33. THEY DON’T TALK ABOUT IT

FOR LUPWAY DOH, 38, a leader in Utica’s Karen community, it is easy to pick up on the signs of trauma around him—because he sees them in himself.

We were heading toward Rome, a small city 20 minutes from Utica, to see a young Karen woman who had left her husband.

The husband—whose leg was amputated when he served in the Karen National Liberation Army—is addicted to alcohol. “He just had his fourth DUI,” LuPway said. “He may be deported to Burma.”

LuPway’s sympathy is with the young woman, who was abused. But he—and other community leaders—have not completely turned their backs on her husband.

“A friend of mine helped him with his legal problems,” LuPway said. If the husband were deported, it would be tough for him to survive.

“But he doesn’t want our help now,” LuPway added, sounding relieved.

In Utica, each refugee group has leaders, who assist those who are struggling. Mohamed Ganiso, the Somali Bantu community leader who owns a small trucking company, may be hauling cargo cross-country when he gets a call. Sakib Duracak, a contractor and the president of the Utica Bosnian Mosque, may be installing a Home Depot kitchen when his cell phone rings.

These leaders help solve disputes; offer guidance to those overwhelmed; raise money during a crisis; and sometimes act as liaisons between members of their community and the city’s institutions: its hospitals, schools, courts, and police force.

And they may sometimes act as chiefs—decision makers—as LuPway and other Karen leaders did in the fall of 2019 when the young woman was thinking of leaving her husband.

LuPway—a soft-spoken man with a long ponytail—was born in Thoo Mweh Hta, a village of about 20 huts on the border of Burma and Thailand. As a child, he was always listening: When the sounds of gunfire and bombing came close, LuPway and his family would run to a Thai village an hour away, crossing the powerful Salween River. When fighting subsided, they would return.

“The threat was everywhere; there was no safety,” he said.

When he was six, fighting along the border became more intense; he and his family strapped bamboo baskets filled with clothes and food to their foreheads, and headed deeper into Thailand.

Going down the river with his father, he saw a dead soldier floating by. This was not the first time. Playing with friends by the river, he would sometimes see the bodies of Burmese soldiers who had been caught spying. “We’d say, ‘I saw it first!’ ”

LuPway knows he has been lucky: At the Thai refugee camp, where his family arrived in 1995, his teachers quickly recognized he was a gifted student. He was selected to attend Assumption University, a Catholic university in Bangkok.

He enjoys his work as a college counselor at On Point for College. He owns a two-family house in East Utica with a big yard, where he lives with his extended family.

But he carries around the sounds of warfare. Other Karen do, too.

“It makes us scared to do anything,” LuPway said. “Is it going to be the right thing? Is it going to cause harm?”

“We try to avoid conflict and that turns into a vulnerability,” he added. “You give away what you have—and people take advantage of your generosity.”

The Karen—a tight-knit community in Utica of about 6,000—have in many ways been successful. Hardworking and anxious for their children to do well academically, they are open to interacting with other cultures. Many of the men work at factories, including the Keymark Corporation, Chobani, and Conmed; many women are employed as housekeepers at Turning Stone.

Their children are high achievers. “About 80 to 90 percent of our kids go on to college,” LuPway said. There are more Karen students at MVCC than any other refugee group.

But there is a hidden thread of depression—and addiction—among the Karen.

Some men drink heavily at home, LuPway said, trying to blunt memories of the war. If a husband loses control, the wife may call LuPway or another community leader.

“I’ve seen a lot of women crying and screaming,” LuPway said. “They’re trying to relieve the stress.”

He tries to mediate, and he encourages women to speak to their family doctor. “But the majority—they don’t talk about it, even in their family.”

If the husband is violent, LuPway calls the police. But the wives do not press charges, he said.

“Men are getting very clever,” he added. Knowing they can be arrested for being physically abusive, they have changed tactics: “They say terrible things to their wives, push, and break things.”

Dr. Natalie Hua, 36, a family doctor at the Sister Rose Vincent Family Medicine Center in Utica, located in one of the poorest sections of Cornhill, does not claim to know what her refugee patients have been through. But she arrived at 16 from Vietnam—not understanding a word of English—so there is a level of awareness.

“I heard the stories growing up,” said Dr. Hua, who lived with her grandparents in Brooklyn; her grandfather was a political refugee.

Dr. Hua is one of dozens of immigrant and refugee doctors working in the Mohawk Valley Health System. “I realized we didn’t have the cultural competency for such a diverse community,” said Dr. Mark Warfel, chief experience officer and former director of the St. Elizabeth Family Medicine Residency Program. “Most people coming from medical school have no understanding of refugees’ problems. I felt we should recruit.”

In 2000, Dr. Warfel began reaching out to young doctors—from Russia, Burma, and Bosnia—helping them through the steps to become viable applicants. In recent years, about half the medical residents have been immigrants.

They care for patients dealing with trauma and depression—and at high risk for diabetes, hypertension, high cholesterol, and obesity. Some cannot read or write; many have never been to a dentist.

The Burmese diet—heavy on rice and low on protein—contributes to an increase in diabetes, Dr. Warfel said. And refugee kids, just like American kids, gravitate to sugary snacks and drinks. During checkups, family doctors talk with parents and kids about healthy eating, and encourage kids to get outside.

“Green stuff?” Dr. Michael Nemirovsky, a family doctor, asked a lively 10-year-old Burmese boy during a recent checkup. Dr. Nemirovsky made a deal with the boy to try some greens.

It will not be easy: There are no grocery stores within walking distance in Utica’s poor neighborhoods; fresh fruits and vegetables are a luxury. It is a pattern repeated in disadvantaged areas across the country.

Utica’s children face a serious threat: The city has a higher rate of lead poisoning in children than Flint, Michigan, did at the height of the city’s lead contamination crisis.

In Flint, 5 percent of children tested under the age of 6 had elevated blood lead levels, which is twice the national average. In East Utica and Cornhill, 36.65 percent of children under 6 who have been tested have elevated levels.

Most of the city’s housing stock—as in other Rust Belt towns—was built before 1978, when the federal government banned consumer use of lead-based paint. Refugees are particularly at risk: Upon arrival in Utica, they have often been placed in poorly maintained houses, where kids may be exposed to lead through plaster dust on windowsills and old paint chips.

Some families live in homes rebuilt after fires. “When a house burns down, lead stays in the soil,” said Dr. Stam, who has worked with refugee children treated for lead poisoning. Kids playing in the backyard may get soil on their hands. Later, if they have a snack—without washing their hands—they can ingest lead.

Refugees are also exposed to lead through certain spices, herbal medicines, incense, toys, and pots brought—or imported—from their home countries. The traditional yellow face paint used by Burmese women contains lead.

In recent years, there has been a push to test all 1-year-old and 18-month-old children. If a child has elevated blood lead levels, they are monitored by a doctor—and the county’s Lead Poisoning Prevention Program does a home inspection to try to identify the sources and educate the family about things they can do, like using wet cloths to get rid of lead dust.

Zahara’s two little boys—and Sofia’s daughter, Amrah—are among the thousands of Utica kids affected.

All three were diagnosed with lead poisoning while living in their grandmother’s old house on Rutger. “They could have eaten paint chips,” Sofia said.

When Zahara moved into her new house, her sons’ blood lead levels improved. Amrah’s improved while living with her mom in the new apartment.

There is reason to be hopeful: In 2018, Utica was awarded a $3.5 million grant from the United States Department of Housing and Urban Development to help remove lead hazards from homes.

And testing is slowly paying off: In 2007, 39.6 percent of Oneida County children under 6 who were tested had high blood lead levels. In 2016, that dropped to 22.5 percent.

Dr. Hua sees a link between her grandparents and her patients: “The way they view pain is very different from Americans,” she said. “They don’t even mention it; it’s a part of life.”

When her grandmother fell down the stairs, her CAT scan showed a brain bleed. “She’s like, ‘I’m good, take me home, I’m fine!’ ” Dr. Hua recalled, laughing.

Recently, during an examination, Dr. Hua lifted a Somali patient’s shirt—and saw hundreds of tiny scars on his back. At first, she thought it was a cultural or religious practice. But he explained the scars were from a traditional treatment he had 20 years ago for back pain. Medicine was inserted through the cuts in his skin.

When Dr. Hua asked, “Do you still have pain?” he said yes. An x-ray showed evidence of an old injury from a fall.

“But he didn’t complain,” she said. “He didn’t ask for pain medication.”

Many of Dr. Hua’s patients have PTSD—but decline counseling.

“It takes a level of trust before patients will share these things with us,” she said. “There are so many roadblocks.”

“It’s almost like the sun, the moon, and the stars have to line up,” she added, before a patient will get therapy.

So, she tries to meet with her patients more often, hoping they will eventually see Dr. Katherine Warden, the only clinical psychologist at the center.

But patients often cancel follow-up appointments. As a first-year medical resident, Dr. Hua was crushed: “I took it very personally.” But then she realized some of her patients have transportation issues. Family crises can crop up.

Now, she gives her patients tools they can use at home: breathing and relaxation exercises.

Recently, a young refugee who was sexually abused as a child had a panic attack in her office. “I turned off the light, did guided breathing meditation with her,” Dr. Hua said. “She calmed down.”

Dr. Warden, 34, director of behavioral medicine at the St. Elizabeth Family Medicine Residency Program, has an open approach when counseling her refugee patients: “I don’t make people tell me their stories,” she said. “It can be retraumatizing.”

She lets her patients choose: “If they want to discuss the trauma, they can. But sometimes it’s OK to let it sit and be healed.”

There is a misconception, she said: “A lot of people think we should be emotionally pain free. That’s completely unrealistic.” She works with her patients to find a level of pain that is tolerable. “It’s becoming used to the new normal.”

When first meeting a patient, Dr. Warden tries to find out: What does your anxiety or depression prevent you from doing? What cultural barriers are standing in your way?

Then she comes up with a plan. “That’s more effective than trying to talk about how we feel about things.”

If patients are afraid to get in a car, she will practice guided imagery with them in her office. Eventually, she will take them out driving.

If a patient has social phobia, Dr. Warden will take them to a nearby coffee shop. As students work at their laptops and families stream in and out, Dr. Warden encourages her patient to order a cup of coffee.

“The point is to become desensitized in a crowded place,” she said. And then take another step: Make small talk with a stranger.

“I point out things that work,” she said, smiling. “ ‘I like your jacket.’ ‘The weather is cold today.’ ”

Whether therapy is effective depends on a lot of factors, she said: the severity of the patient’s psychological condition; the patient’s general neurological-cognitive capacity; the effectiveness of the translator; the level of family support.

“And how willing they are to engage with the things I say to try,” Dr. Warden added.

But it is really about establishing a relationship: “Patients respond if they feel the therapist is empathetic, and genuinely out for their best interests.”

Any grasp of English helps, she explained. “But I have made wonderful connections with people who don’t speak a lick of English.”

Women in violent relationships rarely find their way to Dr. Warden’s office. They are mostly locked into their situation and are only identified when the police are called. Social workers will then offer them counseling and shelter through the YWCA Mohawk Valley, which manages the city’s emergency domestic services.

But sometimes a woman in an abusive situation comes in accompanied by her husband. If Dr. Warden senses the woman feels scared or uncomfortable around her partner, she asks him to leave the room. “Sometimes, the patient will open up about their troubles immediately. Sometimes not.”

Dr. Warden will offer options. “I never tell a patient she has to leave. I let her make up the pros and cons.”

Most refugee women—for cultural and economic reasons—choose to stay with their partners.

Dr. Warden helps them navigate their relationships: “For two sessions, I’ll let a woman talk nonstop about her spouse.”

Then she shifts the focus. “I’ll talk about how we can change our own thoughts and behavior, and our priorities.”

The young woman who left her abusive husband opened the door. Shyly—but confidently—she showed LuPway and me into a large living room.

She had recently moved in but will not be staying long, she explained. The subsidized duplex apartment is $700 a month—too expensive given her salary as a housekeeper at Turning Stone. She is looking for another place.

There was little furniture—just a few chairs and a folding table. But there was a Karen flag on the wall, along with photos of her five kids, and a large portrait of her parents on their wedding day: two solemn-looking young people in traditional clothing.

Her own marriage was arranged by her mother, she said, as LuPway translated from Karen. “These marriages are not always peaceful,” she added, smiling.

Though she was coming out of a violent marriage, there was a sunniness about her. Her round face was framed by straight-cut bangs, and she wore a batiked top and pajama bottoms that had teddy bears on them. Her toenails were polished blue.

Her mother had hoped the young man would provide protection for their family; the young woman’s father had recently been killed by the Burmese military. But her husband drank and was abusive from the start. “I was too young,” she said. Her marriage took place when she was 13. “I didn’t know right and wrong.”

Her mother witnessed some of the abuse. “But she couldn’t do anything about it.”

Yet later, when they were all living in a refugee camp in Thailand, her mother suggested she take her kids to a town and find work. But she stayed.

The final straw came late at night, four months ago: Her husband’s friends were over, drinking, and talking loudly. “I had to go to work soon,” she said, and told them to be quiet. Her work is arduous; she cleans eight or nine large hotel rooms per shift.

After his friends left, her husband opened the front door and all the windows. It was a cold November night; the children were asleep. He started calling her foul names, screaming so the neighbors could hear.

Yet, she has worse memories from childhood, she explained: Burmese soldiers captured her father, used him as a porter to carry their military equipment, then killed him. Her cousin’s husband was tortured. Six members of her family lost their legs to land mines.

“We had to suffer a lot when we were kids,” she said.

A couple of years ago, her doctor diagnosed her as having PTSD and suggested therapy. “But I was too busy,” she said. “It did not happen.” Taking antidepressants helped. “But if you take them too long, then stop, you feel frustrated.”

After the frightening incident in November, she spoke to LuPway and other community leaders. They said she was free to leave her husband. When she moved out, her husband said, “You find your own way!”

“Yes, I found it,” she told LuPway and me. “I always listened to my parents. Now I’m an adult and can do my own thing.”

But then her face clouded over. “If he calls, then I don’t want to do anything. I start getting nervous, I can’t breathe—all these combined feelings.”

When LuPway got back in the car, he was quiet. Then he said that after dropping me off, he was going to the cemetery to meet the family of a close friend. His friend—who suffered from depression—had recently killed himself.

“We are self-treating,” LuPway said, referring to how his community handles trauma. “A lot of us go hiking. We cook in the park in the summer.” But it is an uphill battle: Not long ago, he took his close friend to the Finger Lakes.

“I think I handle my trauma pretty well,” LuPway added. He often heads to Bald Mountain in the Adirondacks with friends. “By the time I reach the top, I feel better.”

And he spends a lot of time in his backyard, growing the vegetables of his country: long beans, pumpkins, and tiny, hot red peppers.

But when nothing works, he drinks a shot of whiskey. “Some nights you cannot really sleep,” he said. “Once these thoughts kick in, you can’t really kick them out.”