Becoming an Advocate
Avdic came to the United States with her family at age 16 from Bosnia and Herzegovina.
She spent her teen years adjusting to a new language, new school and new city. As
her own English skills improved, she acted as a medical translator for her parents.
Like many Bosnians who had come of age prior to the 1990s, she explained, her parents
resisted talking about many health issues or seeking medical help.
During the 1990s, about 300,000 Bosnians resettled in the United States as refugees
during and after the war in Bosnia and Herzegovina. About 70,000 settled in St. Louis,
which is now home to the largest Bosnian community in the world outside of Bosnia. The horror of war, she said, left its mark physically, psychologically and culturally
on many in the community.
“They built a wall around them,” Avdic said. “My people have been through a lot of
traumatic events. My people come from war. They are survivors but the aftermath of
war continues to haunt them and I know what it is like because I am a survivor myself.”
"I was forced to grow up prematurely because I had to think about survival," she continued.
"On the one hand I can see that some of us have become a lot more serious and responsible
because of this, but on the other hand, some always feel as if something is lacking
because we did not group up at a normal pace."
When an opportunity in 2016 arose to join SLUCare as a medical interpreter working
with Bosnian patients, Avdic jumped at the chance.
“My goal is to build a relationship with Bosnian patients, to understand their needs
and to advocate for them,” Avdic said. “I am their voice. I want them to feel welcome
Like Avdic, Zimmerman, whose full name was originally Andrja Stavljenic before her
marriage, is Croatian. Unlike Avdic, Zimmerman was born in the United States to immigrant
parents from the former Yugoslavia. Ties to her heritage run deep and led her directly
to SLU. After growing up in St. Joseph’s Croatian Catholic Church in Soulard, a parish
member gave Zimmerman the financial support to pursue her undergraduate education
at SLU. She received her bachelor’s degree in 1995 and her MBA, also from SLU, 1999.
She was married at St. Francis Xavier College Church.
Zimmerman connects community physicians and their patients to the right SLUCare physicians
and specialists. Her desire to help members of the Bosnian-Croatian community access
SLU’s programs also comes from her own experience. Her father, she said, worked hard
to support his family after coming to the U.S. but suffered a devastating stroke at
a young age. Taking care of him inspired her to help others in her community, and
SLU’s mission, she said, ties directly to that passion.
“If I could save one person from having a stroke or having an outcome which resulted
in no quality of life like my dad did, that would be enough,” Zimmerman said. “There’s
a huge need in the community. Health care is already difficult to navigate, much less
with a language barrier.”
Reaching Out to Patients
As SLUCare’s interpreters assist patients, SLUCare physicians also are reaching out
to the Bosnian community through programs that promote wellness. They also conduct
research to find the best practices to improve health.
The Bosnian community in St. Louis faces several health challenges, including heart
disease and mental health concerns stemming from historic trauma. Researchers, physicians
and community leaders acknowledge the need for continued work to address those issues.
SLUCare physicians Dawn Hui, M.D. , and Robert Morgan, M.D., are initiating interactions to draw members of the community into SLU’s wider range
of programs geared to the area’s Bosnian residents.
“In the United States, health is something that you can manage, health care is a right,”
Hui, a cardiothoracic surgeon, said, “whereas other countries look at health differently,
more as ‘this is the thing that will kill you.’ You tough it out because you’ve gone
through some tougher things.”
Hui learned about the Bosnian community after moving to St. Louis. The Texas native
said that in talking with Zimmerman, she saw the need to reach out to the community
and realized building trust would be critical so people could make informed choices
as patients. Hui applied for and won funding from the Greater St. Louis Health Foundation
in 2014 for a community outreach program focused on cardiovascular health.
While the screenings were a first step, she also saw a need for data and more on-the-ground
research. In collaboration with Zimmerman, Avdic and other members of the community,
Hui approached Bosnian groups and leaders for help. Bosnian students at SLU assisted
with screenings and collected data. A partnership with SSM Health Saint Louis University
Hospital was also critical to the project’s success.
“We could not have done it without that support,” she said.
The team’s research, published in 2017 in The Journal of Immigrant and Minority Health, found that of the 128 people who participated in the study, about two-thirds were
overweight or obese. While many displayed other risk factors for developing heart
disease including lack of physical exercise and high smoking rates, over 80 percent
had medical insurance that they could use to seek medical help to manage their risk.
My goal is to build a relationship with Bosnian patients, to understand their needs and to advocate for them. I am their voice. I want them to feel welcome and understood.”
Eldina "Elly" Avdic, SLUCare interpreter
With the findings in mind, Hui said that translating better health practices into
action for the community is about understanding the Bosnian culture.
Hui herself started exploring Bosnian culture to discover why some advice about diet
and other risk factors for cardiovascular disease seemed to fall flat. Eating at Bosnian
restaurants, she recalled, led her to one epiphany.
“Cheerios for breakfast wouldn’t resonate,” she explained. While Americans might conceive
of the cereal as nutrition, Hui said, traditional Bosnian cooking emphasizes different
ingredients, other meal staples and people grow up attuned to other tastes to start
Adapting American health care practices and advice to suit the patient, she said,
is the key to improving a patient’s overall health while also supporting the person
as a whole.
“When I encounter a patient, I try to be sensitive to how I counsel them,” Hui said.
“Asking and probing to find the barriers is how we find a solution and compromise.
You have to approach your patients differently.”
Navigating Family Dynamics
Morgan, who came to SLU a year ago from the University of Minnesota-Twin Cities, sees
forming partnerships with patients as one of the reasons SLUCare’s commitment to the
Bosnian community has been a success for both patients and health care providers.
“Care is not a technical exercise, it’s a human enterprise,” said Morgan, who is an
orthopedic surgeon who specializes in spinal reconstruction. “For the really complicated
things, I really need a human person for a human interaction.”
Morgan remembered one Bosnian patient who was suffering from increasing paralysis.
While the man’s family was there to support him, they were also withholding information
in an attempt to protect him. Bringing in SLUCare’s Bosnian interpreters, with their
language skills and sensitivities to Bosnian family life, helped Morgan and his patient
“The interpreters helped me to navigate the language and the family dynamics to have
a conversation with my patient so he could make an informed decision,” Morgan said.
Based on that conversation, the patient was able to take control of his health care
and has since recovered.
That kind of service, at the heart of SLU and SLUCare’s mission, drew Morgan to Saint
“To practice informed medicine, to actually engage the patient in their care, you
can’t just cross the language chasm,” Morgan noted. “You have to cross the cultural
chasm and you need human interpreters to do that. And sometimes you just need someone
to hold a hand. An iPad can do many things, but it can’t hold a hand or wipe a brow.”
Caring for the Whole Patient
Ajlina Karamehic-Muratovic, Ph.D., assistant professor of sociology and anthropology at SLU, agreed that bridging cultural
gaps between the Bosnian community and the health care system is challenging. She
has studied health interventions in Bosnian communities, most recently collaborating
with Yale University on a nationwide look at Bosnian health outcomes. She has a new
research project underway with the University of Missouri-St. Louis that is examining
bicultural identity in second-generation Bosnian Americans.
To practice informed medicine, to actually engage the patient in their care, you can’t
just cross the language chasm. You have to cross the cultural chasm and you need human interpreters
to do that."
Robert Morgan, Ph.D.
“Usually the physician is focused on a specific body part, the diagnosis and the treatment,”
Karamehic-Muratovic explained. “Sometimes the physician cannot care for the whole,
the mind of the patient,” which is what many Bosnians seek and need. Karamehic-Muratovic,
who left Bosnia in 1988 and settled in St. Louis more than a decade ago, said that
understanding Bosnian attitudes toward health, particularly as influenced by their
war and relocation experiences, is crucial.
For many Bosnian patients, she continued, addressing psychological issues like post-traumatic
stress disorder, isolation and stress is stigmatized culturally, but still influences
how they approach working with a physician.
“They have the upmost respect for their doctors,” Karamehic-Muratovic said. “But they
want to be heard and listened to. They don’t want to be treated as a collection of
body parts, but rather as a whole.”
Expanding the SLU-Bosnian Connection
Akif Cogo, SLU’s assistant director of custodial services, came to St. Louis from
Bosnia and Herzegovina 17 years ago. Drawn to SLU by its mission, he said, in his
five years working at the University, he’s watched the connections between SLU and
his community expand, from the health fairs SLU faculty, physicians and staff members
have undertaken, to the growth of SLU’s Bosnian student population. “I think we’ve
just scratched the surface,” said Cogo, who is president of St. Louis Bosnians Inc., a nonprofit organization that advocates on behalf of St. Louis’s Bosnian community
through educational, cultural and relief programs. “I think the studies and research
being done at SLU really shines a light on something that we knew before but it wasn’t
communicated well before and now gives evidence to solidify approaches to help the
SLU’s willingness to reach across language and cultural barriers, he said, has been
a key factor to grow its relationship with the Bosnian community.
“SLU is so embedded in our community and it shows the great diversity that Saint Louis
University is known for,” Cogo said.
About Saint Louis University
Founded in 1818, Saint Louis University is one of the nation’s oldest and most prestigious
Catholic institutions. Rooted in Jesuit values and its pioneering history as the first
university west of the Mississippi River, SLU offers nearly 13,000 students a rigorous,
transformative education of the whole person. At the core of the University’s diverse
community of scholars is SLU’s service-focused mission, which challenges and prepares
students to make the world a better, more just place. For more information, visit
About SLUCare Physician Group
SLUCare Physician Group is the academic medical practice of Saint Louis University,
with more than 500 health care providers and 1,200 staff members in hospitals and
medical offices throughout the St. Louis region. SLUCare physicians are among the
most highly trained in their fields — more than 50 specialties in all — and are national
and international experts, renowned for research and innovations in medicine. For
more information, visit www.slucare.edu.