Rounding in the Morning, News in the Evening
by Tessa Adzemovic, 2022 Medical Fellow
When I was little, my family’s living room TV was always turned to CNN. My parents watched from our one-bedroom apartment in Toronto as their home city, Sarajevo, burned to the ground. Meanwhile, only three years old, I begged to put on Sesame Street. My parents, Bosnian immigrants who moved to North America in the 1990s, built a new world while their old one crumbled. I grew up in this so-called “new” world, with the knowledge that the rest of my extended family was living in the other.
Now, I am a third-year resident in Medicine and Pediatrics at the University of Michigan in Ann Arbor. In August of last year, the state of Michigan began to welcome new arrivals from Afghanistan—individuals forced out of their home country by the Taliban. My continuity clinic, located in a small shabby building on a historical street in the city of Ypsilanti, Michigan became the primary care site for many of them. In Afghanistan, only 17% of the country’s 2,300 health clinics are currently functional. What that means is that many of the Afghani refugees who are resettling in Michigan have never been seen by a physician. I, in other words, have the great privilege of being their first doctor.
The Afghani adolescents I see in my clinic remind me of my cousins still living in Bosnia. They were stripped not only of their high school education but the important memories that come during that time—first kisses, high school dances, soccer games.
Recently, one of my patients proudly showed me his transcript from his high school in Kandahar province. “93%” he stated, signifying his approximate grade point average. I responded by telling him he should go to college here, and he stated, “I will.” Another patient of mine is a young woman from Kabul who speaks four different languages: Pashto, Dari, Uzbek, and Farsi. She explained to me how she gets abdominal pain when she gets angry. She told me keenly, “this is somatization”. She worries daily about the mental health toll this crisis will take on all Afghani refugees.
Meanwhile, I worry about the clinical care I’m providing to my new patient panel. Or more frankly, I carry a serious ethical concern regarding how to provide complete, culturally humble, and empathetic care to these non-English speaking populations.
Most of my patients now speak Pashto or Dari, languages I do not. In clinic, we use phone interpreters—but with the influx of patients, these phone interpreters are in high demand and sometimes, we can’t get a hold of one. In these situations, if I am lucky, a family member speaks English, presenting another ethical dilemma: how can I ask a daughter to translate to her father, “are you sexually active?”. If I am unlucky, it means examining a patient without being able to fully explain the care they are receiving—imagine performing a pap smear and having the interpreter call drop halfway through. Just the other day I spent half an hour trying to obtain a history on a seven-month-old with acute otitis media—only to realize that the interpreter and my patient’s mother spoke completely different dialects.
These questions of language and interpretation, however, are still overshadowed by the challenges surrounding cultural humility and understanding.
This past winter, I had a twelve-year-old Afghani refugee come into clinic with her mother for a well-child visit. After I had stepped into the room and introduced myself, her mother asked me to examine her daughter’s hymen. She explained to me that this was important to her faith community, that if her daughter’s hymen were torn, she would never be able to get married, as the implication would be that she was no longer a virgin. When I began to explain that a hymen can be broken without the act of intercourse, she said it didn’t matter. I developed a cold sweat, wondering if I were missing something. I declined to do the exam and then spent the rest of the evening wondering if I had ruined any and all possible rapport with the family. I would later learn that the UN had recently come out against this so-called virginity testing, in a global call to end violence against women and girls. There was no class in medical school on this; I worried about what other things I could be doing wrong, things I could possibly be missing.
Many of my new patients have not received medical care in years, as seeking it would have meant risking their lives. I perform well-child visits that often feel irrelevant (“do you have a car seat?”, I ask. “We don’t have a car,” they answer). During my intake visits, I cover a miniscule amount of what I feel I should. How could it be otherwise at a busy clinic with limited resources operating according to market logic? My appointments are scheduled for 20 minutes. Spending more time with one child means less time with the next. It doesn’t just mean sacrificing listening to stories and offering empathy, it often means prioritizing only necessary vaccines and prescriptions. It is an ugly and inevitable truth.
But most of my training has not been in this fast-paced ambulatory setting; rather, it has been under the canopy of my large pediatric hospital, the same hospital where I first learned the language of medicine as a medical student. During my first two years of training, the hospital became a sanctuary: spending 70-90 hours a week there, my days on service still consist exclusively of eating, sleeping, and taking care of my patients. I reveled in how the white walls and fluorescent lights immersed me, in its ability to let me let go of everything that did not reside within its walls.
It’s easy to recognize both the beauty and the danger of this.
After the pandemic cast a shade on my internship year, I dove deeper and deeper into that sacred space to absolve myself of my guilt for ignoring the other things, things that felt too large and too painful: global vaccine inequities, increasing pediatric gun violence, and the racially skewed infant mortality rate in Michigan.
In no uncertain terms, the hospital had become my real-life Sesame Street, a way to ignore the frequent injustices on the outside by making small fixes on the inside. My mother, an architect, once referenced an ABC 20/20 special filmed in 2001 about a surgeon couple who didn’t know who was running for president during the Bush v. Gore election. She used this story to point out an embarrassing reality: that either intentionally or unintentionally doctors often lose sight of the world around them. I took a silent vow to myself that I would never be this way, and yet here I was, focusing on supplementing potassium, while suicide rates for adolescent populations were at an all-time high.
My Afghani patients reminded me on a weekly basis, however, that ignorance was no longer an option. Soon, they were being admitted to my safe haven, the hospital, which for them was anything but. This past winter, a three-year-old patient of mine was admitted to our community hospital. In referring to him, one provider said, “It appears the pediatrician and the patient’s family have been unable to get in touch since the patient’s initial visit because the pediatrician didn’t have the family’s contact information and the family didn’t have the pediatrician's contact information.” After his discharge, I called repeatedly and was never able to reach them. I worried—had they been relocated (several families were moved from one resettlement center to another)? Had they switched pediatricians (I swallowed my pride)? Or did they just not have the resources (a phone, transportation) to come in?
Then it was February 2022, and after seven years of war, Russia invaded Ukraine. On March 10, there was an attack on a Women’s and Children’s hospital in Mariupol—a hospital hardly all that different from mine. The attack left three people, including one child, dead. The footage reminded me of reporting in Sarajevo from thirty years before, memories I wasn’t sure I owned myself or if I had adopted through hearing about them throughout my childhood. A picture of a Bosniak pediatric surgeon carrying a child out of a burning building remained seared into my mind. It reminded me of the stories my Afghani patients told about standing at the airport waiting to be evacuated, stories they are now starting to chronicle.
What I realized was that the hospital could no longer be my sacred space, that “never again” cannot truly be never again if physicians are not taking an active role in the protection of their patients both inside and outside of the hospital walls.
The remedy lies in working toward systemic change, assembling physicians to advocate for our refugee populations. It is my individual responsibility to ensure I have learned, to the best of my ability, about Afghanistan's geopolitical context as well as medical practices. It will mean many uncomfortable and humbling moments and it will mean striving tirelessly to provide the most compassionate, ethical care possible. It will be a lifetime of trying to implement appropriate policy and protecting healthcare for all, recognizing that healthcare is a human right no matter where you are from, what language you speak, or the color of your skin. Ultimately, it’s the physician’s prerogative, our communal service: we must not absolve ourselves of the duty to be informed; we must attempt to bend existing social assumptions. As Mohsin Hamid’s Exit West so firmly attests, “everyone migrates, even if we stay in the same houses our whole lives, because we can’t help it. We are all migrants through time.”1 It is our common humanity that begs us to remember that genocide can be stopped, that health is more than what happens in the hospital, that mortality rates are largely governed by the world outside of the clinical domain.
Now, while on service in the hospital, my Daily CNN Top 5 e-mail newsletters pile up in my inbox as clinical pages come through to my phone. But rather than beg not to watch the news, I recognize that this is exactly what I signed up for—rounding on patients in the morning and watching the news in the evening. These two activities are inextricably linked. The inside and the outside cannot be disentangled. As Dr. William C. Bell said in a 2011 speech, “We cannot rest until all children are well; we cannot be satisfied until all children are well; we cannot say my family is OK until all children are well.”2
Tessa Adzemovic was a 2022 FASPE Medical Fellow. She is an Internal Medicine-Pediatrics resident at the University of Michigan.
- Hamid, Mohsin. Exit West (Riverhead Books, 2017), 221.
- Bell, William C., “Keynote at the 2011 Latino Health Access Tamalada,” https://www.casey.org/lha-celebration/.