Back to Refugees

Refugee Health culture health refugees immigrants


Introduction

Health care may not be the highest priority to newly-arrived refugees. We have seen, for example, Somali refugees misrepresent family units at the time of State Department interviews if they view their chances for resettlement improved. We have seen alleged family units of husband, wife and children all go their separate ways upon arrival. As this secondary migration frequently involves moving out of state, medical followup is significantly difficult.

Even more pronounced, we have seen a case where consent for medical care for a woman's children was withheld in an attempt to barter for a preferred living arrangement. While this case is extreme, it does illustrate the great lengths we have observed refugees go in order to meet their need or fulfill their expectations.

The first interaction new arrivals have with the health care system is with the Refugee Domestic Health Assessment through local health departments. The basis for this screening and referral is to eliminate health-related barriers to successful adaptation. At this time the refugee is rescreened for tuberculosis and other communicable diseases, and a health assessment of various depth is performed. Positive findings are referred for treatment; however, in many localities, only tuberculosis and sexually transmitted diseases are treated within the health department. Other health problems, such as hypertension, are referred out to the primary care sector, a vital link that sometimes is broken.

Refugees, at first, enter the health care sector with the aid of caseworkers, or more rarely, previously resettled family members who sponsor them. Caseworkers, because of financial constraints of the VOLAG, are not always bilingual in the language of the refugee, especially when that refugee's group was not deemed sufficiently large for the agency to hire additional staff. Also, many agencies, either through loyalty to employees or inability to keep up with refugee trends, retain ethnic employees long after their countrymen have been resettled. This is mostly true of Southeast Asian employees, who were of critical importance five years ago but less vital today. However, in these cases, where they lack in language proficiency of the new arrivals they possess skill in negotiating bureaucracies and maintain vast networks which can assist refugees. Agencies usually put a definite time cap on service provision to new arrivals, as short as two months.

Typically, with the present reality of sparse resettlement dollars, the voluntary agency's chief concern is the encouragement of economic self-sufficiency, i.e. job placement. Health care can then be viewed as a means toward employability. Alternatively, the health care sector may be called upon by the agency for disability evaluation, another potential route toward economic self-sufficiency.

Refugee health epidemiology is very complex and wide-ranging, especially given the diversity in background socioeconomic status, ethnicity, geography, and the like. For example, many refugees from rural, third world countries may have had little if any prior experience with Western medicine, whereas others, like Cubans, Bosnians, and Soviets, come from quality health care backgrounds. Similarly, refugees from Africa or Southeast Asia arrive from areas where "tropical diseases" like malaria or schistosomiasis are endemic, and yet are virtually unknown to physicians in the United States.

Despite these types of dissimilarities, however, most refugees also share common experiences through the refugee experience. For example, they have undergone physical and psychological hardship in the period prior to resettlement, as they have been fleeing wars or other disruptions. Similarly, they flee with very little advanced preparation, so few if any medical documents, including immunization records for children and medical records, are brought with them to the United States. Often they have been destroyed or are otherwise unobtainable from the hostile home government.

Refugee health epidemiology is quite complex but may be best understood within the framework of a longitudinal model. The following discussion looks at refugee health at the level of a few representative ethnic groups, noting certain generalizations about their health pictures at the present time. Concordantly, we look at the changing picture of health longitudinally through the resettlement process, as each group explored can be viewed on the whole as representative of a different stage in the resettlement process.

In sum, we view the refugee health profile as changing along a hypothetical continuum from the acute phase, where illness is mostly a result of antecedent factors to resettlement, through to the chronic level, where the health picture is largely a consequence of long-term resettlement itself. For purposes of illustration, we discuss specific refugee groups found in Dallas whose adaptation overall represents different points along this continuum. The populations discussed here include: Sudanese, Amerasians and their kin, Iraqis, Kurds from northern Iraq, and Cambodians. A broad summary of health risks and screening parameters are given at the end of this chapter, along with screening guidelines.

Level I: Acute Phase

This is the level that attracts the most concern in the health arena, primarily because of the communicable nature of the illness with which new arrivals present, and consequently the public health threat they represent. The groups we have chosen as representative here, Sudanese, Amerasians, and Iraqis, are typical of new arrivals frequently coming from poor health care backgrounds. For the Sudanese, the traumas of civil war, refugee flight and camp life are very recent. And for the Amerasians and their families, the discrimination they endured in Vietnam is reflected in the poor health statuses here. Similarly for the Iraqis: many came from prison camps in Saudi Arabia. Parasitism abounds in all groups, as sanitation facilities were typically poor in the recent past for these groups. Positive tuberculosis skin test reactors and Hepatitis B-positive patients are also numerous. And we see some of the more rare, tropical diseases like schistosomiasis and malaria among Sudanese and Hansen's disease (leprosy) among Vietnamese.

With all new arrivals, in addition to the acute, there are chronic conditions which can be a function of events leading up to refugee flight, e.g. war-related trauma that has been left untreated, like past fractures, common to all new arrivals. We make a lot of orthopedic referrals, but frequently no treatment is warranted for these old injuries, to the dismay of the patient.

Often, our outreach clinic represents the first access to a doctor in many years, so we frequently get a litany of physical woes that frustrate the provider. We recently had an encounter with a Sudanese woman who came with a pre-translated page of complaints which she presented: "severe headache always, fever, loss of weight, loss of appetite, emaciation, dizziness, weakness of the body, coughing, sometimes heart pain, unbalance of the body, and sometimes choking, the duration since we came from Africa." The bewildered physician did not know where to start, so he ordered several labs. The patient left dissatisfied that she did not receive medicine for anything.

Similarly, at least some new arrivals present with more hypochondriacal complaints. A big factor here is the emphasis on qualifying for SSI and other disability benefits, encouraged by the caseworkers and even the more savvy refugees themselves.

Another component of the health picture that should be mentioned is the potentially deleterious consequences of certain types of employment common to new arrivals. Immediately coming to mind are the strain and sprain injuries resulting from unaccustomed heavy labor or repetitious movements like factory work. Furthermore, because of their lack of skills, refugees are often forced to take the more dangerous jobs in our society. Significantly, and sadly, at least two new arrivals working as late-night convenience store clerks have been shot to death in robbery attempts in recent months.

LEVEL II. Transition

The Kurdish community in Dallas can be viewed as representing an intermediate stage of resettlement. The majority of the 1,000 or so individuals fled to Turkey during the Anfal in the late 1980's and were resettled in Dallas in 1991-92. Hence they have been here at least five years, and most of the younger men and even some women are now well-integrated into the workforce.

Many believe that they are here only in a temporary state and will return with the eventuality that Saddam will be defeated in the next uprising. Quite a number of Kurds have saved money and returned to visit family and friends in Kurdistan, via Turkey, for extended periods. This is a rather unique situation in the refugee scenario of maintaining ties to the homeland. In fact, the bodies of several elderly Kurds who have died here of natural causes have been sent back to Kurdistan for burial.

This temporariness is further reflected in the attitudes toward children: the children represent the future peshmerga, freedom fighters, so their health and education takes precedence. There is very good compliance with immunizations, for example, with this population, as parents are eager to get everything they can.

Only more recently, since the children's needs have largely been met, have adults come forward in greater numbers seeking care. Even with these cases, frequently the initial access has been to ask for prescription drugs needed by family members still in Kurdistan. And although we have not systematically inquired into this sensitive topic, we are sure that some of the medications prescribed for patients here find their way back to Kurdistan. Doctor shopping is common, as increasing numbers learn to manipulate the system to get what they want.

As with most groups, communicable diseases were prevalent in the first stages of resettlement, but now hypertension and diabetes are two of the more frequent diagnoses. Some patients report that their symptoms began in Kurdistan or in Turkey, and a few had received medicine in these locations. Another chronic condition of very high prevalence we have seen in this population is goiter, with a prevalence of 32% in all adults seen at clinic. Given its prevalence, we initially hypothesized that these thyroid conditions were sequelae from exposure to gas or chemical attacks well-documented to have been leveled against the Kurds by Saddam Hussein during the Anfal. While the hypothesis was intriguing, follow up research shows that the vast majority of cases began symptomatically well before these attacks, and furthermore, most of the resettled population here in Dallas did not report direct exposure to these agents of warfare.

Regardless of the lack of direct contact with the biological and chemical weapons, the Kurds did suffer mightily at the hands of Saddam. Many witnessed atrocities firsthand and the loss of family members through warfare, starvation and "disappearance" has been great. Not unexpectedly, the rate of psychological disorders runs high, like conversion reactions, seizures and other post traumatic stress sequelae, from these recent events, particularly as the "honeymoon period" of early resettlement fades.

LEVEL III. Chronic

At this theoretical stage, ten or more years down the road, the resettled refugee can suffer from a variety of chronic conditions that did not preexist in the country of origin, or have worsened, and hence can in part be seen as a consequence of resettlement. Resettled Cambodians on the whole, and to a lesser extent, long-term Vietnamese, are arguably the most affected of all groups, for many possible reasons. For one, by this point in time, these refugees no longer have American sponsors or caseworkers to help them with their health and social problems. And at present, elite and middle-class Cambodians and Vietnamese, those with the means, are returning to Asia at a great rate, creating a leadership vacuum in the resettled communities. Also, family structures break down at an alarming rate at this juncture: children acculturate at a far different level than parents, and intergenerational conflicts abound, with consequences like the gang problem resulting. Acculturational stressors can manifest physically by this time, as the gap widens between those within the ethnic group who have gained a level of assimilation versus those who have withdrawn. For the latter, the refugee is caught in the "neither here nor there" world of the ethnic ghetto.

Take hypertension, for instance. According to the early epidemiological accounts of newly-arrived Cambodians, hypertension took a back seat in prevalence to the myriad of acute problems, such as hepatitis, parasitism, TB, and the like, as with the Amerasians and Sudanese today. Presently, ten years or more later, hypertension, along with coronary heart disease and diabetes are the most frequently seen disorders among Cambodian and Vietnamese patients accessing our clinic, though frequently incidental findings. While the causation of these chronic conditions may in part be idiopathic, lifestyle changes in coming from an agrarian world to a sedentary, welfare-based economy surely play an important role here, coupled with other aspects like dietary changes.

A recent case involved a forty year-old Cambodian male who suffered a heart attack and eventually died in the hospital after a week of heroic life-saving measures, including the removal of a leg. While he had a known recent history of hypertension, he went relatively unmedicated by choice, claiming, naturally, that he was young and felt fine. Ironically, after his death, and several other similar examples, rumors were rampant in the community that it was the hospitalization itself that caused this patient to die. Who could explain how a young man in visibly good health could die from this Western disease? The fear of hospitalization remains among a portion of the community, further propagated by a Kru Khmer (traditional Cambodian healer).

Consider another illustrative case: the recent death of a middle-aged woman from heart failure, after missing several follow-up appointments and failing to obtain refills for her anti-hypertensives. She was initially hooked into the system by zealous community health workers who diagnosed her hypertension through routine screening. However, an all-too-familiar scenario played out when the outreach workers eventually became involved elsewhere and she either did not seek further care for lack of concern or could not due to accessibility barriers. While the compassion fatigue is marked within the medical community, so too is the weariness of battling an often-insurmountable medical system on the part of the refugees. People frequently just give up. So prevalent is this scenario of the lack of compliance on drug therapies for chronic problems.

As with hypertension, other aspects of the epidemiological profile of the Southeast Asian community begin to resemble that of the host society. Chronic conditions like HIV/AIDS and Systemic Lupus Erythematosus (SLE) have begun to surface, with very complex management regimens, requiring more interaction with the medical community than the former refugee can often negotiate. Similarly, the morbidity and mortality from cancers are alarmingly high, particularly cervical cancer.

The case of one woman being diagnosed with end-stage cervical cancer represents some of the profound complexities of managing terminal illness among Southeast Asian refugees. She was in and out of the hospital for extended stays for over a year as the chemotherapy and radiation destroyed her intestinal tract, together with the cancer's spread. During this period her already-disrupted family unit fell to pieces as her teenage son was arrested for armed robbery. She blamed herself, and wished to leave the hospital, but she could not until she was further rehydrated from the IV's that were sustaining her. After repeated attempts to tear the IV's away, her arms were bound, and though she still could not tolerate oral foods, she begged to be given rice. To her, the past horrors of Khmer Rouge torture were being relived. Finally, after many attempts at intervention by community workers, she left the hospital "against medical advice" to home, in the care of a twelve year-old daughter and alcoholic husband. As she left "AMA," professional homecare was limited primarily to volunteer providers. She died from the sequelae of starvation, but with some dignity, a few weeks later. This case points to the complexities of providing palliative care to the Southeast Asian refugee population.

Another sure indicator of acculturative stress, the wear and tear of material and spiritual poverty, on the health of resettled Cambodians is the increase in prevalence of self-abusive behaviors and the concomitant health sequelae. Notable here is the widespread use and abuse of alcohol. At the risk of overstatement, one of the most frequent pastimes for women in the inner-city enclave, those widowed or having husbands working, is the day-long card game, gambling, complete with the continuous consumption of betel nut and cigarettes, and the slow but steady imbibition of Budweiser or Zima. In fact, in the Khmer language, card playing and beer drinking are linguistically synonymous- "leng bier." Not surprisingly, we have seen high rates of liver disease, cirrhoses, and other concomitants to heavy alcohol consumption in this population, especially among women, with several dying in recent months of end-stage kidney and liver disease.

Similarly, many Cambodians are seen at our clinic for gastritis symptoms and the sequelae to peptic ulcer disease. Hardly do I enter a home when a woman does not approach me, half doubled over holding her stomach and complaining of epigastric distress. The first course of treatment has been Tagamet, which has been prescribed in high quantities to this segment of the community. We have even taken, somewhat unprofessionally, to calling this group the "Tagamet ladies." On repeated occasions the medicines would be completed well before the dosage indicated, suggesting either over-dosing, or more likely, the giving or bartering away of this valued commodity to others, a very common occurrence in this population. In fact, the amount of prescription medications sent from the U.S. and stockpiled in relatives' homes throughout Southeast Asia is astounding, as we have witnessed.

Furthermore, as an aspect of therapeutic diagnostics, upper GI's are indicated for patients on prolonged courses of Tagamet with no apparent relief of symptoms. Surprisingly, not one of these Upper GI's showed evidence of peptic ulcer disease. So, while there is always the possibility of differential diagnoses, the determination of no apparent organic causation points to another variable- somatization of symptoms.

Somatoform or psychosomatic disorders, defined as recurrent somatic complaints not due to any physical illness, are common in this and other resettled Cambodian populations. Here, the complaint is one guaranteed to produce a biomedical remedy. In fact, as other researchers have pointed out, in the absence of adequate psychosocial screening for this population, and a general reluctance to seek psychiatric services on their part, the medical care setting is the most frequent point of entry into mental health services.

By all accounts, mental health issues loom large in this population. For example, Carlson and Rosser-Hogan note that "a large proportion of Cambodian refugees still suffer from severe psychiatric symptoms" years after the trauma events they experienced while still in Cambodia. These premigration distress predictors have been shown to bear heavily on the acculturational outcomes of not only Cambodians but Vietnamese and Lao refugees as well.

Conclusions

In sum, we have shown that there are various layers to refugee health and illness, and outreach must be broadly-based in order to address this range, from the acute to the chronic. In the refugee, illness from the refugee experience and morbidity as a consequence of resettlement are two distinct entities. For long-term resettled refugees like Cambodians and other Southeast Asians, some having been here fifteen years or more, there is a general dearth of long-term care. It is often an uphill battle to get support for outreach efforts in this community, particularly in light of the more acute, and quite frankly more public health-threatening illnesses of the more recent arrivals. Clearly, public health agencies must continue to focus on identifying and treating acute diseases, and primary care providers need to do more outreach into addressing health risk behaviors, e.g. alcohol abuse, before the chronic problems develop. Integral to this situation is a discussion of definition- When does one stop being a refugee? While there is no simple answer, we believe that the legal and political definitions drawn are frequently far too limited and unrealistic. Of course, the history of the United States is built upon the successful adaptation of immigrant and refugee groups. However, it is obvious that some refugees remain who are not here by choice and who may even wish to return home if they could, and this "hidden minority" must not be forgotten.

Health Risks and Screening Parameters (Note that these are not completely inclusive. Clinical and other judgments are essential in determining health risks and screening requirements of groups and individuals). Conditions in regions of the world change and problems not noted here may arise (Ackerman, 1997; Gavagan & Brodyaga, 1998). A more complete discussion of health risks, endemic diseases, and related is found in the Infectious Disease section of this web site.

Health Risks: Global

  • Malnutrition
  • Intestinal parasites (amebiasis, giardiasis, ascariasis, strongyloidiasis, hookworm, trichuriasis, enterobiasis)
  • Hepatitis B
  • Tuberculosis
  • Low immunization rate (risk for measles, mumps, rubella, diptheria, pertussis, tetanus)
  • Dental caries
  • Malaria
  • Syphilis, other STDs, including HIV infection
  • Diarrheal illnesses
  • Long-term effects of trauma, rape, torture (PTSD)
  • Neonatal tetanus
  • Rheumatic heart disease
  • Among children, high lead levels are increasingly seen world-wide

Screening Recommendations (Global): See regions, below; and the updated and more complete Infectious Disease section of this web site.

Health Risks in Refugees from East Africa

  • Malnutrition
  • Intestinal parasites (Enterobius, Trichuris, Strongyloides, and Ascaris)
  • Filariasis
  • Leishmaniasis
  • Hepatitis B
  • Tuberculosis
  • Low immunization rate
  • Dental caries
  • Typhoid fever
  • Malaria
  • Trachoma
  • Syphilis
  • Dengue fever
  • HIV infection
  • Diarrheal illnesses
  • Hansen's disease

Recommended Laboratory and Other Tests for Refugees from East Africa

  • Nutritional assessment
  • Stool for ova and parasites
  • Hepatitis B surface antigen
  • Hemoglobin or hematocrit
  • VDRL
  • HIV
  • PPD
  • Peripheral smear for malaria should be considered

Other problems that practitioners should be especially alert to are cervical cancer, ectoparasites, and post-traumatic stress disorder.

Health Risks in Refugees from Latin America (except Cuba, where the primary risks are malnutrition, tuberculosis, and dengue fever)

  • Malaria
  • Intestiinal parasites (helminthic, amebiasis, giardiasis)
  • Hepatitis B
  • Low immunization rate (risk for measles, mumps, rubella, diptheria, pertussis, tetanus)
  • Chagas disease (trypanosomiasis)
  • Filariasis, Leishmaniasis, onchocerciasis, lymphaticfilariasis, cysticercosis, schistosomiasis, echinococcosis
  • Typhoid fever
  • STDs, including HIV

Recommended Laboratory and Other Tests for Refugees from Latin America (except Cuba, where recommended tests are nutritional assessment, PPD, and consider hemoglobin or hematocrit)

  • Nutritional assessment
  • Stool for ova and parasites
  • Hepatitis B surface antigen
  • Hemoglobin or hematocrit
  • VDRL
  • HIV
  • PPD

Health Risks in Refugees from the Middle East

  • Thalassemia
  • Schistosomiasis
  • Parasites (hookworm, amoebae, echinococcosis)
  • Leprosy
  • Tuberculosis
  • PTSD

Recommended Laboratory and Other Tests for Refugees from the Middle East

  • Nutritional assessment
  • Stool for ova and parasites
  • PPD

Hepatitis B surface antigen and hemoglobin or hematocrit should be considered

Health Risks in Refugees from Asia

  • Nutritional deficits
  • Hepatitis B
  • Tuberculosis
  • Parasites (roundworm, hookworm, filaria, flukes, amoebae, giardia)
  • Malaria
  • HIV
  • Hansen's disease
  • PTSD

Recommended Laboratory and Other Tests for Refugees from Asia

  • Nutritional assessment
  • Stool for ova and parasites
  • Hemoglobin or hematocrit
  • PPD

VDRL should be considered

Health Risks in Refugees from Eastern Europe or Russia

  • Nutritional deficit
  • Hepatitis B
  • Tuberculosis
  • PTSD (Bosnia)

Recommended Laboratory and Other Tests for Refugees from Eastern Europe or Russia

  • Hepatitis B surface antigen
  • PPD

Nutritional assessment, hemoglobin or hematocrit, and (for Bosnians) stool for ova and parasites should be considered.

The below health assessment forms are from the Dallas County Health Department


Adult Health Assessment Form

Date ______

Adult History

Last Name ______________________ First____________________ MI _____

DOB _______________ Age _________

Address _______________________________________________________

Female History

1. Para ____________ Gravida ____________ Ab ___________

2. LMP ____________

Health History ...............No................ Yes/Comments

1. Hospitalization

2. Surgery

3. Major illnesses

4. Allergies

5. Drug allergies

6. Accidents

7. Recent medications/remedies

8. Immunizations (attach record)

9. Smoking

10. Alcohol use

Review of Systems ................................. Norm .............. Abnorm/Comments

1. General (malnutrition, wt., fever)

2. Skin (rash, scars, wounds)

3. Neuro (seizures, HA, vision, hearing)

4. ENT (throat, masses, caries, discharge)

5. Chest (SOB, cough)

6. Heart (BP, pain)

7. GI (N&V, constipation, bloody stool)

8. GU (discharge, hernia, urinary problems)

GYN (preg., discharge, bleeding, b.c.)

9. Ortho (limp, pain, swelling, back pain)

10. Psych (depression, anxiety, nightmares, suicidal)

ADULT ASSESSMENT

Height ______ Wt ______ BP ______ Temp ______ P ______ R ______

Hgb ________ PPD ________ UA ________

O&P ________________________________________________

Concerns

 

 

Referrals Reason

__________ Medical _________________________________

__________ Dental _________________________________

__________ Hospital _________________________________

 


Pediatric Health Assessment Form

Date ______

Pediatric History

Last Name _______________________ First_________________ MI ______

DOB _______________ Age _________

Address _______________________________________________________

Birth History No Yes/Comments

1. Problems in pregnancy

2. Problems in birth

3. Maternal medications

Health History

1. Hospitalization

2. Surgery

3. Major illnesses

4. Allergies

5. Drug allergies

6. Accidents

7. Recent medications/remedies

8. Needs immunization (attach record)

 

Review of Systems Norm Abnorm/Comments

1. General (malnutrition, wt., fever)

2. Skin (rash, scars, wounds)

3. Neuro (seizures, HA, vision, hearing)

4. ENT (throat, masses, caries, discharge)

5. Chest (SOB, cough)

6. Heart (murmers, pain)

7. GI (N&V, constipation, bloody stool)

8. GU (discharge, hernia, urinary problems)

9. Ortho (limp, pain, swelling, back pain)

10. Psych (depression, anxiety, nightmares, suicidal)

 

Pediatric Assessment

Height _____ Wt ____ FOC _____ BP _____ Temp _____ P _____ R _____

Hgb ________ PPD ________ UA ________ NBS _________

O&P ________________________________________________

Concerns

 

 

Referrals Reason

__________ Medical _________________________________

__________ Dental _________________________________

__________ Hospital _________________________________

 

Recommend visiting the Infectious Disease section of this web site.

Top OR Back to Refugee Health

 

References

Ackerman, L. K. (1997). Health problems of refugees. Journal of the American Board of Family Practice, 10(5), 337-348.

Ethnomed

Gavagan, T. & Brodyaga, L. (1998). Medical Care for immigrants and refugees. American Family Physician, 57(5), 1061-1068.