Care Beyond the Clinic

Six people were seated at a table in a bright, modern room on the second floor of the public library in Lawrence, Massachusetts. For generations, Lawrence has been a city of immigrants—with successive waves of newcomers arriving from such countries as Ireland, Canada, Poland, Lithuania and, more recently, the Dominican Republic and Puerto Rico. One place that has not tended to send people to Lawrence, though, is Haiti. And that, in a way, is why the people around the table were at the library on this night.

The five women and one man were all Haitian refugees who fled their homeland following the massive earthquake in 2010 that killed 230,000 people, injured another 300,000 and displaced a total of one million. In Lawrence, a city of 80,000 people, they were part of a community of just a few hundred, culturally isolated and speaking Creole, a language that is seldom heard in their new home. So there they were at the library, learning to speak English as part of a program organized by, of all things, a health clinic.

Joseph Gravel Jr., A82, M86, an adjunct professor of family medicine at Tufts, serves as the chief medical officer of the Greater Lawrence Family Health Center, an innovative community resource that opened up in this economically depressed city in 1994. Through its six bustling clinics, the health center tends to 56,000 patients per year, or about two-thirds of the city’s population.

“There’s a real sense of mission here, and of deep purpose,” Gravel said. The health center, in turn, is the parent organization of the Lawrence Family Medicine Residency, a highly selective four-year residency program directed by Wendy Barr, M99, who took part in the residency in 2002. The program recruits and trains medical school graduates from around the country for careers in community health.

One of these residents, Clark VanDenBerghe, had the bright idea of creating a weekly English class to help local refugees thrive in their new milieu.

Leading the hour-long class was Anthony Cimea, a 26-year-old native Creole speaker who was born in Haiti and came to the United States with his family at age 9. “You are walking down the street,” Cimea told the group. “A person says, ‘Hi, hello,’ really informal; you say back, ‘Hi, hello.’ Repeat it back to them. You may hear, ‘How are you?’ Then you say, ‘How are you?’” Cimea looked at his students and said, “So do that—practice these little conversations.” With that, everyone began talking at once, practicing their inflections.

A Mormon, VanDenBerghe was on a two-year mission in France as a younger man when he encountered Haitians for the first time. He said he immediately fell in love with their warm, open-hearted natures. So after completing medical school at Northwestern, and eager to extend and deepen his connections to the community, VanDenBerghe applied for a spot at the Lawrence Family Medicine Residency program and was accepted into the program as a member of the Class of 2017.

Upon his arrival in Lawrence, VanDenBerghe began seeking many Haitians out as patients. Fluent in Creole—the native language of Haiti—he said if he hears someone speaking Creole on the street in Lawrence, “I’ll go up to them and give them my card.” He estimated that as many as 60 Haitians in the city, or about 20 percent of the total number, are now his patients.

VanDenBerghe also approached the three Haitian churches in the city and asked the congregation what they wanted most—an excellent question to pose in medicine or in life. Their answer: to learn English. So VanDenBerghe approached the library, which had already taken some steps in that direction, to set up the weekly lessons. Cimea was hired to teach the classes. (Subsequently the language classes at the library were discontinued.)

Top-Tier Residency

The Haitians in that class were all people of modest means whose lives were torn apart by the earthquake. They had landed in a hollowed-out mill city in northeastern Massachusetts dominated by immense brick buildings, once booming textile mills, now largely vacant, that flank the Merrimack River for several miles. As refugees of a natural disaster, they were doing the best they could, struggling to comprehend verb tenses, colors, seasons, hot and cold, days of the week and everything else that comes with a new language, a new culture and an abrupt change in geography.

It was a classic immigrant story. The Haitians said they wanted to be able to greet their neighbors and understand the bills that come in the mail. They wanted to get jobs. They wanted their children to respect them more.

A huge number of people in Lawrence have been struggling to fit in since the first millwheel began to turn; they don’t call this the City of Immigrants for nothing. By 1860, the town’s population was 17,639, and 42 percent of residents were foreign born. That included a large contingent of Irish workers who presumably had fled the potato famine back home. In 1890, the population was 44,654, with 45 percent foreign born. In 1990, the immigrant segment was about the same, at 41 percent, although the home regions for those unpacking their bags in the town’s tenements had shifted from Europe and Canada to the Caribbean and Central America.

By 2015, about three-quarters of the population was Hispanic or Latino, with new residents arriving mainly from Puerto Rico and the Dominican Republic. Lawrence now claims the nation’s second-largest Dominican population, after New York City. And as has so often been the case when immigrants first establish roots in the U.S., a large percentage of the children, about 40 percent at last count, are living in poverty.

In a challenging circumstance like this, the Lawrence residency program has made a name for itself. Among people who have graduated from medical school and want to work with underserved populations, Gravel said, “we are in the top tier in the country.” When it first began, the Lawrence program was the nation’s first accredited family-medicine residency sponsored by a community health center. Now, for its eight openings for residents each year, the program receives a staggering 700 applications, a matriculation rate of about 1 percent.

The program is not kidding about community engagement. Because most Lawrence residents speak Spanish as a first language, new arrivals at the residency program are routinely sent to Dartmouth College for 10 days to cultivate their skills in Spanish. The outreach never really stops. Lawrence doctors-in-training have, among other efforts, sponsored a health clinic at the high school and worked with the local YWCA to promote mammograms among Hispanic women. “You can’t just address things in the clinic,” Gravel said. “You have to get outside the clinic. What Clark’s been doing [by launching the English class at the library] is not aberrant, but typical.”

The Hope of Immigrants

In the library, Cimea told his students, “When in doubt, just sound it out. YELL-ow. YELL-ow.” On this evening, a quiz was scheduled for the seven students in attendance (a tall, shyly smiling man wearing a Red Sox ball cap had newly joined the group). One of the class members finished the exercise early and came over, with Cimea acting as interpreter, to tell me about her life.

Her name was Agathe Bellevue, and she was 37 years old. She had a 16-month-old daughter. Her husband, the family’s only source of income, worked in the kitchen of a nearby nursing home. She’d been in the United States since late 2013, when she and her husband fled Haiti. “She had a fear of being kidnapped by gangs in the streets,” Cimea translated. It occurred to me that for all the media coverage that poured out of Haiti in the weeks and months following the earthquake, this was a story I hadn’t heard.

The earthquake did more than destroy structures—in Bellevue’s hometown of Léogâne, near the epicenter, 90 percent of the buildings were reduced to rubble and an estimated 30,000 people died. It also flattened the existing social order and brought on another kind of ruin. “My husband said, ‘We have to get out,’” she recalled. And this harrowing experience was more than hers alone.

VanDenBerghe told me that all of his Haitian patients suffer from PTSD. When I asked the class if they had been living in Haiti at the time of the earthquake, they all nodded their heads, but when I asked what they remembered, they fell silent. Bellevue eventually spoke up. She said she didn’t want to talk about that because it brought back such feelings.

Against this backdrop, it was easy to see how the residency program’s simple gesture of offering to help bring these refugees a step closer to American culture, even for an hour, was seen by them as so valuable. When I inquired how welcome they felt in America, they nearly cried. “Oh, this country, everybody welcome you; they put their arms around you. They say hello; they want you to do well, like Dr. Clark,” Bellevue blurted out, glancing toward the young doctor, who stood nearby.

Part of the emotion may owe to the fact that even in their home country, Haitians don’t always feel welcome. In a strange way, collectively, they are no strangers to the degraded-outsider status that refugees sometimes feel in America. VanDenBerghe explained that on their home island of Hispaniola, which includes both Haiti and the Dominican Republic, Haitians are being persecuted in their neighboring country.

He saw this firsthand on a recent trip there. “If you’re in the Dominican and you have darker skin, they’ll call you Haitian, and it’s meant as an insult,” he told me. “There’s an undercurrent of racism. In the past few years, police will drive around, watch for people who look Haitian, then pick them up to send them back to Haiti.”

How do you persevere through something like that—through persecution, natural disaster and starting over in a new place? At the conclusion of the first class I attended, I was talking quietly with Cimea and heard a sound beginning very low, just behind me. The six Haitians were standing around the table where they had just been concentrating so hard on learning a new language, and within a moment they were in full voice. “They do this all the time,” Cimea explained. “They are singing a hymn to God.” 

This article first appeared in the Winter 2017 issue of Tufts Medicine magazine.