'Congratulations, your son is dead."
It was a phone call that Eman Fihan would never forget. On New Year's Day 2006 in Basra, Iraq, her son's attackers used his cell phone to deliver this message. They believed that they had stabbed her 20-year-old son, Yassen Yassen, to death.
Yassen survived the attack - several stab wounds in his chest and abdomen - but the assault was just the beginning. Relentless threats began, and the family fled to Syria.
One letter spelled it out: " 'All Sunnis in this area need to leave by January 7, 2006,' or we would get killed," said Fihan, 45, now a Philadelphia resident, speaking through an interpreter.
Similar accounts of assaults, torture, threats, and attempted kidnapping are common among the patients seen at Jefferson Family Medicine's weekly refugee clinic on Wednesday afternoons.
Jefferson launched the service more than three years ago to serve these immigrants, including several hundred Iraqis now living in Philadelphia.
The clinic, a joint venture with the nonprofit Nationalities Services Center, also serves refugees across the world. And their needs provide a unique look into the world of their home countries and the fears and health problems that they typically experience here.
The Jefferson clinic has screened about 600 newly arrived refugees - including some who are seeing a doctor for the first time. The Iraqis, Burmese, and Nepalese have been the largest groups, but the clinic also sees refugees from Bhutan and Sierra Leone, said clinic director Marc Altshuler, a Jefferson family practice doctor.
Another way that Iraqi women immigrants like Fihan are getting help is a Jefferson-led group that meets about one Sunday a month in their homes and discusses topics from breast cancer to nutrition.
While the meetings are focused on women's health, they're also a chance for the women to discuss their daily struggles and share comfort foods such as freshly baked Iraqi flatbread, tabbouleh, and stuffed pastries.
The American invasion of Iraq in 2003 and the sectarian violence that followed drove more than 2 million Iraqi refugees into exile and displaced an additional 2.7 million, according to the United Nations. Most fled to Syria and Jordan.
Nearly 20,000 Iraqi refugees arrived in the United States between February 2007 and February 2009. And 725 Iraqi refugees settled in Pennsylvania, federal records show.
All that was before a second Iraqi exodus began this fall, inducing thousands to leave their homeland to escape the rising violence and lack of jobs.
The major health problem for Iraqi refugees here is depression followed by posttraumatic stress disorder. Many also suffer from chronic ailments, such as heart disease and diabetes, said Hikmet Jamil, professor of environmental and occupational health at Wayne State University in Detroit, which is home to a large Arab community.
Iraqis find it especially hard to see a doctor for depression and similar ailments.
"In our culture, to go seek help for mental health, people think that it's for crazy people," Jamil said.
"We believe the best way to reduce mental illness is to help these people find work or put them in courses related to their line of work in Iraq," Jamil said. Many highly educated Iraqis cannot find work in their fields because U.S. authorities don't recognize their licensing.
At Jefferson, some Iraqis have been open to working with a therapist, said Altshuler.
Hazim Ibrahem, an oral pathologist in Iraq, said he encouraged his wife, Shatha Ali, to seek help when she showed signs of depression, including suicidal thoughts. Ali did not need therapy, and was given a prescription for antidepressants.
"My wife was afraid no one was going to try to help her," said Ibrahem, a Philadelphia resident for three years.
"It was so hard in the beginning," Ali said through an interpreter. "I felt isolated when I first came, but now I feel better."
Iraqi refugees - accustomed to a state-run health care system - also face problems in navigating the bewildering world of U.S. health care.
Refugees in the U.S. qualify for eight months of Refugee Medical Assistance, which starts when they enter the country. After this, the medical coverage depends on various factors, such as a person's employment, said Leyla Dursunova, a nationalities center spokesperson.
Iraqi refugees are not used to making appointments and waiting more than a month to see a doctor, said Hend Azzerayer, a volunteer translator at the weekly clinic and at the women's health meetings who has a background in public health. Routine checkups and screenings as preventive care aren't common either.
The Iraqi women's health meetings "are a way to get people introduced on how things are run here and a means to get to know people," said Azzerayer.
"The real goal at the end of day is for these women to empower themselves," added Altshuler. "We want to keep [our refugee patients] in the health care system, instead of scaring them away."
Aimee Packer, a third-year resident at Jefferson Family Medicine, began the home meetings in October 2009 after she found the Iraqi women needed a more relaxed setting to talk about health.
During appointments, doctors would ask the women about previous Pap smears, testing for sexually transmitted diseases, and birth control. Often they were ill at ease because they were seen with their husbands or were sharing through a male translator, Packer said.
"We felt there was a need for education before we could make these recommendations to them," Packer said. "Now that they have the information, it's much less of a barrier."
The meetings have introduced the women to nutrition, mammograms, prenatal care, and cervical cancer as well as domestic abuse and menopause.
"These aren't foreign topics, but not talked about in Iraq," said Fihan. "In Iraq, they don't have support groups like they do here, and we benefit from these groups."
Fihan, her husband, and two children have lived in Philadelphia for almost a year and a half, but two of her children, including Yassen, remain in the Middle East because of paperwork issues, she said.
"I try to be patient and hide it," said Fihan. "My husband's health has deteriorated due to this stress. He had a stroke. . . . We're even considering returning to Syria if they can't join us here."