamps she has, so, yeah. I mean, it’s an interesting question, but I think you can but you can’t it depends, to a certain extent depending on your situation. It’s like—it’s a tricky question, so, but it, it’s not just, and you can’t—it’s not individual, I think here, it’s a very population, socially construed answer, or topic, so. Yeah, I don’t know. I don’t have a good answer to that.
AS: No that was, that was a good answer. Are there any major barriers that we haven’t talked about thus far?
SZT: Let me think, let’s see. I think we talked about education, we talked about transportation, food, health, mental health access, uninsured. I think we’ve touched on, we’ve touched on most things. I’m trying to think if there’s anything else. I’ll think about it. I think those are, you’ve touched about all the major things.
AS: Cool. Okay, and then, [00:38:08] I know that you’re an immigrant yourself. Has that kind of, I don’t know, affected at all how you interact with immigrant populations or anything, or the way you think about immigrant populations?
SZT: That’s interesting, I’ve actually never thought of it that way. I think it definitely does though, because, you know, I mean, I’ve seen firsthand the things that my parents dealt with when they first came here. And, you know, we all have very similar—the reasons why, everybody, the immigrants that come to this country is for trying to better the future for the next generation. That’s the only reason why my parents came here, so I could have a better life. You know, they largely succeeded on that. They didn’t, they went through a lot of sacrificies, it wasn’t like we were rich when we came here. You know, they, they were pretty, we stayed in a small studio, little apartment when we, they kind of worked their way up, but it wasn’t, it took many many many years before they were able to, you know, get a house, for example. So it was, I mean, we did, we struggled a lot in the beginning. And I think I can relate, relate to some of the other immigrant families who are kind of going through the same thing and I think, I mean, and especially nowadays getting—it’s just, it’s a weird time. I don’t know. It’s, it’s interesting, we all, I think, my parents dealt with their own kind of discrimination, but, but I feel like it’s just escalated now, it’s a weird, it’s an interesting time for you to be doing this project, because there’s so much tension right now, especially with—I feel like me being Asian, it’s like we’re kind of left out of a lot of this racial discourse, but, that’s a whole other topic that I won’t get into, but.
AS: ( )
SZT: Oh really? Yeah, so, but yeah I mean yeah, I feel I can really relate to a lot of the immigrant story just because I’ve been through some of it myself. But, I mean, we’ll see what the future brings, but right now, I mean, I feel like it’s gotten better, but right now, at this time, it’s kind of in a weird moment where we can either way, but, yeah, we’ll see.
AS: Yeah. Did your parents know any English before they came here, or have they learned it here?
SZT: They were—they did, and didn’t. And so my dad, my dad came first. He, his English wasn’t good, they had to learn a little bit, you know, but obviously his conversational English was pretty terrible. It took, I think it took him, he said that he practiced, oh what was it he, he practiced in front of his mirror like fifty-something times, where can I get a taxi? That was like the first thing he had to ask somebody, but he, you know, he’s like, he was a, top of his class, valedictorian when he was in China, but he was getting Cs, almost failing his classes when he came here because he couldn’t understand, so, but then, you know, he, they—my parents both were well educated, so they were able to eventually learn English and being able to get, get there, but it took a while. And they still, there’s still little things, you know, when you learn a new language in your twenties, it’s never gonna be perfect, you know, like if you learn it as you were a child. So, but yeah. They did, they were a little bit more fortunate, though ( ).
AS: Yeah, yeah. Okay, kind of a little bit of a different topic, [00:42:22] I think Bryan said when I was interviewing him that you had gone out with them before to the fields—
SZT: Oh yeah
AS: Yeah, could you tell me a little bit about that?
SZT: Yeah, yeah I’ve just, I’ve only gotten to go out with him once. We went to, we went to this one—we went to a couple families. One of them was, it was this—it was a migrant farmworkers who was, I forgot how, I think they were there just for a few months. Pretty modest, they lived in this, they all live in these little mobile homes. And, it was a great experience. Most of the time they just spent, we just spent kind of chatting with them about completely non-health related things and just kind of, they were just, we were just, you know, talking about their, I don’t know everyday, something, like they were making jokes and everything like that. But it was a great experience because you got to see how they lived, got to kind of see what kind of conditions they lived in. I think relatively speaking, I mean that’s a whole, a whole different topic too, but they have, there’s a lot, there’s been a lot of farmworkers that go through—I mean you know, there’s a lot of maltreatment in the history of that, where they’ve taken advantage of, where they don’t—they get pretty minimal payment for the amount of work they do. I think the different policies like that have changed a lot but, but yeah, I mean overall it’s like, they seem to have a pretty, I mean they all have a pretty modest living, but they, you know, they haven’t seen a doctor in many years, so I ended up trying to get them to come see us, but then it’s like being able to have them find a time to see us. They really, they usually, the only time they can come is on Thursday nights when they, you know, they can, they can, where they’re done with work. But, yeah, but I mean I really liked it, just to be able to kind of see how they’re living and kind of just chat with them, just see how they are. But, I mean it’s hard, because they’ll be in a, they’re away from their families for sometimes like a year at a time, but they’re all doing this just so they can bring money back to their family, so, it’s kind of cool to see that. They work extremely hard, so yeah, but, I mean, it’s a cool program, I think.
AS: Yeah, yeah, for sure. Sorry, I’m jumping all over the place a little bit here, the questions are just kind of popping into my head.
SZT: It’s okay.
[00:44:59] AS: Have there been any, I guess, immigrant stories that have been particularly difficult for you to kind of hear? Probably a lot, but I don’t know if anything sticks out.
SZT: Yeah, yeah. I think Melissa would be a great person to talk to about that, but I mean one time—well I had one, one lady come see me. She came to see me for an acute complaint, for something, I forget what it was, it was like, I don’t know, pain somewhere or was it, I don’t know, vaginal discharge, I don’t remember what it was, but it was one of those where I was running behind, per usual, was my, maybe like half way done, and there were patients waiting, and I was like oh this will be easy, I’m gonna get this done really quickly. And then, something didn’t feel right with her, I don’t know how, what it was, but just it was the first time I was meeting her but just something wasn’t right, and then, as soon as I was kind of done with her, I was about to, I wanted to just kind of get things done, but then, just noticing that there was, I don’t know, like there was something off. So I just kind of probed a little bit and asked her if there was something, you know, if there was anything else she wanted to talk about, what else is going on. And I, and usually, when I’m in a hurry I don’t ask that because I know I need to move along but with her, I don’t know. And then she just started bursting into tears. And then you’re like okay, now I’m screwed, like the rest of my day is done.
AS: Yeah, yeah.
SZT: And then basically she told me that they went to the—her and her family, her husband and her, their son, went to a beach in Myrtle Beach for vacation the past week. And then, her husband was basically just, their son was like five years old, and he peed on himself, so, accidentally peed on himself, so he was just changing his clothes on the beach. And then they said that when they were going back to the hotel there was cops there. And then apparently, they took, they basically took him in for questioning, said that somebody from the beach, or somebody reported that he was molesting this child or something like that. And, of course, there was a language barrier and blah blah blah, she was letting them know like no, this is his son, he was changing his pants. And, but somebody reported that they were, that whatever, and, and so, what ended up happening, they had to take him in for questioning with, go through his records, and they found out that he was undocumented, and then, now, he, basically they’ve detained him, and then were kind of in that process of getting him deported. All because somebody, somebody from the beach was, I mean, it was very very clear that he was his dad, and was doing that, but, I don’t know. And so, so she was really upset because she didn’t know what to do, and she was trying to, in the process of trying to get a lawyer, and trying to, but, you know, didn’t have the money to do that, it was just a mess. So, I don’t know, so that kind of stuck with me. Just like a nice little vacation and then having somebody say—accuse your husband of, of abusing your child, and then having, the next thing you know having him be under ICE detention and being deported, so, it’s like, I don’t know, it sucks.
AS: Yeah, yeah.
SZT: And she’s, and she’s afraid to do something about it because she’s also undocumented, so it’s like, a mess.
AS: Yeah, that’s, that’s pretty awful. Do you, you mentioned the time thing, having enough time to talk to the patients. [00:49:15] Do you feel like that’s an issue for you, not having enough time to be with each patient?
SZT: I mean, that’s, that’s a struggle. That’s a huge struggle in primary care because, you know, on average we get fifteen minutes for each patient and that’s literally impossible to get through any really, true visit, unless they’re, you know, they’re coming in with a cold, you can deal with that. But most people, most people don’t, don’t come in with just one complaint, especially, especially, and even if they’re Spanish-speaking sometimes it takes a little bit longer, you know, mostly just because there’s sometimes words that if I don’t understand I have to re ask them and things like that, but yeah. Or if they’re traveling so far and then they get here and, you know, you want to get all their complaints because you now they’re not gonna come back, and then you realize a lot of these patients don’t, aren’t able to, like having a visit to come is a big deal for them because of the, of a lot of the barriers that we already have talked about. So, you want to try to get, address all of their issues, but time is always, it’s always an issue. And I feel like, it doesn’t ever feel, you know, like you’re able to get everything done. You can’t, you can’t get anything done in fifteen/twenty minutes, I mean yeah, so. I mean the other day I had a twenty minute visit for a new patient who was in her forties. She was Latina too, and she hasn’t seen a doctor for twenty years. So, you’re like, great. And then her sugars were so high that you couldn’t read it on the, on the glucometer. She’s like, her sister brought her in and her sister tells me that she, she stopped speaking fifteen years ago, so this patient’s mute, so she can’t talk. And so you have no idea what happened, she can’t, she, yeah I don’t know, she just stopped talking, she just suddenly stopped talking. So you have no idea, and literally this was the visit. Like this [laughter], this patient just comes in and then, of course every single thing. Her blood pressure was messed up, her, everything was just, it was just a mess of a, a visit. That you can, twenty minutes for, fifteen/twenty minutes for trying to figure out all of those things and why she stopped talking. Later on, I found out it was trauma, actually, it was abuse by her uncle that we found out later on, with, through Melissa, but, with Melissa’s help. But this was after multiple visits, you know, so, but yeah, that is what we deal with, people that come in who haven’t been seen, so.
AS: Yeah. I think that is all the questions that I have, is there anything else that you want to add?
SZT: I don’t know—yeah, I mean, thanks for doing this project. [00:52:21] I think this is a very valuable, and I’m really happy that, that you guys are studying this, and that that will hopefully increasing some more exposure, understanding to the, to the, you know. I think, I just feel like there’d be so much more love and so much more relationships, or, I mean, communication between different types of people if we just had, if we were just exposed, or if—
AS: Yeah.
SZT: You know, people who, I guess, people who might have these types of biases, just kind of learn about their situation and then, yeah. I just think, we just, we would make a big difference, so.
AS: Yeah.
SZT: So I’m glad that you’re doing this project.
AS: Yeah, thank you so much for your time, for helping out.
SZT: Yeah, yeah. [00:53:17]
END OF INTERVIEW
TRANSCRIBED BY ANNA SILVER
12 APRIL 2018
[00:00:31] Serena Zhou-Talbert: Okay, so, a brief history. I was born in China—Shanghai, China—came to the United States when I was three. Moved—moved around a bunch of places, so, went from Minnesota to Mississippi, lived there for a year, spent a little bit of time in Arizona, and then moved to Connecticut for high school. Went to college at Johns Hopkins to study behavioral biology there, and then during the interim, when I was in Johns Hopkins, my parents moved to South Carolina, which is where they are now. And then I was also pre-med in Johns Hopkins, that was kind of, wasn’t really sure I wanted to go to med school though, however. Ended up doing an internship, worked with a lot of issues—dealt with issues with racial and ethnic health disparities, and that was kind of how I started getting interested in public health and health disparities and issues like that. And then after that, I spent a little time abroad in, in Shanghai, China, and then, got exposed to alternative types of medicine I think so, that was kind of my first interest in medicine. After college, I spent a year abroad in Ecuador, and I was working—working in community development, so I was in charge of this, the health programs for a nonprofit called Manna Project International, and then I think that’s kind of how I got interested in working with Latino populations, like global health and kind of tied that into healthcare. And then after that I spent, moved to California, where my then boyfriend, now husband was, and then spent a year kind of doing random jobs and then did an MPH, deferred a year for med school to do an MPH in public health, and global health, a focus on global health. And then ended up going to Michigan State University for med school, mainly chose that because of their, their—they have a pretty high emphasis on primary care, strong primary care focus, so went there for medical school. Did a, was under there—there was a leadership for the underserved track that they did, so I was a part of that. And then ended up going into family medicine for a lot of the same issues, or a lot of the same reasons as I mentioned, their emphasis in public health and being able to kind of, being able to have that first point of contact, the first point of relationship for patients, and have that, maintain that kind of continuity, being able to deal with a wide variety of issues, and then, yeah. So chose UNC Family Medicine because there’s really strong primary care in North Carolina, and then, they have this underserved track that I was really interested in, especially the clinic at Prospect Hill. So it was an FQHC, so I wanted to kind of work in an FQHC, and they have 60% Latino patients that we see, so that’s kind of how I ended up here, long story short, yeah. And I’ll be continuing actually working with a similar type of population after I graduate in June, so I’ll be working at Caswell Family Medical Center, which is about twenty minutes north of Prospect Hill, so, a rural clinic there, yeah.
AS: Cool, perfect. You mentioned the Manna Project International in Ecuador, what is that nonprofit, what do they do? And also, is that where you learned Spanish, or did you—
[00:04:22] SZT: Yeah, that’s where I learned Spanish. Yeah, it is, it’s a—so, basically, it’s a community development type of nonprofit organization where they take graduate students from college and kind of have, they, whatever passions that they specifically have, so they kind of can start their own programs. But when we were there, it was actually just the second year, so it was still really early on in its, this was like 2008, so it was started in 2007, and so a lot of it was foundation building and starting new programs. So my focus was on everything health related, so kind of starting any sort of health related programs. A lot of it was kind of, we did a community needs assessment to see what kind of programs the community would be interested in, so, ended up starting a women’s health and an exercise, a nutrition program there, which actually is still running today, which is really exciting. And then, did a lot of work with working with the Ministry of Health, and then trying to connect patients, or trying to connect a lot of the community members with the public health system there. And then doing a lot of, a lot of my work was with networking and then working with these other local clinics to try to expand their clinic. And then we host a bunch of medical students and spring break volunteers and things like that, and, I think those were the main things. We—oh, and we started a, a library, a teen library in the community, which is actually where, it was actually really cool that we did that, because now that kind of is our base now where people can go there for resources, public health type resources, medical resources, so we’re starting kind of expanding there. So, I haven’t been back since then, but I heard it’s doing really really well, so I think those were the main things, but yeah, that’s kind of, so, my niche was health, and then seven other graduates who were there with me—one person was focused on English, another person was focused on art, another one was focused on microfinance, another was agriculture, so it was kind of a little bit of everybody doing their own thing, so kind of things like that.
AS: That’s really cool.
SZT: Yeah so it was kind of cool. And it’s asset-based community development is kind of the things that we were doing.
AS: That’s awesome. [00:06:50] Okay, can you explain to me what an FQHC is, to start, and then, a little bit about the Prospect Hill clinic in particular, like the range of services that you guys offer?
SZT: Sure. So federal—FQHC stands for federally qualified health center, so, the brief explanation of that is basically, there’s—it’s—there’s a lot of different types of safety net clinics in the, in the country, and it’s federally funded so they have to—there’s a bunch of different rules that I won’t go into detail with, but every single clinic has to meet a specific criteria, has to serve a specific amount of underserved, Medicaid underserved patients. But they basically just provide a lot of the services that they, and otherwise other people can’t get. And Prospect Hill has been, is one of several, I forget how many exactly, but there’s—it’s part of the PHS community, the Piedmont Health Services, and so, there’s quite a few in this area, I don’t know, I think five or six, they’re expanding, and Prospect Hill is the largest one in the area. The headquarters are in Carrboro, but, so basically it offers primary care, and dental care, WIC, pharmacy, they have this migrant healthcare program, and they serve mainly, like 60% Latino patients, and the rest of it’s kind of mixed Caucasian, African Americans, and then others. And it is, and I don’t know the exact percentages, but there, majority is uninsured, and then I think—I wanna say like thirty, thirty-something percent or forty-something percent, and then I think after that is like twenty-something percent Medicaid, and then after that Medicare, and then a smaller percentage private insurance. Is there anything specific else that you wanted to know about it?
AS: No, I think that covered everything.
SZT: Yeah, okay. Yeah, they have a pretty wide range of services that they, that they provide for patients and, but yeah, it’s mainly primary care, we do, we do, it’s like, Prospect Hill specifically is run by, is a resident—so it’s a teaching clinic, so residents work there, and our program, two from each—they’re expanding—but in our, in my class, it’s ten total residents, and two of us are in the underserved track, so we work in Prospect Hill. But then, after that, or before, or the classes after us it’s three, three residents, so there’s eleven total and three of them, and then actually next year they’re, we’re expanding to fourteen total, so there will be three residents from, going to Prospect Hill and three residents going to Siler City PHS, yeah, and then the rest of them are in the main family medicine clinic. So it’s kind of neat, so we’re getting more, more people, so yeah.
AS: Do you know—I just thought of this—do you know how long the clinic has been around?
SZT: Oh, man. I’d have to look it up. I don’t want to give you the wrong information.
AS: Yeah, no, that’s fine.
SZT: I feel like seventies, but, I’ll look it up for you.
AS: Yeah, that’s fine. [00:10:21] Okay, we’re gonna move into talking a little bit about the barriers to healthcare that these Latin American immigrant patients are facing. So I know you speak fluent Spanish; how much do you feel that has helped you connect with your patients and work with them?
SZT: Yeah, I think it’s, it’s helped a lot. I wouldn’t say I’m completely fluent, but, you know, enough to, enough to understand people and not cause a lawsuit, but it helps so much because there’s a lot of things that get lost in translation, and, and that’s a reason why there’s so many Latinos that come to our clinic, because, because we have bilingual staff members. And then, and the providers obviously have to be able to speak Spanish because we don’t have interpreters there, but there’s a huge difference when you—because I’ve definitely dealt with patients who speak a different language and, and there’s almost always something that I know is lost in translation. And I speak Mandarin so I know I used to interpret for Mandarin, and there’s many many times where they would speak to, you know the, when the patient would tell me something, and it’s like impossible to translate because there’s just, there’s a lot of cultural implications to it that it’s very difficult to translate into English without those backgrounds, and I think—and I know I’m from a different culture so there’s still probably things that I’m, that I’m not getting completely, but just being able to have the patient communicate you directly and being able to know that you’re at least, you know, in there, speaking their language and trying to understand them and get to their level I think makes a big difference in their relationship and having them, and trying to meet them where they’re at. So, I think it makes a big difference to try to at least get rid of those barriers, because that’s one of the things that they have to deal, another barrier they have to deal with in this, trying to, you know, getting used to being in this country, so.
[00:12:30] AS: Then, aside from language, are there other cultural barriers that you’ve encountered—maybe like differences of opinion on medicine, or any sort of thing like that?
SZT: Yeah, yeah. I think, there’s a lot of subtle things. I’m trying to think of a specific, a specific example. I mean little things, like in a lot of—I’ve noticed in Latino cultures, they’ll take medicines, but they’ll stop taking them as soon as they feel better, and there’s not really an understanding that you have to keep taking this medicine in order for you to get better, like, for instance, antibiotics is an example, they start feeling better and they stop early. Blood pressure medication, any sort of medication really is once they start feeling better, they think they can stop. And this has been a problem that I’ve seen over and over again with medication adherence. With people that come back a lot, you know, keep coming back, and then you realize they, you realize that they, they just stopped their medication. And a lot of this is cultural, but a lot of this is education as well. I can think of one of my patients actually who I just saw and diagnosed him with heart failure, really really really bad heart failure, so, ended up getting him on the right medication and then getting him, getting all these tests and things like that got him to take them and then literally I’ve been seeing him every three to six months—he no shows a lot—but when he does come, it’s the same, we’ve had the same conversation like six times, where he just, he just stopped taking his meds, that he hasn’t filled them for three months because he said he feels fine, he doesn’t need to take them. Doesn’t seem to get it that you have to keep taking them in order to prevent complications. I think we finally got to him, but it took like six or seven visits to finally, to finally have him understand that. And, so that’s one thing, and there’s little things like, I don’t know. I feel like there’s a lot of Hispanic people that I’ve seen who think, who attribute high cholesterol to, I’m trying to think what was it—I think, any time they have sort of, muscle pains or some sort of issues they always attribute it to cholesterol problems. I don’t know, that’s just a random thing I thought of. That’s not really that relevant. So, but those are, I mean that’s one example, but. And they basically, I’ve found that, a big difference in Latino populations and maybe more so, than in comparison to maybe white and African Americans, they’re very respectful, they’re very respectful of your authority, and they listen to everything that you, that you say. And, so, I mean, it makes them really—it’s a really really great population to work with. They, they do, it is, they do, they—I’m trying to think of a way to say it—they’re just, they’re really appreciative, you know, and they don’t take what, they don’t take coming to the doctor all those things for granted, they really do take that for heart, so I think that makes your job easier, even though you deal with very complex patients, complex social issues, things like that, but, I don’t know, they’re just a joy to kind of work with.
AS: Yeah. [00:16:20] What about alternative medicine, do any of them talk about that at all?
SZT: No I personally haven’t, I know that that’s been something, I know a—I always ask but actually I personally haven’t seen that much, which I was actually really surprised about. I saw, I see it a lot more in different types of non-Latino cultures, which actually was really, is really surprising to me. But in this specific clinic, not a lot of people I know have been doing alternative-type medicines. I mean, some people take supplements and things like that, but I actually found that a lot of people who are even poor more, it’s ironic like a lot of people who are more, even more educated or have a, come from affluent backgrounds, do more alternative medicines. But, at least from my experiences in this clinic, not many people do alternative medicines. When you say alternative medicine, do you mean things like herbs, or, you know, like shaman, things like that, or like acupuncture, or…
AS: Yeah. When I talked to Bryan, he mentioned some of the farmworkers talking about going to see hueseros or curanderos.
SZT: Oh yeah, yeah. I haven’t personally dealt with it but I think that’s something that I don’t routinely ask and I should, I know I should be asking, but we generally have so many other things to deal with that I usually don’t end up asking. But that’s actually a good point, I’m sure that some of them do, but, I always recommend, you know, an alternative approach in many different types of things but most people can’t afford it. But, yeah. I, I don’t personally know, at least in my patients, I’ve never had that problem or at least yeah…
AS: So, another thing, I know—[00:18:28] I’ve read things about, with mental health, Latino populations maybe not being as open to talking about that. Have you found that to be accurate or no?
SZT: Yeah, pretty accurate, depending on, yeah, depending on the situation, but what I’ve found is that a lot of times, people will come in with somatic complaints, and there’s usually, when you can’t find a—most of the time—you can’t find a physical cause, and it ends up being, being a, something psychological. So, there’s usually, for example, the other day I saw a guy in his fifties with erectile dysfunction, and after talking to him for a bit, you know, he, finally he opened up a little bit, and it was, I found out it was because his brother was murdered, and about a month ago when all of this stuff happened—when it started happening, so, that’s, you know, that’s an example, where they, and he has been super, you know, going through a lot of acute stress and all of these issues, and then it ends up manifesting in a variety of other physical complaints. So they come to, they come to me for these physical complaints, but then once you explore further you realize there’s, most of the time it’s some sort of something else is going on. I saw this a lot after Trump got elected, actually, and I’m not gonna go into politics a lot, but we saw actually back we saw a lot of people come in with actual physical symptoms, like vomiting, nausea, abdominal pain, which did not have any medical causes, and it all had to do with anxiety and things like that, so Melissa was really busy then—you know Melissa, she’s our behavioral health—so, but yeah. I mean, it’s a big issue. And a lot of people don’t talk about it until, but then if you, once you develop a relationship with them, they’re a lot more open, but almost every single one I would feel like has some sort of manifestation, psychological manifestation from a lot of the stress that they deal with from being in, you know, just living, being an immigrant and not understanding a lot of the, a lot of the policies and things like that, but, yeah.
AS: That is very interesting. And then if something like that happens, if you recommend that they get kind of some mental health treatment, are they normally open to it at that point?
SZT: Yeah, most of them are, and I think once you start, once we identify the issue I think they all, most of them are always open to wanting to try any—something. I think a lot of the problems, I don’t know, this would be—I wish you could talk to Luke Smith, because he’s the psychiatrist, but he, but he sees a lot of, a lot of people with a wide variety of issues, but he actually has had to deliver medicines to their homes because—like literally he would personally take these medicines and drive and go to these peoples’ homes and give them the medicines because they have been, [00:22:04] they have been afraid to come to the clinic, and we’ve seen that happen a lot in the aftermath of the election too, where, I know I’m kind of going on a tangent, but they—
AS: You’re good. It’s relevant.
SZT: They, a lot of times, we—you know, we have, we start people on treatment, or start getting them into behavioral therapy, but then the problem is follow-up and having them come back and then, especially, it’s getting a little better now but there was a period of time where we would see a lot of gaps where people would just stop coming in, for months upon months and months and then a lot of it has to do with fear of being caught, of being, you know, I know that deals with more the undocumented part, but it was a huge issue back at that time. We saw a lot of the first hand consequences of that. But yeah, to the point where people have to go to their house to deliver the medicines because they were afraid, you know, to come to the clinic, so, yeah.
AS: Yeah, I read actually a New York Times article about that, because Bryan mentioned it to me during the interview—
SZT: Oh yeah.
AS: Where they interviewed Dr. Ashkin for it. Yeah, yeah. Okay, is—aside from just fear, [00:23:29] is having the time to come in or being able to get transportation ever an issue for your patients?
SZT: Yeah, yeah. Transportation is a huge issue, and our, we have, we have a pretty—I think our no show rate is about 30ish percentage, and transpor—there’s a lot of barriers, but transportation is one of them. A huge issue, because, you know, we’re, most of these families are single family homes, they have a breadwinner, they usually have one car, and they always have to find a way to get them to the clinic, and then if some—you know, it’s like—or a single mom, or—overall it’s a big issue, a lot of them can’t drive and, so that’s one of the reasons why our no show rate is so high is because they can’t get a way, find a way to get to the clinic. Some people come from really far away. A lot of actually our patients drive all the way from Virginia, or from Greensboro because we’re the closest safety net clinic in their area because it’s a little bit cheaper to go to our clinic than some of the other clinics in their area, so. There’s also just a lack overall of access to clinics in the rural communities overall, especially these types of FQHC clinics, especially nowadays where they’re closing a lot of these community health centers in the area, or at least defunding, not closing, but there’s a lot, there’s a huge problem with defunding these community health centers with this new administration, so—so yeah, people travel for like two hours, up to two hours, I think one of my patients went three, traveled three hours just to get here, so, you know. It’s like, when you find that out, that you know they’re, if they’re late, or they no show, you know, you kind of, it’s like they, they drove really far to get here to see us, so.
AS: That’s pretty crazy. So then, in terms of paying for the appointments, I know obviously the prices are reduced a lot and you have the sliding scale, right, based on income, [00:25:50] but is payment still an issue for some patients?
SZT: Payment is still an issue, especially—I think with the primary care stuff, especially if they don’t have insurance, I think it’s fine, but the problem really is getting specialty care or getting any sort of further diagnostic tests and things like that, and affording medicines and things. But I mean, coming to the visit and all those things, that’s, they usually, you know, will cover it, if you’re uninsured it’s like twenty-five dollars. And if they’re in a sliding scale I’m not really sure I think they don’t have to pay anything. I’m not, I’m not sure the details I’ll have to ask Tashia the exact cost of it, but, but yeah, I mean I think the biggest issue is really just getting full care, because they, you know, we have to be really careful about what labs we order, in case they get charged for it. You know, we have to be very careful about what tests to order. There are times we absolutely need this person to get, this person needs this, needs this CT scan, or needs this MRI scan, and we know they can’t afford it. So, those are always problems that we deal with on a regular basis, where Tashia ends up having to try to get them into either emergency Medicaid, or some sort of charity care, but then, but then there’s problems with trying to, understanding how to apply for that, and all of those problems, but. But yeah, cost is always an issue, we always have to keep that in mind when we’re ordering tests and when we’re putting them into referrals, because we know most of the time they won’t end up going because they—it’s not because they don’t want to, they know, or they can’t, it’s because they can’t, you know, they can’t afford it. They are afraid of, ( ) or they have to, it’s either, you know, they pay for their medicines or they pay for, they feed their family. Or it’s like, you know, they have have to make that choice, so, you know.
AS: Yeah. Okay, let’s see. What about, we talked about—a little bit—about education being an issue. [00:28:13] Is there also a lot of confusion and misinformation, I guess, about how the American healthcare system works? Do your patients have difficulty understanding that? I would imagine, it’s kind of confusing [laughter].
SZT: Yeah, I mean, I don’t get it, I don’t get it. I actually studied it, and I still don’t get it. So, I mean, if I don’t get it, I mean I’m pretty sure somebody with a third grade education who can’t speak English doesn’t get it. It’s so confusing, and I feel like it, it’s just, it keeps changing, and it definitely affects them because most, a lot of the, a lot of immigrants don’t realize—Latino immigrants—don’t realize that they are eligible for, for example Medicaid, or if they’re pregnant they, they are eligible for emergency Medicaid. Most people are uninsured because they don’t know how to, they don’t know how to navigate the system or they don’t have the resources, they don’t have somebody to kind of help them with it. So, they come to our clinic for the first time, even though you realize they, they are eligible, and then, but the paperwork to even get them—even I look at the paperwork and it’s so confusing, and then having to deal with it and trying to get it in Spanish and things like that, and a lot people, we get this all the time, where even some, some, some staff members are like why can’t, you know, if they’ve been in this country for this many years, how come they can’t speak English yet? But it’s, it’s a lot more complicated than that, when, you know, when you, when you only have a, a elementary school education, you know, and coming to this country and then learning a new language as an adult without even that primary education, it’s sometimes nearly impossible to try to learn a new language, so, it’s like—and then a lot of these, a lot of these people are coming from backgrounds where they had to deal with trauma, or they left their country because of trauma, or some other issue, and that has a huge effect, detrimental effect on your cognitive, learning and all of those abilities. And so, it’s not, it’s not that simple to be able to learn a new language and be able to navigate those systems and understand these things. So, I’m really impressed by a lot of, how a lot of the, a lot of these, our patients have been able to navigate the system, like being able to at least deal with kind of assimilate—or not assimilate that’s the wrong word—but being able to kind of adjust to a lot of the cultures here. But, yeah, I mean, it’s very confusing, and, so, coming from a whole different culture, a whole different background—I, I, I’m really impressed that they are able to figure it out because it’s really—with minimal assistance, because they, you know, overall have to, there’s a lot of other things I’m sure that they have to deal with, so. But yeah, that’s a huge barrier, just being able to know if you’re eligible or not, and being able to get all that paperwork filled out, so.
AS: Are there any, I know you mentioned the physical manifestations of mental health issues being pretty common, but [00:31:37] are there any issues that are particularly prevalent among the Latino populations that you serve?
SZT: Like different types of medical conditions or things like that?
AS: Yeah.
SZT: Yeah so, I would say it’s pretty common, pretty similar maybe to the, any sort of, like the general population, but there’s, I think, there’s definitely more disparities that you see in Latino populations, but there’s disproportionately higher numbers of obesity, diabetes, and that kind of comes with heart disease and blood pressure issues—hypertension, depression, and then, the common musculoskeletal things, like back pain, shoulder pains, and, you know, a lot of—depends on their occupation too, but people who work in, you know, farmworkers, they come in with a bunch of different musculoskeletal issues. But, but mainly the biggest things we still see are just diabetes, obesity, hypertension, like the rest of this population, but more, much more so in the Latino population because, because of their lack of access to healthy foods, and their diet in general, it’s a very carb-heavy diet, but yeah, we see that, we see that a lot, and so, yeah.
AS: Yeah.
SZT: Hepatitis ( )
AS: Gotcha. This is somewhat related to that, I’m kind of curious what you think. I was asked in a public health class one time, we were asked to write a paper, the question was do you choose your own health, and they asked us to kind of put a percentage on it, like [00:33:31] how much do you choose your own health, or how much is it affected by other things. You don’t have to necessarily put a percentage on it, but I’m kind of curious what you would think about that question.
SZT: Oh that’s a, yeah, choose your own health—that’s hard. I—there’s so much more to health than just, and obviously we say, you know, you can, we, I feel like our society blames so much on the individual, like you get to choose to be healthy, you get to kind of, you know, choose not to smoke and eat healthy and all of these things, but only if you have a certain amount of money, only if you have a certain amount of support and live in a certain amount of, certain area, it’s—if you’re gonna live in a rural community, where the nearest store is a liquor store or a, you know a ( ), nearest is a Dollar General and, you know, you’re making less than, way less than fifty percent of the federal poverty level, you, you obviously want to choose to be healthy, but you don’t have the resources to be healthy. So, there’s so much more than just—I don’t know how to put it into a percentage—but, you can choose to be healthy if you have the resources to do that. But if you, if you, you know, if you’re one of—I’m trying to think—one of my patients who’s like, who has—okay, I’m just thinking of one patient I just saw. She’s, she has seven children, she’s pregnant with her eighth, who has Down—now we found out that her, has Down Syndrome. And not all of these pregnancies were from the same dad, a lot of them were forced, wasn’t like she was trying to get pregnant, they were forced, like rape, basically. And no access to family planning, so it’s, she wasn’t able to—a lot of this happened in other, I think it was El Salvador, and, she’s by herself, she’s single now, because the dad was abusive, so now they’re out of the picture. Her other kids, literally one time I had a visit with her and six of her children. It was a well child visit that were not well child. Like every single one of their kids has issues because of the trauma that they’ve been through. I mean, I don’t know, and then, obviously she has health, she has a bunch of health issues. She has diabetes, and hypertension, and all this other stuff because she has to, she has to feed her, her family, and she has to, she can’t eat healthy because she doesn’t, it’s too expensive to eat healthy, and so they have to take fast food, or they have to eat, you know, spend whatever little money, food stamps she has, so, yeah. I mean, it’s an interesting question, but I think you can but you can’t it depends, to a certain extent depending on your situation. It’s like—it’s a tricky question, so, but it, it’s not just, and you can’t—it’s not individual, I think here, it’s a very population, socially construed answer, or topic, so. Yeah, I don’t know. I don’t have a good answer to that.
AS: No that was, that was a good answer. Are there any major barriers that we haven’t talked about thus far?
SZT: Let me think, let’s see. I think we talked about education, we talked about transportation, food, health, mental health access, uninsured. I think we’ve touched on, we’ve touched on most things. I’m trying to think if there’s anything else. I’ll think about it. I think those are, you’ve touched about all the major things.
AS: Cool. Okay, and then, [00:38:08] I know that you’re an immigrant yourself. Has that kind of, I don’t know, affected at all how you interact with immigrant populations or anything, or the way you think about immigrant populations?
SZT: That’s interesting, I’ve actually never thought of it that way. I think it definitely does though, because, you know, I mean, I’ve seen firsthand the things that my parents dealt with when they first came here. And, you know, we all have very similar—the reasons why, everybody, the immigrants that come to this country is for trying to better the future for the next generation. That’s the only reason why my parents came here, so I could have a better life. You know, they largely succeeded on that. They didn’t, they went through a lot of sacrificies, it wasn’t like we were rich when we came here. You know, they, they were pretty, we stayed in a small studio, little apartment when we, they kind of worked their way up, but it wasn’t, it took many many many years before they were able to, you know, get a house, for example. So it was, I mean, we did, we struggled a lot in the beginning. And I think I can relate, relate to some of the other immigrant families who are kind of going through the same thing and I think, I mean, and especially nowadays getting—it’s just, it’s a weird time. I don’t know. It’s, it’s interesting, we all, I think, my parents dealt with their own kind of discrimination, but, but I feel like it’s just escalated now, it’s a weird, it’s an interesting time for you to be doing this project, because there’s so much tension right now, especially with—I feel like me being Asian, it’s like we’re kind of left out of a lot of this racial discourse, but, that’s a whole other topic that I won’t get into, but.
AS: ( )
SZT: Oh really? Yeah, so, but yeah I mean yeah, I feel I can really relate to a lot of the immigrant story just because I’ve been through some of it myself. But, I mean, we’ll see what the future brings, but right now, I mean, I feel like it’s gotten better, but right now, at this time, it’s kind of in a weird moment where we can either way, but, yeah, we’ll see.
AS: Yeah. Did your parents know any English before they came here, or have they learned it here?
SZT: They were—they did, and didn’t. And so my dad, my dad came first. He, his English wasn’t good, they had to learn a little bit, you know, but obviously his conversational English was pretty terrible. It took, I think it took him, he said that he practiced, oh what was it he, he practiced in front of his mirror like fifty-something times, where can I get a taxi? That was like the first thing he had to ask somebody, but he, you know, he’s like, he was a, top of his class, valedictorian when he was in China, but he was getting Cs, almost failing his classes when he came here because he couldn’t understand, so, but then, you know, he, they—my parents both were well educated, so they were able to eventually learn English and being able to get, get there, but it took a while. And they still, there’s still little things, you know, when you learn a new language in your twenties, it’s never gonna be perfect, you know, like if you learn it as you were a child. So, but yeah. They did, they were a little bit more fortunate, though ( ).
AS: Yeah, yeah. Okay, kind of a little bit of a different topic, [00:42:22] I think Bryan said when I was interviewing him that you had gone out with them before to the fields—
SZT: Oh yeah
AS: Yeah, could you tell me a little bit about that?
SZT: Yeah, yeah I’ve just, I’ve only gotten to go out with him once. We went to, we went to this one—we went to a couple families. One of them was, it was this—it was a migrant farmworkers who was, I forgot how, I think they were there just for a few months. Pretty modest, they lived in this, they all live in these little mobile homes. And, it was a great experience. Most of the time they just spent, we just spent kind of chatting with them about completely non-health related things and just kind of, they were just, we were just, you know, talking about their, I don’t know everyday, something, like they were making jokes and everything like that. But it was a great experience because you got to see how they lived, got to kind of see what kind of conditions they lived in. I think relatively speaking, I mean that’s a whole, a whole different topic too, but they have, there’s a lot, there’s been a lot of farmworkers that go through—I mean you know, there’s a lot of maltreatment in the history of that, where they’ve taken advantage of, where they don’t—they get pretty minimal payment for the amount of work they do. I think the different policies like that have changed a lot but, but yeah, I mean overall it’s like, they seem to have a pretty, I mean they all have a pretty modest living, but they, you know, they haven’t seen a doctor in many years, so I ended up trying to get them to come see us, but then it’s like being able to have them find a time to see us. They really, they usually, the only time they can come is on Thursday nights when they, you know, they can, they can, where they’re done with work. But, yeah, but I mean I really liked it, just to be able to kind of see how they’re living and kind of just chat with them, just see how they are. But, I mean it’s hard, because they’ll be in a, they’re away from their families for sometimes like a year at a time, but they’re all doing this just so they can bring money back to their family, so, it’s kind of cool to see that. They work extremely hard, so yeah, but, I mean, it’s a cool program, I think.
AS: Yeah, yeah, for sure. Sorry, I’m jumping all over the place a little bit here, the questions are just kind of popping into my head.
SZT: It’s okay.
[00:44:59] AS: Have there been any, I guess, immigrant stories that have been particularly difficult for you to kind of hear? Probably a lot, but I don’t know if anything sticks out.
SZT: Yeah, yeah. I think Melissa would be a great person to talk to about that, but I mean one time—well I had one, one lady come see me. She came to see me for an acute complaint, for something, I forget what it was, it was like, I don’t know, pain somewhere or was it, I don’t know, vaginal discharge, I don’t remember what it was, but it was one of those where I was running behind, per usual, was my, maybe like half way done, and there were patients waiting, and I was like oh this will be easy, I’m gonna get this done really quickly. And then, something didn’t feel right with her, I don’t know how, what it was, but just it was the first time I was meeting her but just something wasn’t right, and then, as soon as I was kind of done with her, I was about to, I wanted to just kind of get things done, but then, just noticing that there was, I don’t know, like there was something off. So I just kind of probed a little bit and asked her if there was something, you know, if there was anything else she wanted to talk about, what else is going on. And I, and usually, when I’m in a hurry I don’t ask that because I know I need to move along but with her, I don’t know. And then she just started bursting into tears. And then you’re like okay, now I’m screwed, like the rest of my day is done.
AS: Yeah, yeah.
SZT: And then basically she told me that they went to the—her and her family, her husband and her, their son, went to a beach in Myrtle Beach for vacation the past week. And then, her husband was basically just, their son was like five years old, and he peed on himself, so, accidentally peed on himself, so he was just changing his clothes on the beach. And then they said that when they were going back to the hotel there was cops there. And then apparently, they took, they basically took him in for questioning, said that somebody from the beach, or somebody reported that he was molesting this child or something like that. And, of course, there was a language barrier and blah blah blah, she was letting them know like no, this is his son, he was changing his pants. And, but somebody reported that they were, that whatever, and, and so, what ended up happening, they had to take him in for questioning with, go through his records, and they found out that he was undocumented, and then, now, he, basically they’ve detained him, and then were kind of in that process of getting him deported. All because somebody, somebody from the beach was, I mean, it was very very clear that he was his dad, and was doing that, but, I don’t know. And so, so she was really upset because she didn’t know what to do, and she was trying to, in the process of trying to get a lawyer, and trying to, but, you know, didn’t have the money to do that, it was just a mess. So, I don’t know, so that kind of stuck with me. Just like a nice little vacation and then having somebody say—accuse your husband of, of abusing your child, and then having, the next thing you know having him be under ICE detention and being deported, so, it’s like, I don’t know, it sucks.
AS: Yeah, yeah.
SZT: And she’s, and she’s afraid to do something about it because she’s also undocumented, so it’s like, a mess.
AS: Yeah, that’s, that’s pretty awful. Do you, you mentioned the time thing, having enough time to talk to the patients. [00:49:15] Do you feel like that’s an issue for you, not having enough time to be with each patient?
SZT: I mean, that’s, that’s a struggle. That’s a huge struggle in primary care because, you know, on average we get fifteen minutes for each patient and that’s literally impossible to get through any really, true visit, unless they’re, you know, they’re coming in with a cold, you can deal with that. But most people, most people don’t, don’t come in with just one complaint, especially, especially, and even if they’re Spanish-speaking sometimes it takes a little bit longer, you know, mostly just because there’s sometimes words that if I don’t understand I have to re ask them and things like that, but yeah. Or if they’re traveling so far and then they get here and, you know, you want to get all their complaints because you now they’re not gonna come back, and then you realize a lot of these patients don’t, aren’t able to, like having a visit to come is a big deal for them because of the, of a lot of the barriers that we already have talked about. So, you want to try to get, address all of their issues, but time is always, it’s always an issue. And I feel like, it doesn’t ever feel, you know, like you’re able to get everything done. You can’t, you can’t get anything done in fifteen/twenty minutes, I mean yeah, so. I mean the other day I had a twenty minute visit for a new patient who was in her forties. She was Latina too, and she hasn’t seen a doctor for twenty years. So, you’re like, great. And then her sugars were so high that you couldn’t read it on the, on the glucometer. She’s like, her sister brought her in and her sister tells me that she, she stopped speaking fifteen years ago, so this patient’s mute, so she can’t talk. And so you have no idea what happened, she can’t, she, yeah I don’t know, she just stopped talking, she just suddenly stopped talking. So you have no idea, and literally this was the visit. Like this [laughter], this patient just comes in and then, of course every single thing. Her blood pressure was messed up, her, everything was just, it was just a mess of a, a visit. That you can, twenty minutes for, fifteen/twenty minutes for trying to figure out all of those things and why she stopped talking. Later on, I found out it was trauma, actually, it was abuse by her uncle that we found out later on, with, through Melissa, but, with Melissa’s help. But this was after multiple visits, you know, so, but yeah, that is what we deal with, people that come in who haven’t been seen, so.
AS: Yeah. I think that is all the questions that I have, is there anything else that you want to add?
SZT: I don’t know—yeah, I mean, thanks for doing this project. [00:52:21] I think this is a very valuable, and I’m really happy that, that you guys are studying this, and that that will hopefully increasing some more exposure, understanding to the, to the, you know. I think, I just feel like there’d be so much more love and so much more relationships, or, I mean, communication between different types of people if we just had, if we were just exposed, or if—
AS: Yeah.
SZT: You know, people who, I guess, people who might have these types of biases, just kind of learn about their situation and then, yeah. I just think, we just, we would make a big difference, so.
AS: Yeah.
SZT: So I’m glad that you’re doing this project.
AS: Yeah, thank you so much for your time, for helping out.
SZT: Yeah, yeah. [00:53:17]
END OF INTERVIEW
TRANSCRIBED BY ANNA SILVER
12 APRIL 2018
