Refugee 101
for 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, is
unwilling 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
`80,000 Arrivals in FY 2010
Latin
America/The
Carribean
7%
Africa
21%
East Asia
23%
Europe/Central
Asia
3%
South Asia
46%
Refugee in Tucson
Top 10 Nations – 6 years summary
Total: 4,376
1200
1000
800
600
400
200
0
985 973
676
362
243 214 177 154
111 104
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 Nepaleseinfluenced 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)
Resettlement in Tucson
PRE-ARRIVAL:
Locate & Furnish Apartment
Connect utilities
6 MONTHS:
Start paying on
IOM Travel Loan
1 YEAR:
Apply for Permanent
Residency (Green Card)
5 YEARS:
Apply for Citizenship
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
Challenges of Resettlement
• Insufficient financial assistance for the first 90
days ($900 per person)
• Shortage of Staff
• Caseload
Resettlement in Tucson
 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.)
REFUGEE HEALTH CARE
REQUIREMENTS
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
Health Insurance
RMAP
AHCCCS
• Federally-funded
• Arizona/Federal Medicaid
temporary public benefits
health insurance program
program for new refugees
for qualified low-income
residents
• Covers medical costs during
first 8 months not covered • Coverage for medically
by AHCCCS
necessary care with
limitations
• Also covers immunizations
and dental and eye exams
• Broader coverage for
for refugees including over
children under 21 years and
21 years
ALTCS members
Preventive Health Screening
• 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
Common Refugee Health Issues
Mental
Health
Chronic
Conditions
Headache
PTSD
Anemia
Neck pain
Depression
Asthma
Back Pain
Anxiety
Abdominal Pain
Adjustment Disorder
Pain
Female Pelvic Pain
Social Isolation
Diabetes
Dyslipidemia
COPD
Hypertension
Vitamin D def
Vitamin B12 def
(Bhutanese)
Vaccine Requirements for Green Card
Patient and Provider Challenges
 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
Link between Migration & Resettlement Health
Burden
• 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
Mental Health
Considerations
Triple Trauma Paradigm
• Pre-Flight
– Disruption, secrecy, fear, traumatic events
• Flight
– Food insecurity, separation, lack of trust
• Resettlement
– Cultural isolation, loss of status, limited social
support
Pre-flight
•
•
•
•
•
•
Kidnappings
Rapes
Threats of harm
Family members tortured and killed
Tortured by militia or government officials
Witnessing and experiencing shootings and
bombings
• Long term discrimination and oppression
Flight
•
•
•
•
Limited resources
Lack of status
Discrimination
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 English
Refugees who speak excellent English
A family that is less educated
A family that is highly skilled and educated
People that seem very conservative or foreign
People 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