The screening process for refugees entering the U.S. involves multi-layered security checks, interviews, and an overseas medical exam. After their arrival, families will undergo another health assessment, usually coordinated by a resettlement agency.
It’s where their stories begin to unfold to the doctors and physicians-in-training at Yale University's Pediatric Refugee Clinic.
Mom, dad, and doctor huddled with a teary-eyed five-year-old boy in a small exam room with soft yellow walls. Like any child who just got his vaccine shots, he has a sore arm, and he’s ready to go.
"I promise the next visits that you have will be a lot shorter than this," said Dr. Camille Brown, the director of Yale’s pediatric refugee clinic. The boy was from Afghanistan, and had arrived in New Haven 10 days earlier. He was given a clean bill of health.
"All his other immunizations are up to date, which is great. His vision’s fine. His hearing passed. We have no mental health concerns about him," said Brown.
Children are also tested for infectious diseases – things like tuberculosis and parasitic infections. Their growth and dental care are charted, which is not too uncommon for a child born in America.
But the boy's father, Mohammad Daad Serweri, said it’s nothing like what they got in Afghanistan.
For one thing, the doctors here ask a lot more questions.
"Where he was born, and what kind of medication he took, and with what kind of people we lived with," said Serweri. "The members of even our family -- in case they had some sort of illness that affects our son. The hair, even the eyes, the ears – thorough checkup, a thorough medical assessment. We found ourselves so lucky."
These refugee health assessments take time and require cross-cultural medical knowledge.
For instance, refugees from Afghanistan often have high levels of lead in their systems. As in many developing countries, cars in Afghanistan run on leaded gasoline.
And lead is also used in eyeliner, Brown said, often applied directly to the mucosal surface of the eye. The eyeliner "is made out of stibnite. So they ground the stone, and then because there’s so much lead, they have contamination with lead," she said. "So we see some high leads coming from Afghanistan."
Vitamin D deficiencies are also common, but not just due to diet. Girls who wear a hijab aren’t always exposed to enough sun, and children who live in war zones can’t often play outside in the daylight, robbing them of Vitamin D.
But it robs them of something else, too. Serwari said his son is terrified by the sound of sirens, because back home, that means bombs.
"We try to convince him that here, there is no explosion," said Serweri. "Nothing. Those are some police cars that are going somewhere from one location to another location."
Brown said it’s important to hear these stories in order to get the full picture.
"The health of the child is in the context of the whole family," she said. "So we may be asking some hard, or some personal stories about what their experiences are, but that helps to give us that cultural context, and then we can start to see the child -- the child’s health, the child’s mental health, their whole well-being."
That's why Brown encourages medical residents, who will become the primary doctors for the children, to get to know their patients first, before talking about health care.
But even with trained medical interpreters, cultural and language barriers can be difficult.
"I think learning how to deal not just with families with different cultures, but different educational levels," said Brown. "How we’re presenting our idea, or our word, that doesn’t have a similar word in their language. We, as doctors, have to break down our medical jargon into: what do we mean when we’re saying this? Even a word as simple as development."
Swati Antala is a third-year resident at the clinic. She said sometimes the patients and their stories stay with you.
She remembered a patient from Syria.
"It was a 10-year-old boy, and he basically said, 'I could count the number of happy days I’ve had on one hand,'" said Antala. "That was really sad, but it was really also uplifting to see how excited he was to be here, and how much he was looking forward to starting school, and making friends."
The clinic stays involved in the families’ lives, helping them navigate the health care system.
Medical residents advocate for the children at school, if necessary, and they set up future preventative appointments – a new concept for most refugee families that only saw a doctor if their child was sick.
Brown said she's amazed at the resilience of the refugees.
"They're here trying to give a new life to their children and have the family, and especially the children, move beyond the trauma and the terrible situations that they’ve been exposed to," she said.
Yale’s Pediatric Refugee Clinic saw more than 150 children last year from 10 different countries.
As for the five-year-old with the sore arm, he went home from the clinic with an ice pack and a new toy truck.