Health Matters: As county’s demographics change, immigrants struggle to access health care

Pa Ousman Joor, executive director of the Washington West African Center. (Photo by Kellie Schmitt)

The My Neighborhood News Network introduces “Health Matters,” a  five-part series focused on health topics in South Snohomish County and sponsored by the Verdant Health Commission.

At the Washington West African Center in Lynnwood, Executive Director Pa Ousman Joof often hears stories of immigrants who can’t access health care.

Community members without insurance fear crippling medical bills and end up delaying crucial care. Some people aren’t provided with accurate interpreters for their language needs. Others worry about cultural preferences, such as wanting to see a same-gender physician.

“There are huge disparities when it comes to health,” he said. “So many people in our community are struggling.”

As the population of Edmonds and the surrounding areas has shifted in recent years, new health care needs have emerged. In Snohomish County, about 17% of people were born in a foreign country, higher than the rates for Washington state as well as in the U.S., according to a 2023 community needs assessment. This growth underscores the importance of  identifying and addressing health care barriers and helping immigrant communities better access services.

“There is a growing diversity in our population across Snohomish, more than historically has ever been seen before,” said Tanya Baniak, a program planner for the county and a tribal member. “How do we start to build good, culturally appropriate systems, training and services that have better relevance for a diverse population? The question puts an onus on us to grow our own knowledge and practices that meet the diverse needs of the community.”

In the past decade, Snohomish County has experienced significant population movements. While 74.5% of Snohomish County residents identified as non-Hispanic white in 2010, that number dropped to 68% in 2020, notes a 2022 Community Health Assessment. By 2022, the number fell to 64%. During that time, nearly all other racial/ethnic groups increased.

“Our non-white, BIPOC population is growing, bringing diversity, breadth of experience and world views into our county,” said Dr. James Lewis, the county’s health officer.

Language interpretation needs soar

The community’s language needs reflect these changing demographics. Countywide, more than one in five people age 5 and older speak a language other than at English in their home, with Spanish the most common. Among the people using the most common 10 non-English languages, 44% report speaking English less than “very well,” according to the health report.

The variety of languages spoken reflects the region’s changes, too. In 2023, the Community Health Center (CHC) of Snohomish County provided interpretation for 91 languages. Along with consistent growth in Spanish-language speakers, which make up about 13% of patient languages, the CHC has also experienced upticks in patients from Ukraine and Afghanistan as refugees have relocated to the region.

In health care settings like that, it’s vital to offer robust interpretation services since language barriers can pose significant challenges to patient experiences, the quality of health care delivery and safety, numerous studies have found.

That’s why Edmonds resident Sebastian Metaute, a recent Edmonds College graduate who moved to the area from Colombia, said he prefers Spanish interpretation even though he speaks English.

“Because it’s health care, I want to be 100% sure what the provider is telling me,” he said. “If I’m not getting the jargon from the doctors, I will ask if I can I use the translators.”

But matching patients and interpreters can be tricky. Immigrants interviewed for this article described difficulties with imprecise translations as well as with finding people who speak their dialects in various health care experiences throughout the county’s hospitals and clinics. Others pointed to inaccurate language matches, such as offering an Arabic translator for a Farsi speaker.

Zenab Soumahoro (Photo by Kellie Schmitt)

Lynnwood resident Zenab Soumahoro, who previously lived in the Ivory Coast, struggled with a translator she couldn’t understand when she was hospitalized in 2021. At the time, Soumahoro said she couldn’t say even “good morning” in English. A friend from Madagascar offered guidance in her native French for an otherwise intimidating experience.

“When you’re not speaking the language, you’re more scared of everything,” Soumahoro said.

At the hospital, though, she couldn’t completely understand the supposed French translator and worried miscommunication would result in the wrong medication. She left, and waited for her friend to accompany her days later—even as her condition worsened.

Even if an interpreter uses the same official language, dialects can add important nuance, explained Awuor, an immigrant from Kenya who asked to use her middle name. Even though she’s been able to access Swahili in health care settings, there’s a difference between that language in distinct regions of Kenya. If the dialects don’t match, that can lead to imprecise interpretations. Awuor has also experienced cultural differences when it comes to seeing a provider.

“In my culture, we feel a woman should be attended by a woman and a man attended by a man,” she said, adding that she also feels uncomfortable seeing a young provider.

Adjusting approaches to care

Immigrant health needs extend beyond language to the way patients interact with physicians and medical staff. Providers are increasingly responding to the area’s changing demographics with culturally humble care, explains Kush Doshi, a program manager for immigrant and refugee health with Community Health Plan of Washington. That means approaching patients in an open-minded and engaging way, asking questions to learn about their culture – and its impact on their health care.

Kush Doshi (Photo courtesy Kush Doshi)

In his own life, health providers have helped him balance Western medical guidance with traditional Indian remedies. When Doshi saw a Sea Mar clinic provider for a sore throat, he shared his mom’s advice to consume turmeric. Together, he and the provider decided that he would try that home remedy first and return for medication if symptoms progressed. Similarly, when he had COVID-19, the provider was open to his idea of hydrotherapy such as using cold showers to adjust his body’s heat.

 “It’s allowing me to use my cultural values first, and if that doesn’t work, I can go back and ask for other options,” he said.

At the CHC in Edmonds, that approach is familiar to Dr. Douglas McMillen, the senior medical director. When a patient with uncontrolled diabetes refused insulin, McMillen tried to understand why he didn’t want the commonly used treatment. The patient described how his mother, who had lived in India, blamed the medication for her declining health and made him swear on her deathbed never to use it himself.

McMillen listened without judgment and then explored other options to treat diabetes—and whether these alternatives would be covered by the patient’s insurance. Trying to use medical facts to convince the patient of insulin’s safety wasn’t the best approach.

“It doesn’t matter – it’s what he had sworn to her,” McMillen said. “When people come from different cultures, and different viewpoints of medicine, they’re not always accepting of a Western perspective. We need to work with them where they’re at.”

Similarly, when patients need to adapt diets for health reasons, providers will try to understand what kind of changes make sense, vs. simply telling them how to adjust the menu. Providers also try to be responsive to how health care decisions are made in different cultures, such as inviting a full family into the discussion, or deferring to an adult child for guidance.

In immigrant communities, access gaps persist

A lack of insurance provides another health access challenge in many immigrant communities, including Hispanic residents. While the numbers of uninsured Hispanic individuals have steadily declined statewide in recent years, their rates are still about three times higher than non-Hispanic groups. Locally, these disparities are evident, said Marisol Bejarano, the director of health and wellness programs for the Lynnwood-based Latino Educational Training Institute (LETI).

In a recent survey of 420 local residents, LETI asked participants about the last time they saw a health provider. About 44% reported they had not been to the doctor in the last year. In Snohomish County overall, about 26% of people were unable to access medical care in the past year.

Marisol Bejarano, director of health and wellness programs for the Latino Educational Training Institute (LETI), speaking during a LETI-sponsored event in April. (Photo by Jasmine Contreras-Lewis)

“That’s just something that’s normal in our community and it shouldn’t be,” Bejarano said. “That gap is why a lot of our community is so impacted by diabetes, high cholesterol and high rates of chronic disease that we have to deal with.”

People without insurance are often reluctant to see a provider until they experience a health emergency, she explained. That delay can not only impact their health but lead to high medical bills and debt. Sometimes people don’t apply for Medicaid, the state’s health insurance for low-income individuals, even if they qualify. Misinformation and fear that the process may negatively impacting a citizenship application might dissuade people from applying.

“It’s something people are often unsure about,” Bejarano said.

That’s why LETI is promoting education and insurance applications in places where people frequent, such as churches or local fairs and festivals. The group often partners with Medicaid providers to set up booths and explain the process and qualifications.

“I’m a firm believer of coming to the community, where people are at,” she said. “Our community is busy and working, and going out of your way is hard. Coming to them is a good option.”

Community connections bolster mental health

Community gatherings can also improve mental health and ease the stress and anxiety that comes from moving to a new country, explains Ahmad Hilal Abid, who moved to South Snohomish County from Afghanistan and now runs a Lynnwood-based tutoring service called House of Wisdom.

The struggles inherent in relocation – especially among refugees—can create mental health struggles. For younger immigrants, it’s difficult to fit in when you can’t speak the local language and worry people might make fun of you, he explained.

House of Wisdom Founder and President Ahmad Hilal Abid greets a guest at the Edmonds Waterfront Center for the Ramadan celebration in March. (Photo by Nick Ng)

“You want to find friends, but when you have this language barrier, and people find it funny when we speak English,” he said. “You’re facing social anxiety and a lot of issues.”

A common medical recommendation for depression and anxiety may be to seek a therapist. That’s tough when you don’t speak English fluently, he said. Plus, there are cultural hesitations surrounding privacy and sharing personal experiences with a stranger in immigrant communities like his, Abid said.

Instead, Abid sees local immigrants bolstering their mental health through community connections. His organization’s tutoring work in places like Edmonds College helps create a space for people to connect and relate – improving mental health in the process. Gathering with others to share cultural experiences can help too, such as a recent Ramadan celebration at the Edmonds Waterfront Center.

“We all came together to celebrate and we learned about each other,” he said. “Their cultures are being appreciated and welcomed.”

Organizations strive to improve immigrant health

From the medical setting to public health outreach and data collection, the community is responding to the populations shifts – and the changing health needs.

At Edmonds’ Community Health Center, staff arranges in-person interpreters for prescheduled appointments, McMillen said. As technology has improved, the clinic has also increased the use of video interpretation services. Medical assistants typically start video conferences before the provider enters the exam room so that it doesn’t slow down the appointments. Even so, rarer languages like Mongolian can require additional legwork.

In hiring, the group offers an extra stipend for staff and providers who can speak another language. Another operational shift: The organization is offering health services in the community, from shelters to school-based health centers at places like Meadowdale High School.

Community Health Center of Edmonds Medical Director Dr. Doug McMillen at the Edmonds clinic. (Photo by Nick Ng)

“We’re working to bring care more to where people are,” McMillen said.

For the Snohomish County Health Department, the pandemic provided many lessons in outreach, such as the importance of partnering with trusted community organizations. Efforts like vaccine outreach paved the way for better understanding how to reach people, like using radio to share health information in Spanish-speaking communities, Lewis said.

Data collection is also important for pinpointing communities that have pressing health needs and directing resources there, said Jennifer King, a county human services specialist. Understanding where people come from can help health leaders provide materials and resources in residents’ preferred languages. While data can help educate outreach, numbers alone don’t tell the full story, acknowledged Baniak, the county program planner. Fear and mistrust can influence whether someone even participates in data collection and U.S. Census requests in the first place.

This summer, a significant change to the state’s health care landscape could impact many local residents’ ability to get free or low-cost health insurance. Washington plans to expand Apple Health to thousands of undocumented immigrants who qualify.

For community members at the West African Center, creating more access to affordable health care is urgent, Joof says. Despite positive strides in areas like cultural humility and community outreach, immigrants still face tremendous health hurdles when it comes to paying for care.

Joof thinks about his sister, who has navigated a patchwork of sliding scales at clinics and charity care and his mother, who moved to the area about one-and-a-half years ago and has struggled to access health care. Without consistent affordable care, his mother’s advanced arthritis has worsened. When deciding between shouldering a hefty bill and taking care of health, too often people forego care.

“We’d rather sit and get really sick and let our health deteriorate, then go to the hospital,” he said. “Insurance is key for members of our community and it’s hindering our access to health care.”

For More Information

Check out the following websites to learn more about immigrant services and health care:

Refugee & Immigrant Services Northwest (RISNW)

The Snohomish County Health Department’s Refugee Health

Washington State Office of Refugee and Immigrant Assistance

Immigrant and Refugee Health Alliance 

Guide to Health Insurance for Immigrants in Washington State 

— By Kellie Schmitt

Kellie Schmitt is an award-winning health reporter based in Edmonds. She covers health policy, public health and children’s health for a variety of publications including the Johns Hopkins University Public Health Magazine, ParentMap, and USC’s Center for Health Journalism. She has a master’s in science writing from Johns Hopkins University.

This series is supported by funding from the Verdant Health Commission. The My Neighborhood News Network maintains full editorial control over content produced as part of this series.


Leave a Reply

Your email address will not be published. Required fields are marked *

Real first and last names — as well as city of residence — are required for all commenters.
This is so we can verify your identity before approving your comment.