‘My heart it is delicious’

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Book tells stories of refugees and cross-cultural health care

It’s a beautiful book. The cover is interesting and makes you want to look inside, where thick, glossy pages of text are interspersed with arresting images. The oversized hardcover volume looks, at first glance, like a “coffee table book”-one of those volumes that are long on good looks and short on substance. But read more than a paragraph and you’ll discover that nothing could be further from the truth. The real beauty of “My Heart It Is Delicious” are the poignant and mesmerizing stories of refugees, interwoven with the fascinating story of St. Paul physician Patricia Walker and St. Paul’s Center for International Health.

Author Biloine W. Young knows how to tell a story and this book is stuffed full of them. “This is the story of what a few committed people can do,” Young said. She weaves complex material and human stories without once losing the reader’s interest in the inspiring tale of how Minnesota medical professionals brought home from a refugee camp the knowledge about how to transform cross-cultural health care.

Going home
So how did a Mayo medical student end up in a Cambodian refugee camp? Blame it on Susan Walker. When she heard the news that Cambodians fleeing Pol Pot’s genocidal Khmer Rouge government were flooding into Thailand, she called her younger sister, Pat, the medical student.

“Susan told me that three-quarters of a million refugees were flooding into Thailand, and the American Refugee Committee (ARC) was organizing a medical relief team to help the refugees,” Pat Walker recalled. “You’ve got to go,” Susan told Pat.

Pat Walker didn’t hesitate. She picked up the phone and called the new Minneapolis-based nonprofit. She was, she explained, a third-year medical student whose main contribution would be that she knew Thailand and spoke Thai. The ARC manager told her she was on the team. “ARC was so small at the time that they didn’t even have money in the bank to pay for our tickets back,” Walker said.

When the team of 15 medical professionals-seven doctors, six nurses, a paramedic and Walker-landed in Thailand in late November 1979, it was 100 degrees. For the young medical student, it wasn’t like going home-it was going home. Walker, born in Taiwan to American parents, lived in Bangkok until she was 11. Walker’s father was chief pilot for Air America, the airline run by the CIA.

The ‘ARC 15’
The group that called itself the ARC 15 made personal sacrifices to make the trip. One of the nurses was a newlywed with a young child; she had never been outside the U.S. A doctor who was new to his job was nearly fired when he informed his boss he was taking a leave of absence. Walker herself had to twist the arm of her medical school dean-the school had never before allowed a student to do overseas volunteer work. But of course the team’s circumstances paled in comparison to the needs of their Cambodian patients, many of whom were starving to death. Others had malnutrition-related and tropical diseases the westerners had never seen. Leprosy, pellagra and beriberi were common. Young patients suffered from heart failure due to vitamin B deficiency.

When the camp’s population swelled to a staggering 135,000 refugees, the ARC 15 realized they needed to do things differently. “We couldn’t help everyone … and what would happen after we left?” They began to train Cambodian refugees to become medics, and transformed the camps’ medical care delivery system.

When ARC 15 member Neal Holtan, M.D., arrived home after a few months to his job at the St. Paul-Ramsey Medical Center, he saw a medical system ill-equipped to deal with refugees who did not speak English and whose cultural differences and non-western health concerns made providing care chaotic. The hospital’s medical director agreed that things needed to be done differently. The Center for International Health was established, with Holtan as its director.

The Center for International Health
Meanwhile, Walker completed medical school and started working in hospital emergency rooms. She was getting ready to go back to Thailand to work in Cambodian refugee camps when Holtan, her ARC 15 colleague, told her he wanted her to work with him. She agreed to join the Center for International Health after working in Thailand for a year.

When Walker arrived back in Minnesota in the summer of 1988, she sponsored a Cambodian medic and his brother, who would live with her while they got their feet on the ground. She walked into her new job at the Center for International Health expecting to learn from Neal Holtan. Instead, he told her that he had decided to step down as director-and named her to take his place.

Nine years later, Walker remains the director of the Center, which is now a HealthPartners clinic. Her patients had illnesses, such as parasites and tropical diseases, that western doctors were frequently unprepared to deal with-and often misdiagnosed or missed altogether.

Along with her work at the Center, Walker wears several other hats; one is that of an associate professor of at the University of Minnesota medical school, where she teaches about international health issues. She has seen patients’ lives endangered by missed or misdiagnoses. “That’s why I was interested in starting the global health pathway,” Walker said. “[A physician] may not know every disease from every country. You have to know you don’t know it.”

The challenges posed by language barriers and cultural differences are as great as the medical issues. In the early days of the Center, children, who tended to learn English faster than the adults, were often relied on to translate between parents and doctors. “Children couldn’t understand or explain complicated medical diagnoses,” Walker explained. “A recent study at Yale showed that 58 percent of white English-speaking American adults misunderstand hypertension as [being] easily upset. How can we expect children to interpret complex medical problems? Imagine a 13-year-old child thrown into the mix, being asked to interpret her mom’s medical pain and then having to explain [the mother needs] her uterus taken out.”

When Walker joined the Center, there were four translators on staff; today, there are 10, many of whom were refugees or immigrants. Many more are on call, and the clinic has access, via phone, to translators of more than 80 languages. According to Conni Conner, Walker’s assistant, “We have speaker phones in the exam rooms and translators are accessible within 5 minutes of being called.”

Respecting and honoring cultural differences are at the heart of the care the Center provides. “Pat knew [from the beginning] the importance of treating [immigrant] values with respect and understanding,” Young said.

Other physicians don’t always feel the same way. Sometimes a simple lack of knowledge causes problems, such as the male doctor who horrified a Somali woman by trying to shake her hand (in Somali culture, when a woman gives her hand to a man, she is giving herself to him). Other times it’s a lack of respect: When a surgeon, frustrated about his patient’s repeated questions about a proposed foot amputation, told the man not to come back until he was ready to have surgery, Walker found him a more patient surgeon. Understanding these differences, Walker said, is key to providing health care that is both effective and culturally competent.

A good match
In addition to her work at the Center and the University of Minnesota, Walker is an internationally renowned tropical medicine specialist, she directs HealthPartners’ International Travel Clinic and sees patients at Health-Partners’ Health Center for Women. It was there that she met St. Paul author Biloine Young-Walker is Young’s doctor-and the two women talked for years about the book that became “My Heart It Is Delicious” before it became a reality. It is a good match, the writer and the healer. For Young, one of the most meaningful parts of working on the book was meeting the people whose stories she tells. “I’m a storyteller in the journalism tradition,” Young said. And even though Walker has become a respected expert in her field, Young said, “Pat Walker is still that kid who went over there [to the refugee camps]. She has a passionate belief in immigrants.

“She understands that [the U.S.] is not the center of the world.”

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