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Her head drooping, Florida Ndagijimana buries her face in the palm of her hand, her delicate fingers catching the tears snaking down her cheek. Paul Swoboda, her doctor, hasn't been able to find her a traditional healer. It's devastating news for a 20-year-old woman who thinks a spell has been cast on her family since they fled a refugee camp in Uganda.

Ndagijimana's 5-year-old daughter has been hospitalized with unexplained bouts of fever; Ndagijimana, meanwhile, is wrestling with severe depression and anxiety. Today she is in Swoboda's office complaining of pain in her abdomen that is keeping her up at night.

"We were trying to find her a traditional healer, see if that might help," Swoboda says, "because clearly medication hasn't worked."

This is a typical day for Swoboda, one of only two Salt Lake City doctors who contract with the Utah Department of Health to give hundreds of refugees their first physical exam within 30 days of arriving here.

Swoboda and colleague Mara Rabin are among the first Utahns who reach out to many exhausted and bewildered refugees. The physician team is their door into a health care system that they may only have access to for eight months, which is the temporary Medicaid coverage they are entitled to as refugees.

Driven from their homelands and forced to spend months, sometimes years, in refugee camps, they show up at the Salt Lake Family Health Clinic with health histories that range from a lack of basic care to torture.

Some have suffered perforated ear drums from untreated ear infections and have lost their hearing. Others have mouths full of black, decaying teeth.

Two of Swoboda's Burmese patients have shorter legs because their feet are partially gone, blasted off by a land mine they stepped on that wasn't strong enough to do more damage, he said.

Tropical infectious diseases, which some American doctors have never treated, are commonplace. Schistosomiasis, a waterborne parasite that burrows into the skin and migrates to the lungs and liver, is frequently seen in southeast Asians, Swoboda said. So is Strongyloides, a roundworm that lives in the tunnels of the small intestines.

Tougher to identify are refugees' mental health problems, among them depression, anxiety and post-traumatic stress disorder.

While up to 35 percent of refugees are victims of torture - for Somalis, that number can be as high as 90 percent - the symptoms of PTSD may not appear until months after a refugee has been seen by a doctor, said Rabin, who is also the medical director of the Utah Health and Human Rights Project.

A car accident or a troubling encounter with an authority figure can send a person who has been "white knuckling it" for years reeling. "One pin drops out and the trauma comes flooding back," she said.

Barriers to care

Language, culture and a lack of transportation can easily dissuade a refugee from getting help - or a doctor from offering it.

"Unless you have interest or empathy or compassion for an individual, you just want to get them in and out of your office as fast as possible," Rabin said.

At the Salt Lake Family Health Clinic, the two doctors strive to be culturally sensitive, but diagnosis and treatment can be difficult.

Their patients hailing from nearly every region of the world, Swoboda and Rabin hear more than a dozen languages spoken in their offices. They've tried to pick up a few words from every one of them: "Welcome." "Take a deep breath." "Are you in pain?"

Their physical interactions with patients also had to be learned. A Burmese woman will shake their hands, but an Afghan woman, who might perceive the gesture as overly familiar, will not. In some cultures, walking in front of an elderly person is considered rude. So is making direct eye contact.

"I don't shake hands with people," Rabin said, "I try to take cues with eye contact, ask the interpreter, 'Is it OK I'm looking this person in the eye? May I shake their hand?' I always sort of ask before I do something."

Lost in translation

Swoboda and Rabin rely heavily on interpreters to help them communicate with their nonEnglish speaking patients - a problem if the interpreter isn't well versed in the lexicon of medicine or has objections to something being asked of them.

Some male interpreters, for example, won't ask a woman if she is pregnant or when her last menstrual period occurred. Others don't believe in mental health diagnoses and won't refer a family for help. Sometimes, the words simply get lost in translation.

Rabin once asked a Burmese family if they were victims of violence or torture. They said no, and then smiled and laughed - an odd response, the doctor thought. She asked the interpreter, who was hard of hearing, to explain how he had phrased the question.

"I asked them if they torture children," he told Rabin.

Swoboda's patients have misunderstood directions for medications and for whom they had been intended, he said. One man lathered up in a cream designed to treat scabies, which was actually meant for his children.

Interrupted care

Juggling priorities after their initial visit, refugees are often more concerned about learning English and finding work than tending to their health, Swoboda said. Surgeries are put off; appointments are broken.

The state's resettlement agencies play a key role keeping tabs on refugees once they've been seen at the clinic. But in the coming months, they will be busy. Swoboda said more than 100 refugees will filter into Utah each month.

They will need help with Medicaid cards, interpreters and transportation to doctors' offices. Even the most trivial of matters has the potential to disrupt their care.

One woman's doctor, Swoboda said, rescheduled her appointment and left a message on the patient's phone, but she missed it because she didn't know how to access voice mail.

"There are people who fall through the cracks for all kinds of reasons," he said.

One boon for continued care: After their initial Medicaid eligibility ends, many refugees qualify to remain covered due to their low incomes.

Human strength

Despite the challenges, these doctors don't want to do anything else. Seeing people from all over the world who have endured "unbelievable, adversarial, tragic life situations and make it through is a testament to the resilience of the human species," Rabin said.

She recounted the story of a Bosnian couple who she saw five years ago. Survivors of severe war trauma and torture, they arrived in Utah with high blood pressure and diabetes. Rabin made home visits because they were too frightened to leave their apartment.

Today, their blood pressure is under control and they are being treated for depression. They are happy, they have told her, and are taking walks outside.

The last time she saw them, she says, "They just looked radiant."

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