EL CAJON, Calif. — In his native Syria, Mahmoud spent months in captivity in a crowded room three floors underground, never seeing the sun. Disease spread quickly among the prisoners, he said. Food was scarce, often spoiled.
Mahmoud said his captors, foot soldiers of Syrian President Bashar Assad, tortured him and shot him in the leg.
“I was in jail for seven months. They let me go, but I was physically sick and tired,” the 29-year-old refugee said, speaking inside a cheerful, modern medical clinic with signs posted in English and Arabic. “I had infections, inflammation. I’m still trying to get treated for it all.”
Mahmoud, tall and friendly, agreed to be interviewed on the condition only his first name be used for fear of retaliation against family back home. He settled in one of the largest Syrian refugee communities in the U.S. — a midsize California town near San Diego.
By virtue of this influx of refugees, the town has become a health care hub for a traumatized and physically ailing population.
The bustling El Cajon Family Health Center, which serves Mahmoud and other victims of Syria’s devastating civil war, sits on an old-fashioned Main Street among Western-themed murals, thrift shops and halal markets.
Syrian refugees struggle disproportionately with post-traumatic stress disorder, anxiety and depression because of their exposure to extreme violence and anxiety about relatives still in Syria, clinic staff and community volunteers said. Most who fled spent years holed up in camps or apartments, with little access to routine medical care for war wounds or chronic conditions such as diabetes and heart disease.
Virtually all the people who enter this country as part of the federal government’s refugee resettlement program qualify for Medicaid, the government-run health insurance program for low-income people known in California as Medi-Cal.
Physicians and others who work with Syrian patients said the refugees experience long waits and must often travel long distances to see specialists — challenges shared by many other low-income groups.
But access to medical interpreters is woefully insufficient and refugees are often stymied by paperwork and bureaucracy so unlike what they had back home. There, they were accustomed to walking in and seeing a doctor without having to wait, Suzanne Akhras Sahloul, founder of the Syrian Community Network, a Chicago-based nonprofit that aids refugees, said.
Patients are often confused by Medicaid and the managed-care plans that provide it. They sometimes switch health plans inadvertently, which can lead to delays in care, El Cajon Family Health Center physicians and caseworkers said.
Over 1,000 Syrian refugees, more than any other U.S. metro area, have resettled in San Diego County as of the first quarter of 2017, according to the State Department. And more than 80% of them live in El Cajon, where county service providers and resettlement agency offices abound, said Chris Williams, executive director of the Syrian Community Network-San Diego, a local branch of the aid organization.
Resettlement agencies, which work with the State Department to smooth entry into the U.S., generally help refugees sign up for Medicaid and get the care they need for their first three months in the country. After that, they are largely on their own to maintain coverage and get care.
“They will say, ‘Why do I need to visit the family doctor? Why can’t I go to the specialist?’” Aileen Dehnel, a case manager at the El Cajon Family Health Center, said.
“Everywhere we go, people are helpful,” Mahmoud, who now lives in Anaheim, California, said. “But the No. 1 challenge is the language.”
Relatively few trained interpreters in the area speak Arabic, and they are in high demand. In a communication vacuum, Mahmoud said, information gets passed from neighbor to neighbor, changing slightly with each telling as it would in a game of telephone.
“We don’t know what’s going on,” he said.
Translators don’t always help, he added. One time, Mahmoud had to rush to the emergency room after a gallbladder attack, where an interpreter on the phone kept asking everyone to repeat themselves and blamed the difficulty on bad audio equipment. Mahmoud and his wife, Noura, became so frustrated she used Google Translate to figure out what the nurses and doctors were saying. (Noura also spoke on the condition her last name not be used.)
Another refugee, 34-year-old Nisreen Tlaas, recalled having fainting spells after her arrival from Homs, Syria, in 2016. Two emergency rooms misdiagnosed her illness before the staff at a third hospital performed an MRI and saw an aneurysm in her brain.
She finally received lifesaving surgery, but only after a caseworker from the Syrian Community Network smoothed communications between a surgeon and a medical interpreter.
Dehnel, of the El Cajon Family Health Center, said she writes detailed instructions in Arabic for the patients she works with; many pharmacies in El Cajon now print prescription labels in Arabic, too. But that’s not enough to make sure a diabetic patient gets his insulin or a pregnant woman takes her prenatal vitamins correctly, because many of the patients can’t read in any language, she said.
Language frustrations aside, the main challenge facing many Syrian refugees is psychological distress.
PTSD among Syrian refugees contributes to physical symptoms such as chronic pain, Dr. Mai Duong, a family doctor at the El Cajon Family Health Center, said.
Some patients have seen relatives hurt or killed in fighting. Others don’t know if their friends and family are safe. Syria is among the countries affected by the Trump administration’s travel ban, though the administration is now cracking down on refugee admissions in general.
Adjusting to life in the U.S. can also cause enormous anxiety. But many Syrian refugees resist asking for help for fear that authorities will swoop in.
“People always downplay their distress,” Duong said. “They worry that their kids will be taken from them.”
Mahmoud has tried talking to psychologists, but they haven’t been able to help him escape his dark thoughts.
“Our families are in a war zone right now,” he said. “I’m always in fear that my family will be killed.”
This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN is not affiliated with Kaiser Permanente.