Refugee 101for Healthcare Providers

Refugees from Rwanda arrive in Tanzania. Photo by UNHCR/ P. Moumtzis

Overview• Who is a refugee• Refugee resettlement in Tucson

– Predominant groups and background– Resettlement process and agency roles

• Refugee health– Health screenings– Common health issues and resources

• Language interpretation services• Community resources

•

What does it mean to be a refugee?

What would you do right now if bombs were falling around you?

What would you do if people of your faith or ethnic group were being singled out, tortured, and slaughtered?

What does it mean to be a refugee?

• If you had 15 minutes to

evacuate your home…

what would you take ?

What does it mean to be a refugee?

Where would you go?

Who would help you?

If you could not return

home - would you hope

that someone would

help you?

Who is a Refugee?A refugee is a person who "owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, isunwilling to avail himself of the protection of that country…"

Article 1, The 1951 Convention Relating to the Status of Refugees

Pictures: Courtesy of pubrecord.org and japanfocus.org

Who is a Refugee?This definition of a refugee does not include:

• Economic migrants• Asylum seekers• Persons displaced by natural disasters• Internally displaced persons (IDPs)

Refugees in the World

Refugees in the World ~ 11 million

Women/Children ~80%

In the Refugee Camps ~70%

Time in Camps > 10 years

Resettled in the 3rd countries (incl. USA)

< 1%

Refugees in USA

South Asia47%

East Asia23%

Africa21%

Latin America/The Carribean

7%

Europe/Central Asia3%

`80,000 Arrivals in FY 2010

Refugee in Tucson

0400800

1200985 973676

362 243 214 177 154 111 104

Top 10 Nations – 6 years summary

Total: 4,376

Iraq

• About the size of CA

Baghdad (Capital ~5.7 million

(2004)).

• Nationality: Iraqi(s).

Population (07/09): 28,945,657.

Ethnic groups: Arab 75%-80%,

Kurd 15%-20%, others ~ 5%.

Religions: Muslim 97%, Christian

and others ~ 3%.

Languages: Arabic/Kurdish

Iraqi Refugees

Bhutan

• Location: Southern Asia, between

China and India

• Population: `710,000

• Constitutional Monarchy

• Languages: Dzongkha (official),

Tibetan dialects, Nepalese

dialects (among Nepalese)

• Ethnicity/race: Bhote 50%, ethnic

Nepalese 35%, indigenous or

migrant tribes 15%

• Religions: Lamaistic Buddhist

75%, Indian- and Nepalese-

influenced Hinduism 25%

Bhutanese Refugees

Bhutanese Refugees

Somalia• Population (2010 est.): 10,112,453

(growth rate: 2.8%); infant mortality rate: 107.4/1000;

• life expectancy: 50• Capital: Mogadishu • (~ 1,208,800)• Languages: Somali (official),

Arabic, English, Italian• Ethnicity/race: Somali 85%, Bantu

and others 15% (including Arabs 30,000)

• Religion: Islam (Sunni)

Somali/Somali-Bantu Refugees

Democratic Republic of Congo

• Population: 67 million (2010)

• Capital: Kinshasa • Languages: French,

Lingala, Kiswahili, Kikongo, Tshiluba

• Major religions: Christianity, Islam

• Life expectancy: 47 years (men), 50 years (women) (UN)

Refugees from Congo

Eritrea

• Population: 5.2 million (UN, 2010)

• Capital: Asmara • Languages: Tigrinya (official),

Arabic (official), English (official), Tigre, Kunama, Afar, others

• Major religions: Muslim, Coptic Christian, Roman Catholic, Protestant

• Life expectancy: 59 years (men), 64 years (women) (UN)

• Infant Mortality Rate: 41.3/1,000

Eritrean Refugees

How Do Refugees Reach the US?

- Application for resettlement in a third country - Rigorous screening (medical and security)

- Interviews- Cultural orientations

Waiting time: several months to many years

Picture: www.worldreliefmn.org/the-story-in-pictures/

Refugees in the US

• Once approved, refugees are assigned to various sponsoring voluntary agencies in the United States

• 12 Nationwide Refugee Resettlement Agencies• 4 in Phoenix• 3 in Tucson (see handouts)

PRE-ARRIVAL:Locate & Furnish Apartment

Connect utilities

ARRIVAL:Pick up at Airport Home Safety Orientation

WEEK 1:DES Interview (Food

Stamps/AHCCCS)Social Security Card

RMAP card

FIRST 30 DAYS: CORE SERVICES• Ongoing cultural/home orientations• Financial/MG orientations• Health Screening (including TB

screening and Immunizations)• Begin initial doctor visits• Register adults for ESL at Pima• Bus passes• School Enrolment• Employment Assistance

6 MONTHS:Start paying onIOM Travel Loan

1 YEAR:Apply for Permanent

Residency (Green Card)

5 YEARS:Apply for Citizenship

Resettlement in Tucson

• Insufficient financial assistance for the first 90

days ($900 per person)

• Shortage of Staff

• Caseload

Challenges of Resettlement

Common challenges for new arrivals:• Living in poverty• Securing employment• Learning the language• Getting around Tucson• Navigating the healthcare system and

other government services• Adapting to American culture (time,

individualism, the status of women, etc.)

Resettlement in Tucson

Before going to USA:• Medical assessment by International Organization of

Migration/IOM:• TB-screening, Chest X-ray, RPR tests, and general

physical exam;Upon arrival to USA:• TB-screening within first 30 days• Initial medical screening within 30 days after arrival

unless stated differently;• Initial dental screening within first 30 days

REFUGEE HEALTH CARE REQUIREMENTS

Health Insurance

RMAP • Federally-funded

temporary public benefits program for new refugees

• Covers medical costs during first 8 months not covered by AHCCCS

• Also covers immunizations and dental and eye exams for refugees including over 21 years

AHCCCS• Arizona/Federal Medicaid

health insurance program for qualified low-income residents

• Coverage for medically necessary care with limitations

• Broader coverage for children under 21 years and ALTCS members

• Mandatory for all refugees within 30-60 days after arrival • Funded through RMAP• Screening for communicable diseases, mental health,

undiagnosed chronic conditions• Screening tests including TB, Hepatitis B, HIV, Syphilis,

GC/Chl, and Pregnancy test• Vaccinations for children and adults• Follow-up immunizations for adults to fulfill I-693

requirements• Immediate referrals to Center for Well-Being, OB Intake at

FMC, Infectious Diseases Providers at UMC

Preventive Health Screening

Pain

Headache

Neck pain

Back Pain

Abdominal Pain

Female Pelvic Pain

Mental Health

PTSD

Depression

Anxiety

Adjustment Disorder

Social Isolation

Chronic Condition

sAnemia

Asthma

Diabetes

Dyslipidemia

COPD

Hypertension

Vitamin D def

Vitamin B12 def (Bhutanese)

Common Refugee Health Issues

Vaccine Requirements for Green Card

Language barrier

Differences in health beliefs Differing beliefs regarding causes of health and ill health (e.g.

viruses, organ systems) Concept of chronic (vs acute) disease Concept of preventive care (e.g. CA screenings tests)

Difficulty navigating health care system Understanding medication refills Keeping set appointment times Following up with referrals to specialists

Healthy Living: Nutrition, hygiene, sanitation

Patient and Provider Challenges

• Pre-migration: exposure to infectious & parasitic diseases, physical & psychic trauma

• During flight & refugee camps: malnutrition, exposure to the elements, exposure to infectious & parasitic diseases, physical & psychic trauma

• Post-migration/Resettlement: increasing susceptibility to chronic diseases, problems & stressors of resettlement (unemployment, language, etc.)

Source: Globalhealth.gov

Link between Migration & Resettlement Health Burden

Mental HealthConsiderations

Triple Trauma ParadigmPre-Flight

Disruption, secrecy, fear, traumatic eventsFlightFood insecurity, separation, lack of trustResettlementCultural isolation, loss of status, limited social support

Pre-flightKidnappingsRapesThreats of harmFamily members tortured and killedTortured by militia or government officialsWitnessing and experiencing shootings and bombingsLong term discrimination and oppression

Flight

Limited resourcesLack of statusDiscrimination Family still in home country or no knowledge of their whereabouts

Post-flight• New town• Foreign Country• New language• New Culture• Unemployed• New Apartment• New neighbors• New school

• Crowded locations• Heavy traffic• Financial difficulties• No friends• No extended family• Unable to communicate• Role reversal• Changing Gender Roles• Impact of Torture

Services at Center for Well-Being

Clinical Services: Individual, Family and groups counseling for depression, anxiety, and severe trauma

Refugee Well-Being Project: In-home wellness promotion and informational sharing

Survivors of Torture Program: Intensive case management services for those who fit the definition of a survivor of torture

Language and Communication

• Tucson Refugees Speak:

Acholi, Amharic, Anywak, Arabic (several dialects), Bosnian (Serbian/Croatian), Dari, Dinka, English, Farsi, French, Karen, Kinyarwanda, Kirundi, Krahn, Kurdish, Lingala, Mandingo, Maay-Maay, Nepali, Mende, Ndogo, Oromo, Pushtu, Russian, Turkish,

Somali, Spanish, Swahili, Tigrinya, Uzbek, Vietnamese…

Telephone Interpretation

• Cyracom

• Language Line

Telephone Interpretation Services: Typical Process

• Call the specific health plan’s Member Services number• Request interpretation services and specify language• Be prepared to provide the patient’s:

– Name– AHCCCS ID#– DOB– Address

• Also be prepared to provide the doctor’s:– Name – Location– NPI #

Telephone Interpretation Tips

• Specific process and required information for each health plan varies

• See handouts• Contact the applicable health plan’s

Customer Service for any questions or problems

What To Expect When Working With Refugees:

Refugees who speak limited EnglishRefugees who speak excellent English

A family that is less educatedA family that is highly skilled and educated

People that seem very conservative or foreignPeople that seem very liberal or westernized

Slides from The IRC

A Few Tips:

• Release your expectations• Develop Self-Awareness

– Be aware of your worldview, values, and behaviors

– Be aware of your prejudices • Develop Awareness of Different Cultures

– Listen & Learn & Appreciate– Address Misconceptions

• Keep trying and don’t be afraid of mistakes

Slides from The IRC

Contact Information

• International Rescue Committee (IRC): 319-2128

• Lutheran Social Services: 721-4444• Catholic Social Services: 623-0344• See handout form for referrals to IRC’s

Wellbeing and Survivors of Torture Programs

• See handout on community resources