1

2

The Afghan refugee crisis dates back as far as 1978. Since then, as many as a third of Afghanistan's 26 million inhabitants have been forced to flee their homes, temporarily or permanently. The first wave of Afghan refugees came in April of that year, when the country's new communist regime introduced a massive agricultural reform program that the rural population deeply resented and resisted. After a wave of terror on the civilian population under Soviet rule, hundreds of thousands of refugees poured out of Afghanistan. Within two years of the invasion, some 1.5 million Afghans were refugees, mostly in
Pakistan.
By 1986, the number of Afghan refugees in Pakistan and Iran had grown to nearly 5 million. The US and other Western countries were by now supporting the Islamist resistance movement known as the mujahideen in their struggle against the Soviet-led government. When the Soviets pulled out of Afghanistan in 1989, they left in power another communist regime, which the mujahideen defeated in April 1992. Afghan refugees welcomed the mujahideen victory, and over the course of 1992 more than 1.4 million refugees returned home. But far from bringing peace to Afghanistan, the mujahideen conquest only opened a new chapter in the conflict, as warlords fought one another for small pieces of territory.
In 1994, the Taliban emerged as a significant military force, capturing Kabul two years later. This conflict displaced over 100,000 people. The Taliban, who controlled between 90 and 95 percent of Afghanistan, functioned as a repressive police state. Both women and men adhered to strict behavioral codes that prevented women and girls from working, receiving necessary health care and getting an education. In some areas, despite the hunger and grinding poverty, the Taliban obstructed international relief efforts. The
Taliban's ban on the cultivation of poppies (used to make heroin), while welcomed by the international community, left thousands of farmers who grew the crop without any livelihood, and forced many landless laborers to migrate to camps for internally displaced persons, or to Pakistan.
Cultural background: The Soviet-Afghan war has caused grave injury to the civic culture of Afghanistan.
The destruction and disruption wrought by the magnitude of the lethal technology employed was exponentially greater than that of any previous invasion in the past. In addition to extensive ecological damage, including the vicious destruction of Kabul that dwarfs anything previously experienced, the war tore the fabric of the society, threatening to undermine its confidence.
National traits once honored hallmarks of Afghan character were jeopardized. Tolerance for others, forthrightness, aversion to fanatics, respect for women, loyalty to colleagues and classmates, dislike for ostentation, commitment to academic freedom, were all compromised.
Two generations of children have grown up without knowing the joys of childhood, their lives concentrated instead on how to avoid death and deal with emotions associated with death. The war has left terrible scars on minds as well as bodies. These scars threaten to undermine the traditional social infrastructure which served for decades to dampen ethnic, religious, cultural and linguistic differences in this complex multicultural society.
While acknowledging the truth of social aberrations and political intransigence, it must also be noted that
Afghan society continues to exhibit a dynamic meld of change and continuity. Old values have by no means been discarded by the bulk of the society which still holds fast to their standards. The concepts of honor and hospitality, combined with the essence of Islam's teachings embodying honesty, generosity, frugality, fairness, tolerance and respect for others still underlies the every day life of most Afghans. A spirit of courageous conviction that viable solutions will ultimately evolve is abundantly evident as the
Afghans face their uncertain future with quiet dignity. This characteristic of Afghan society remains inviolate.
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In 1996, approximately 40 percent of Afghans were Pashtun (Durrani and Ghilzai groups). Tajiks make up the second largest ethnic group with 25.3 percent of the population, followed by Hazaras, Uzbeks, and
Turkmen.
Afghanistan's ethnic mosaic has no precise boundaries; nor is its national culture uniform. Few of its ethnic groups are indigenous; few maintain racial homogeneity. However, many resentments rising out of wars and conquests still remain.
Medical Background: Twenty-three years of unrelenting conflict, widespread human rights abuses and more recently acute drought have created devastating humanitarian conditions in Afghanistan. Over the course of Afghanistan's civil war, warring factions have repeatedly violated human rights and international humanitarian law, engaging in indiscriminate aerial bombardment and shelling, summary executions, rape, persecution on the basis of religion and the use of anti-personnel mines. Much of the country's infrastructure has been destroyed and many health workers have left their home areas, severely limiting the population's access to health services. The health status of Afghanistan’s population is among the worst in the world, especially among women and young children. One out of every four children dies before the age of five, and approximately 40 percent of the population has no access to primary health care.
Health Risks

Amebiasis

Anthrax

Brucellosis or undulant fever

Cryptococcosis

Cutaneous leishmaniasis

Cysticercosis: See tapeworm

Dracunculiasis (Guinea worm disease)

Echinococcosis (Hydatid disease)

Gnathostomiasis

Guinea worm: See Dracunculiasis

Hookworm

Hydatid disease: See echinococcus

Hymenolepiasis

Leishmaniasis

Malaria

Plague

Relapsing fevers

Schistosomiasis or Bilharzia

Taeniasis

Tapeworms and cysticercosis

Thalassemias

Toxocariasis

Trachoma

Tuberculosis

Visceral leishmaniasis (kala-azar)
4

From 1511 to its independence in 1898 Cuba was a
Spanish colony populated largely by Spanish and black African slaves (slavery was abolished in
1886). Once free of Spanish rule, the Cuban republic came quickly under the rule of dictators such as Gerardo Machado and Fulgencio Batista y
Saldivar.
Despite significant corruption and repression under these regimes, a relatively large middle and professional class developed. After years of guerilla war, communist revolutionaries led by Fidel Castro overthrew the Batista regime in 1959. Castro and the communist government have remained in power since 1959. Communist changes in government and society led to shifts (but no lessening) in repression, increased literacy rates, changes in land ownership, and increased access to basic health care. The country, however, remains impoverished, especially after the collapse of the Soviet Bloc in the early 1990s.
Cultural Background: As with other cultures, differences among Cubans exist according to social class, background, ethnicity, and other factors. Although many Cuban refugees are from urban backgrounds, significant numbers will have lived in the city for less than one generation, hence may have more rural than urban outlook on life. Almost forty years of communist rule have resulted in a culture that is definitely
Latino in nature, yet to some extent has moved away from such traditional influences as that of the Catholic
Church. For example, in a startling testimony to the power that necessity and Marxism can exert over religion, large numbers of Cuban women have had multiple abortions as a means of birth control.
The extended family is idealized and relatively common among Cubans of all social classes. (However, in many cases, the nuclear family is the basic unit of social structure. Men usually have the dominant role, but many Cuban women are outspoken and assertive in public and private. Age, social status, and education are respected. Both within and without families, deference may be given to the elderly, persons of higher social status (especially male), and those with higher education.
The language of Cuba is Spanish, though there may be differences between Spanish spoken by Cubans and the Spanish of Mexicans, for example. Many new refugees and immigrants speak only Spanish.
Conversation tends to be animated, fast, and may seem loud; and communications within families and among friends often seem warm and affectionate. Direct eye contact is the norm in almost all interactions.
Men greet one another with hand shakes and women are often physically affectionate with one another.
Both women and men tend to be passionate and express themselves in a way that may seem demanding to more reserved people. This may result in negative perceptions by health care providers who sometimes expect docility in refugees.
Medical Background: Traditional Cuban culture holds that mind, body, and spirit are inextricably intertwined. Health is viewed as a sense of well-being, freedom from discomfort. Traditionally, many
Cubans believe that moderate obesity indicates good health and thinness indicates poor health. Traditional diet (fried foods, beans, sweets) contributes to obesity and the wide availability of colas, sweets, and fast foods in the U.S. promotes it and attendant its health problems. Meat is a valued part of the Cuban diet.
While biomedical or allopathic medical practices are widespread in Cuba and germ theory is accepted and understood by most Cubans, traditional and other theories of illness causality are also incorporated in health beliefs and practices. Stress is thought to cause a variety of physical and mental health problems.
Supernatural forces (e.g., mal de ojo or evil eye) or a lack of balance are thought by some, especially the less educated, to cause or contribute to physical and mental health problems. Regardless of a person's faith
(Catholic, Protestant, Santeria, or a blend of these), spiritual care/belief is often incorporated in treatment or explanation of illness. Children, pregnant women, and postnatal women are thought to be especially vulnerable to supernaturally influenced health problems.
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Most health indicators in Cuba have shown a general improvement over the past several decades. In fact,
Cuba has the highest healthy life expectancy (68.4 years) in Latin America, which is near U.S. levels of 70 years. The infant mortality rate is the same in Cuba as in the United States (7.2 per 1000). Childhood immunizations (a key reason for improved child mortality rates) are a bright spot in Cuba. General mortality in Cuba since the 1950s and 60s is characterized by a shift from communicable diseases to marked predominance of causes associated with chronic non-communicable diseases. Mortality from diabetes, for example, has more than doubled from 9.9 per 100,000 in the 1970s to 23.4 per 100,000 in
1996.
Tuberculosis and dengue fever are the infectious diseases of greatest interest among recent refugees and immigrants from Cuba. Among Cubans there also has been found an unusual "epidemic neuropathy" which manifests as optic neuropathy with loss of central vision, peripheral neuropathy and mixed optic and peripheral neuropathy; and due probably to nutritional deficiencies.
The mental health status of Cuban refugees is probably similar to that of others who come from developing countries to live in a new and different land. That is, the prevalence of anxiety and affective disorders is likely to be somewhat higher than in non-refugee or immigrant populations. There may, in some cases, be higher rates of post traumatic stress disorder than in non-refugee or immigrant populations.
The health situation in Cuba is reflected among Cuban refugees and immigrants arriving in the U.S. Most arrive in the U.S. with vaccinations up-to-date or near up-to-date. It is common for middle-aged and older
Cubans arriving in the U. S. to present with a variety of untreated chronic illnesses such as diabetes or cardiovascular disease.
Health Risks

Tuberculosis (small risk)

Dengue fever

Malnutrition

Hepatitis A

Intestinal parasites (helminthic, amebiasis, giardiasis)

Hepatitis B

Chagas disease (trypanosomiasis)

Leptospirosis

STDs, including HIV, syphilis, and gonorrhea

Chronic noncommunicable illnesses including (in decreasing order of importance as cause of death) cardiovascular disease, malignant neoplasms, cerebrovascular disease, chronic obstructive pulmonary disease and asthma, and diabetes. The prevalence of hypertension is 30.6%.
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Ethiopia is an arid country located on the Horn of (East) Africa at the
Red Sea. Ethiopia was never colonized, but in 1935 suffered terribly at the hands of Italy's army as a prelude to WWII. The country was ruled from 1930 until 1973 by the Emperor Haile Selassie. In 1973, the
Emperor was overthrown by a group of army officers who established a repressive marxist military regime. Along with the repression came drought, famine, a secessionist movement in Eritrea, and other conflicts.
Ethiopia and Eritrea are now separate countries, but culturally are similar. Major cultural groups living in Ethiopia include the Amhara and in western Ethiopia, the Oromo. In Eritrea, Tigreans are the most common group. Other groups living in Ethiopia/Eritrea include the
Afad-Isas, Somalis, Wolaitas, Sidamas, Kimbatas, and Hadiyas.
Ethiopians/Eritreans living in the West are most often from urban backgrounds and many came with or obtained college degrees in their host countries. Most live in large urban areas on the East and West coasts as well as in Houston and Dallas. As noted in the section on families, Ethiopians/Eritreans living in the
West are disproportionately male and young.
Cultural Background
Influences operational to varying degrees in the lives of Ethiopians/Eritreans include traditional thinking
(especially among the Ormoro and those from rural backgrounds), the Coptic Church, and Islam. Amharic is the national language of Ethiopia (the Amhara people) and Tigrinya the language of Eritrea (the Tigrean people) - though both languages may be used in either country. A third language, Oromigna is used by the
Oromo people living mostly in western Ethiopia. Most Ethiopians/Eritreans prefer translations and other assistance be provided by persons from their own ethnic or linguistic group. Communication tends to be direct, with most people usually speaking softly. Among those who live in the West, eye contact is usually direct. Little emotion or affect is shown to strangers, but physical affection is common between friends.
Most Ethiopians/Eritreans are Coptic Christians (or Ethiopian Orthodox). Some are Muslim and some
Jewish - with many of the later immigrating to Israel 1985 & 1991.
The ideal family structure and living arrangement is the extended family. However, there are few truly extended Ethiopian/Eritrean families living in the West. In most families, men are dominant, although the roles of some Ethiopian/Eritrean women are changing rapidly in the West. At least in the early days of outmigration, there were many more men than women coming to the U.S. and other countries of refuge. The imbalance of men and women has changed somewhat (now 65% male and 35% female), but single
Ethiopian/Eritrean males are more common than among other refugee groups. This is particularly a problem when single men become ill and do not have the social support of family and wife.
Traditionally, disputes are settled by community (male) elders. Originally in the West there were few such men, but leaders and elders have emerged in the Ethiopian/Eritrean communities in host countries.
Medical Background: Traditional Ethiopian/Eritrean belief is that health results from equilibrium between the body and the outside world; and illness from disequilibrium. The external world may be either the physical (sun, temperature, foods, etc.) or the spiritual world. The relationship between the person and the supernatural world is very important in maintaining health and happiness. Those who live in the Western world are more likely to understand biomedical principles of causation.
Traditional herbal medicine is highly developed and widely used in Ethiopia/Eritrea. Analyses of extracts/fractions taken from traditional herbal medicines show that many such substances have significant activity against disorders for which they are used, e.g., parasites, infections, and other medical problems.
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There are at least 21 specialized traditional healers operating in Ethiopia/Eritrea. These include tooth extractors, cuppers, amulet writers, seers, herbalists, and uvula cutters.
As with many others from the Third World, Ethiopians/Eritreans put great stock in medications, with injections more valued than oral medications. Many patients are dissatisfied if medications are not given while diagnostic tests are pending or the illness does not necessarily call for medication.
Several resources note that Ethiopians/Eritreans tend to take less fluids than is healthy. Fluids are particularly a problem when a patient is in the hospital where hydration is most important and drinks are often offered with ice.
Ritual female genital cutting (FGC) is practiced by Ethiopians/Eritreans from all three major religions
(Coptic, Muslim, Jewish).
A person's mental condition is thought to play an important role in her or his physical health, hence shocking or potentially traumatic news should be given with care and with family or friend support at hand.
Many will prefer that a poor prognosis or other such news be given first to a (male) family member. Open discussion of terminal illness is not desired by most.
Family planning was not widely available in Ethiopia/Eritrea, but is well-accepted by many
Ethiopians/Eritreans in the West.
Health Risks
Although the drought has eased and the famine is far less dramatic than in the 1970s, malnutrition remains a widespread problem in rural and, to a lesser extent, urban Ethiopia/Eritrea.

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
8

While the country of Iraq holds great oil wealth, the vast majority of Iraqis have benefited little from this potential.
When Saddam Hussein rose to power in 1979, the country plunged into incessant war and internal strife. First came the disastrous 1980-88 Iran-Iraq war (a million killed at a cost of
100 billion dollars), then the “Anfal” or campaign to destroy
Kurdish culture, followed by the Gulf War upon Saddam's invasion of Kuwait in 1990, and most recently the United
States-led war of 2003. Following the 1991 Gulf War, Shiite
Muslims rebelled against the Iraqi regime. With the collapse of their rebellion in March of 1991, at least 100,000 Iraqi Shiites fled into neighboring Iran, Saudi Arabia, and the U.S.-occupied zone along the Iraq-Kuwait border. In 1994, the United States agreed to resettle these refugees. The government's decision met with considerable opposition, especially from veteran's groups, who argued that the resettled former members of the Iraqi army had been potential adversaries to
Allied troops during the war. Furthermore, the existing resettled Kurdish populations also were distrustful of these potential "agents of Saddam." Nonetheless, over 32,000 Iraqi refugees were resettled in the United
States through 2002, adding to the population of non-refugee Iraqi immigrants, for a total of about 90,000 foreign-born Iraqis. The largest populations in the U.S. are in Detroit, Chicago, and San Diego.
Cultural Background: Iraqi society can be divided into three classes: the political elite, the military and merchant class, and finally, peasants and laborers. However, class differences aside, allegiance to the extended family and tribe are stronger than allegiance to a central government. Throughout the Arab world, loyalty to the family and tribe is core to the cultural.
To Iraqis, especially Shiites, Islamic marriage is not only sacred, but also serves as a bond between families. Early marriages are not uncommon. According to Islam, men may have up to four wives, but this is not common among Shiites. At marriage, women come to live with the husband's family and married sons usually stay within the household. Children are to be the caretakers of their parents when they are elderly. Iraqi households are very private and are sometimes segregated according to gender. Women in general are subservient to male authority, although it should be noted that Iraqi women on the whole enjoy more rights than other women from the Arabian Peninsula. There are many educated and professional women, especially among Iraqi Sunnis. The husband controls the household finances, but women exert considerable influence over the children, including grown sons. Male relatives show concern over the treatment of their female kin after marriage. It is never acceptable for a man to shake the hand of a Shiite woman. Sunni women, on the other hand, are less restricted
Arabic is the universal language of Iraq. However, literacy in Arabic is rather low in Iraq, at an estimated
58%. Most Iraqis are Shiite Muslims, but the political elite, the military and merchant classes, and those living around the capital area of Baghdad in general are Sunni. In general, Shiites are more orthodox and strict in religious practices, food proscriptions, and especially, treatment of women. Both Sunnis and
Shiites adhere to “halal” laws regarding food, which are mostly specific to the consumption of appropriately prepared meat.
Medical Background: Islam and related cultural practices are important influences on health beliefs and practices. Both women and men are modest and either may resist or refuse examination or treatment by a person of the opposite gender. Dietary proscriptions and fasting requirements also influence health. During
Ramadan, for example, more conservative Muslims may refuse medications or medically-indicated foods during daylight hours. The peoples of Iraq have a long tradition of complementary and alternative medical practices, although there is much variation between tribes and across geographical areas. For example, fevers are sometimes treated with cumin and egg yolk heated in water and dipped onto a rag and put over the forehead; conjunctivitis may be treated by laying a cloth boiled in tea over the eye; respiratory distress
9

is sometimes treated with honey and lemon juice. Additionally, Henna dye is considered to have magical healing properties, and is quite commonly seen, especially on Iraqi women. Among the most conservative
Iraqi Muslims, typically the elderly, Western preventive health concepts may conflict with the belief that
God has determined one's lifespan from birth which cannot (and should not) be altered by human intervention. During hospitalizations, the eldest male present will act as family spokesman and should be included in discussions whenever possible. Life-support measures would be acceptable to most Iraqis.
Pregnant women generally receive more attention and care than usual. Some Iraqis believe that sonograms to determine the sex of a developing fetus is against God's will and should not be performed. In Iraq, midwives provide minimal prenatal care and most deliveries are at home. Circumcision of boys usually occurs within the first few days; crushed onions, sumaq seed, and other acidic foods are placed over the circumcision and the umbilicus for a few days to promote healing. During the circumcision, the person who holds the child is perceived to establish a very significant bond with the child. Females get their ears pierced at one week. Breastfeeding is the norm, a least one year, for both sexes. Rice soup, potatoes, and bread are common weaning foods, as is leban, a yogurt-based drink. Birth control is virtually non-existent in Iraq, as limiting births or interfering with conception in any way is thought by many to be against the laws of Islam as life is considered a gift from God. Likewise, abortion in any form is out of the question. In the West, some Iraqi women are beginning to use various forms of contraceptives. Support for birth control is however growing, even among husbands.
Health Risks

Amebiasis

Anthrax

Boutonneuse fever

Brucellosis or undulant fever

Cholera

Crimean-Congo hemorrhagic fever

Cysticercosis (tapeworm)

Dracunculiasis (Guinea worm disease)

Familial Mediterranean fever (Mediterranean area, primarily among persons of Sephardic Jewish,
Armenian, and Arab ancestry)

Giardia

Helminthiasis (ascariasis, echinococcosis/hydatid disease, schistosomiasis)

Hepatitis B (13% carriage rate)

Hookworm

Leishmaniasis

Malaria

Plague

Sickle cell disease or sickle cell hemoglobulinopathies

Thalassemias

Toxocariasis

Trachoma

Trematodes (liver-dwelling: clonorchiasis and opisthorchiasis; blood-dwelling: schistosomiasis or bilharzias; intestine-dwelling; and lung-dwelling: paragonimiasis)

Trichinosis (trichinella)

Tuberculosis

Typhus

Post-traumatic stress disorder

Nutritional deficits
10

The Kurds are a diverse ethnic group of an estimated 22 million living in the homeland known as Kurdistan, encompassing parts of the countries of Turkey, Iran, Iraq,
Syria, as well as provinces of the former Soviet Union. Their struggle for independence has waged for centuries, but political and ethnic divisions within the populations have prevented them from achieving unity. Hence they remain minorities, frequently persecuted, within the countries they live.
The Kurds of Iraq have a long history of persecution under the Baghdad regimes. For example, after the defeat of Iraqi forces in the Iran-Iraq War of 1988, Kurds in northern Iraq were particularly targeted for annihilation, and biological and chemical weapons ostensibly maintained for use against the Iranians were turned against them. A systematic plan, the “Anfal”, to destroy villages controlled by Kurdish resistors was launched by Saddam
Hussein in 1988. The worst of these attacks came on the Kurdish settlement of Halabja, resulting in thousands of casualties and forcing 60,000 refugees to flee to the Turkish border. Some were selected for resettlement by the international community after two to five years, while others were sent back to Iraq. A larger wave of Iraqi Kurds fled Iraq to Turkey and Iran immediately after the failed Kurdish uprising during the Gulf War, in early 1991. The most recent evacuation occurred in the fall of 1996 from Arbil following an Iraqi army incursion and internal political strife.
Cultural Background: The Kurds on the whole come from mountainous regions where they practiced pastoralism of sheep and goats and tended small farms, growing mostly wheat, rice, and fruit. While many of the Kurds have rural origins, many, fleeing warfare, are resettling in cities.
While there are cultural similarities which all Kurds share, especially historical factors, there are also many differences among Kurds. For one, there are two dialects of the Kurdish language: Sorani and Kurmanji
(Bardini), which are mostly mutually-intelligible. Most Iraqi and Iranian Kurds speak Sorani; Kurmanji is the dialect of Dohuk Province in Iraq (where most United States-resettled Kurds originated) as well as most of Turkey, Syria, and former Soviet Union. Most Kurds are also bilingual in the lingua franca of the country in which they live, for example, Arabic in Iraq, Turkish in Turkey, and Farsi in Iran. Most Kurds are literate in their own language, but only those with more advanced education, restricted generally to males, can read and write Arabic, Turkish, or Farsi.
It is appropriate to make eye contact when speaking with Kurds. When greeting, handshakes are usually appropriate between and within the sexes, and a two-handed handshake is considered especially warm and polite. The exception here is that it is inappropriate for a man to shake the hand of an elderly woman. In
Kurdistan, and between very close friends or relatives in the U.S., men may greet each other with a kiss to both cheeks. For the most devout Muslims, especially men, one is not to be touched by anyone, including a spouse, after one has ritually purified oneself prior to the daily prayers.
In terms of religion, most Kurds adhere to the Sunni tradition of Islam, which is widely practiced throughout Iraq and Turkey. A few Kurds in Iran practice Shiite Islam. In general, the status of Kurdish women is higher than in other Islamic cultures; women are not veiled, are freer to associate with men, and they may even occupy political offices. In addition to Islam, there are also converts to Judaism and
Christianity throughout Kurdistan.
Kurds tend to be strongly clannish in their social organization, organized around a male descendent. This is especially true of those descended from important political figures; overall there is much reverence paid to ancestors. Villages are often identified along extended family lines. To protect clan resources, intra-village marriage is preferred; in fact, first cousin marriage is common. Polygamy of up to four wives is allowed by
Islamic as well as cultural mores, but is not common. Marriages were frequently arranged in the past,
11

although this custom is beginning to wane. There is a strong emphasis on large families, and a preference toward males, at least in Kurdistan; not only is birth control considered amoral according to Islamic law, but having a large number of offspring guarantees the family line and provides workers for the homestead.
There are several important holidays in Kurdish culture. For one, the birth of a child is celebrated by a feast given by the parents and their family. Newborn boys are typically circumcised within the first month or two. The most important holiday is Kurdish New Year (Nawruz), on March 21, celebrating an ancient
Kurdish legend marking the independence of Kurds. Kurds also observe the religious period of Ramadan, although the strictness of adherence to the rules on fasting vary considerably according to their orthodoxy.
It might be useful to note that political feuds among Kurds may carry over in the country of resettlement.
Medical Background: Before the uprising of Kurds in Iraq in 1990-91, people in cities and some from the countryside could access regional Government hospitals in Northern Iraq or even Baghdad. However, more recently, with political events in Iraq, even the modern hospitals suffer chronic shortages of medicines and supplies. In villages, Western health care continues to be rudimentary at best; for example, children from these areas rarely receive childhood immunizations.
In terms of non-Western or traditional remedies in Kurdistan, there are shops that sell different herbs, with the proprietors knowledgeable of treatments. However, the Kurdish culture does not seem to revolve around traditional healers; it is the ranking Islamic figure, the Imam, that is seen to have curative power through his spirituality. The Imam is particularly sought after for a certain childhood affliction, " alamk " from evil spirits, which is detected by rapid pulse in the neck and legs, headache, decreased appetite, and pallor. The Imam (or other knowledgeable laypersons) checks the pulse, recites appropriate verses from the
Koran, and then blows air on the patient. Amulets are also used for specific conditions.
As to pregnancy, a midwife generally assists with birth and cuts the umbilical cord, the stump of which is then tied with a string. Until it falls off, the stump is kept clean with a crushed seed mixture (sometimes also mixed with onions), that the mother changes several times a day. In the postpartum, after 40 days, there is a special bath, in which lead mixed in water is poured over the woman to relieve her from bad spirits. While birth control was considered in violation of Islamic law in Kurdistan, this view is changing as some younger married Kurdish women are accepting various forms of birth control, especially the IUD and the pill. Alternatively, infertility is a growing concern for young couples in the West, as a high social value is placed on having children. Pregnancy outside of wedlock is still strictly taboo at this point. Abortion is considered in extreme violation of Islamic law and Kurdish culture.
In Kurd villages, most babies were delivered by midwives; in the U.S., midwives are known among the community, but provide little more than comfort to the pregnant women. Husbands here commonly accompany their wives to the delivery room. Virtually all newborns were breastfed in Kurdistan, for at least one year and sometimes longer. Weaning would always occur at subsequent conception. Here breastfeeding is still common for Kurdish women, but mixed feeding with formula and bottles is becoming common.
Health Risks

Thalassemia

Schistosomiasis

Parasites (hookworm, amoebae, echinococcosis)

Leprosy

Tuberculosis

PTSD
12

Liberia is a diverse country, and one that has undergone rapid sociocultural change in the last 25 years. All Liberians, regardless of their differences, have been touched in some way by the incredibly bloody
Liberian civil war. Liberia has vast resources of iron ore, timber, diamonds, and gold, but due to both the conflict and widespread corruption, most Liberians have never benefited from these. Infant mortality rates in the country are high, estimated at 108.1 deaths /
1,000 live births. Life expectancy at birth is 56 years for men; 61 years for women. The average woman bears 6.23 children in her lifetime. Literacy rate for those older than 15 years is 53.9% for men, but only 22.4% for women.
The Liberian conflict has early historical roots when freed American slaves resettled on the coast of West
Africa in the 1820's. The settlers generally regarded themselves as superior to the tribal peoples of the interior, and over time brought rural areas increasingly under centralized control, located in the coastal capital Monrovia. The national army became the main tool to enforce this control. By the 1970's, Liberian presidents came under increasing political pressure to reform, yet the entrenched political patronage system that had developed, coupled with a depressed worldwide economy, made reforms ineffective. Ensuing coups and insurgencies, in 1980 and 1989, only brought about more false promises and violent repressive regimes. As a mean to control, militias were constantly armed, thus creating a bloody militia warfare that has destroyed any existing structure, whether political, economic, public or social, over the past 20 years.
In eight years of conflict, over 150,000 people died, or one out of every 17 Liberians. Many of Liberia's once 2.5 million people were forced to flee from their homes, giving Liberia the largest percentage of refugees and internally displaced people in the world. Recently, President Taylor, who had won the 1997 presidential elections after an eight-year-long civil war, was never able to fully eliminate rebel groups that sought to oust him by force. Rebel attacks on Monrovia, coupled with two years of UN-imposed sanctions for Taylor’s meddling in Sierra Leone's civil war, finally prompted his abdication from power in August
2003. A transitional government - composed of rebel, government, and civil society groups - assumed control in October 2003.
Cultural Background: The personal experiences of Liberians who survived include rape, prostitution, public humiliation (such as being beaten in front of children and family members), witnessing the murder of family members and friends, loss of property and dignity, and psychological trauma, as well as, for some, the experience of perpetrating violence themselves. For those who took part in brutalities and killings, there will be long-term psychological effects.
Liberian people rarely live alone. They are more likely to live with members of their immediate and extended family. Within the family, roles are quite traditional. The men are supposed to assume the income, while the women are expected to handle all childcare and household duties. While attitudes are changing, the majority of men still do not consider women to be equal to them. Families are often large, and are seen as parts of the community. Physical punishment of a child is therefore not deemed inappropriate by an outsider.
Christianity is the dominant religion, representing around 40 per cent of Liberia’s population. Muslims represent 20 per cent and the remaining 40 per cent are animist.
English is Liberia’s official language and the main language spoken in urban areas. Other spoken languages are Mel, Kwa and Mande. American English is taught in all schools due to Liberia’s historical relationship to the US. Liberians tend to speak very fast and have developed a colloquial version of English similar to
Creole or Patois of merging words together. Also, Liberian refugees resettled in the US are likely to have suffered from a lack of schooling in the camps.
Medical Background: As is often the case in refugee-producing situations, resettled families and individuals have been affected by war-related violence, especially women, many of whom were subject to
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forced sex, either in the form of rape or as a mean to survival. There are also high incidences of psychological trauma, as a result of the violence witnessed or endured.
Liberians in the U.S. or Europe are no more likely to suffer from endemic West African diseases than anyone else, although there is a high incidence of the sickle-cell gene. Liberians just arriving or visiting from West Africa, however, may suffer from a variety of tropical ailments, including latent schistosomiasis, chloroquine-resistant malaria, yellow fever, cholera, typhoid fever, hepatitis A or B, or
STD's (especially gonorrhea, syphilis, Pelvic Inflammatory Disease/PID, or chancroid).
The use of indigenous medicines in Liberia is extremely common, and most individuals have some knowledge of certain plants that may be self-applied in times of sickness. Liberians also have an assortment of indigenous healers, or "native doctors," including herbalists, Muslim holy men, bone specialists, and increasingly, faith healers. The treatments are often complex rituals. Most Liberians see no discrepancy in attributing the etiology of disease to both naturalistic (biological) and supernatural causes. Consequently,
Liberian refugees may commonly combine indigenous and biomedical forms of treatment simultaneously.
If a physician suspects indigenous medication may be interfering with his/her own prescribed treatment, the person in charge of decision-making for the sick person (perhaps a family head) may be sensitively asked what other forms of treatment are being concurrently given. Stay away from making value-judgments about the efficacy of the other treatment, as this may simply result in false information being given.
Little or no sex education, combined with the dynamics of warfare, has resulted in high rates of sexually transmitted diseases. Female genital cutting (FGC) is also quite common in Liberia.
Health Risks

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/AIDS

Diarrheal illnesses

Hansen's disease
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Like many other African countries, the area inhabited by ethnic Somalis has experienced great divisiveness since at least the mid-1800's, when the area was carved into multiple territories. The anti-colonial, pro-
Soviet civilian government formed at independence was toppled in a coup led by General Mohammed Siad Barre in 1969. While popular at first, Barre's regime became increasing oppressive and autocratic, leading to the birth of clan-based opposition militias. In 1988, full scale civil war broke out, leading to Barre's exile in 1991. However, up to the present, the clans have continued the bloody war amongst themselves, with no government being established. The continuous warfare, together with border clashes, has brought the Somali economy to near collapse.
Mass starvation has ensued, and the level of inter-clan violence has become extreme, with rape and torture commonplace. An estimated
400,000 Somalis died during this period, and at least 45% of the population has been displaced by the fighting. Humanitarian relief forces from the U.N. and the U.S. attempted to intervene, but by spring of
1994 all foreign troops had been withdrawn due to the instability.
Beginning in 1991, at least one million Somalis fled to the neighboring countries of Djibouti, Kenya,
Ethiopia, Burundi and Yemen, adding to the already overwhelming populations of refugees in the Horn of
Africa. While most remain in refugee camps, some numbers have been repatriated, and several thousand have been resettled to the U.S. and Europe. In particular, certain clan-based ethnic groups, the Benadir and the Barawans, have been selectively resettled en masse.
Cultural Background: While Islam and the Somali language unite all of Somalia, the societal structure is markedly fractionated by membership in patrilineal clans (descent through male lines). There are a few main clans, and multiple subclans, sometimes with geographical and even social class orientations. For example, the Benadir clan group is comprised mostly of merchants and artisans living in southern coastal areas. The Barawans, on the other hand, are predominantly fishermen and small-scale artisans like shoe cobblers. Much of the current strife in Somalia is centered on clan disputes, as allegiance to the clan far outweighs allegiance to a united Somalia.
Nevertheless, Somalis almost universally can be categorized by their strong adherence to Islam, the Sunni sect in particular. Accordingly, the Islam religion shapes many aspects of Somali culture. For example, there is strict separation of the sexes, and women are expected to cover their bodies, including hair, when in public. However, women in Somali culture have considerable status, and many resettled refugee women are highly educated and held professional positions inside Somalia. Handshakes are appropriate only between men or between women and the right hand is considered clean. Birthdays are not particularly celebrated by
Somalis, and it is common for people to not know the exact date of their birth. Alternatively, the anniversary of family members' deaths are observed and celebrated. When death is imminent, a Muslim cleric, a sheik, is summoned to pray for the person's soul and recite special verses from the Koran. After death, the body is ritually cleansed and clad in white clothes for burial.
Medical Background: There are traditional medical practitioners in Somalia, especially herbalists, bonesetters and religious healers. Herbal medicines are widely used in Somalia, especially for chest and abdominal symptoms; the herbal pharmacopeia is vast, and some recipes are closely guarded by practitioners. Healers treat psychosomatic disorders, sexually transmitted diseases, respiratory and digestive diseases, and snake and other reptile bites. In some cases, concepts involving spirits can be viewed as causing illness. Ritualized dancing is used mostly for psychosomatic disorders, as well as Koranic cures.
There is, however, understanding about the communicability of some diseases, such as tuberculosis and leprosy, and isolation is sometimes performed.
Somali families are typically large: seven or eight children are considered ideal. Contraception and abortion are anathema to most Somalis, given the strong Muslim belief that pregnancy is a blessing from God and should not be interfered with. Even sexing of the fetus is not encouraged. However, prenatal care is sought by refugee Somali women in the United States, although there is a marked preference for female
15

examiners. Most women fear Caesarean section delivery, due to the belief of resulting infirmity.
Alternatively, many women are concerned that episiotomies or even natural childbirth could damage the infibulations and must be repaired.
Breast-feeding is the norm, sometimes for two or more years. However, early supplementation with animal milks in Somalia or formula in the U.S. is not uncommon, and at least some women believe erroneously that colostrum is not healthy for the newborn. Infant care includes massages and warm water baths.
Traditionally, an herb called malmal mixed into a poultice is applied to the umbilicus for a week or so.
The common practice of female genital cutting (FGC) is certain to create controversy here in the U.S. An estimated 98% of Somali girls 8-10 years of age undergo FGC, usually Type III (or infibulation), which consists of the removal of the clitoris, the adjacent labia (majora and minora), followed by the pulling of the scraped sides of the vulva across the vagina. The sides are then secured with thorns or sewn with catgut or thread. A small opening to allow passage of urine and menstrual fluid is left. An infibulated woman must be cut open to allow for intercourse on her wedding night, and the opening may then be closed again afterwards to secure fidelity to her husband. Resettled refugees are warned of the illegality of this practice in the U.S., and Somali caseworkers here are quite emphatic that it is not being performed here.
Health Risks

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
16

In Africa, the Bantu-speaking peoples make up a major part of the population of nearly all African countries south of the Sahara. They belong to over 300 groups, each with its own language or dialect.
The Somali Bantu can be subdivided into distinct groups. There are those who are indigenous to Somalia, those who were brought to Somalia as slaves from Bantu-speaking tribes but integrated into Somali society, and those who were brought to Somalia as slaves but maintained, to varying degrees, their ancestral culture,
Bantu languages, and sense of southeast African identity. It is this last group of Bantu refugees that has particularly suffered persecution in Somalia and that is therefore in need of protection through resettlement.
These Bantu originally sought resettlement to Tanzania in 1993 and 1994, and to Mozambique in 1997 and
1998, before they were considered for resettlement in the United States in 1999.
As a persecuted minority group in Somalia, the Bantu refugees have endured continual marginalization in
Somalia since their arrival as slaves in the 19 th century. Although they have lived in Somalia for approximately two centuries, these Bantu are, in many ways, viewed and treated as foreigners. This history, coupled with their cultural, linguistic and physical differences, distinguishes them from other Somali refugees who have been resettled in the United States. The culture of subjugation under which most of them lived may present special challenges to their American resettlement caseworkers.
Cultural Background: Some Bantu populations still maintain the tribal identities of their ancestral country of origin. However, unlike the nomadic Somalis, who consider clan affiliation and tribal identification sacrosanct and critical to survival, most Bantu people identify themselves by their place of residence, which, for those with strong cultural ties to Tanzania, often corresponds to their ceremonial kin grouping.
The Bantu slated for resettlement in the United States, therefore, place much less emphasis on Somali clan and tribal affiliations than do the non-Bantu Somalis who have been resettled in the United States. Other
Bantu who lived in the vicinity of nomadic Somali clans integrated into the clan system, which provided the Bantu with protection and a sense of identity with the nomads. However, as a marginalized group, the
Bantu lacked true representation in politics and access to government services, educational opportunities, and professional positions in the private sector. This exclusion also resulted in economic development policies and resource allocations that did not take into account Bantu wishes and priorities. The Bantu's lineage to slavery relegated them to second-class status—or worse—in pre-war Somalia. This overt discrimination also carried over to the Kenyan refugee camps, where the Bantu continued to experience discrimination from the other Somali groups.
In terms of religion, the Bantu are among the more liberal Muslims in Somali society.
Medical Background: There is a high birth rate among the Bantu population. An estimated 60% of the
Bantu are under 17, and 31% are under 6. There is also a risk if undiagnosed health conditions and problems once they have settled in the United States. In general, the Somalia Bantu have lower levels of health than others in the camp, primarily due to lower nutritional levels.
Although these characteristics are not unique to the Bantu, let alone other refugee populations, resettlement professionals should be prepared to deal with significant health care, sanitation, and social support issues relating to small children and mothers. For instance, the Bantu use pit latrines and are unfamiliar with typical American bathroom facilities and common sanitation items such as diapers and feminine care products.
Like other Somali groups, the Bantu circumcise both males and females. Aid workers in the refugee camps state that female circumcision practiced by some Bantu is a milder form than that practiced by the other
Somali groups. It should be noted that female circumcision is a tradition that may have accompanied Islam but is not mandated by Islam.
In the United States, the Bantu women will be further challenged if they cannot draw upon their extended family and kin networks to assist them with child rearing and moral support. Providing the Bantu women with appropriate social services and ensuring as much as possible that people belonging to the same social
17

support network are resettled in the same geographic location will assist them in their transition to
American society.
Many Somali Bantu believe that some illnesses are the result of curses or evil spirits and therefore do not seek medical attention, but go to a traditional healer. Beyond rituals, traditional treatments for illnesses often include burning, cutting or lacerations. It is also common that the milk teeth of infants are pulled to heal diarrhea during teething.
From a psychological perspective, resettlement professional and health care providers should that:
The Bantu will be struggling with the after-effects of violence and psychic and physical trauma
Successful psychosocial adaptation and well-being is complicated by an intergenerational culture of inferiority and second class status.
The Bantu have complex historical, cultural, religious and political backgrounds that need to be understood in their current context of resettlement in the United States.
There may be contentious relations between the Bantu and the Somali population in the US.
The Bantu have many psychological and spiritual assets that should be identified in families and individuals and strengthened. Although their needs are great, the Bantu should not be approached as over-dependent, hapless victims.
Health Risks

Malnutrition

Dengue fever

Hepatitis A

Hepatitis B

Hepatitis C

Hepatitis D

HIV/AIDS

Malaria

Measles

Shigellosis or bacillary dysentery

Syphyllis

Trachoma

Tuberculosis

Tyhoid

Ascariasis

Dog tapeworm

Enterobiasis or pinworm infection

Filariasis

Giardia

Guinea worm

Leishmaniasis

Schistosoma

Strongylodiasis

Trichiriasis

Dental problems
18

The people of Sudan have endured great persecution and strife for generations. Political and religious oppression, famine, floods, locusts, and warfare are endemic to Africa's largest country, covering over one million square miles. Sudan is among the poorest countries and its citizens the least literate in the world. According to the WHO, age expectancy averages 42.6 years for men and 43.5 years for women.
Civil war has raged in Sudan nearly continuously since independence from Britain in 1956. The religious war between the
Islamic fundamentalists in the north, and the diverse African ethnic groups, many of whom are Christian, in the south, has devastated the country and its people.
The Islamic government in the north has a long history of persecution of the Sudanese citizenry, especially the southerners. In the late 1980's, military leaders withheld internationally-donated food and relief supplies in the regions of the south already devastated by drought and warfare; the government in Khartoum frequently uses starvation as a warfare or political tactic. In 1988 alone, more than 250,000 Sudanese died of hunger. By 1989, inflation had risen by 80%, and the debt had risen to $13 billion, and yet there was no plan by the government in the capital of Khartoum to rebuild the country. The corruption of the country's leaders prevented aid from such organizations as the United Nations, USAID, and UNICEF from reaching the rebel-held areas. The cities swelled with refugees fleeing the devastated countryside, and millions of
Sudanese fled to the neighboring countries of Ethiopia, Uganda, Kenya, and Egypt. In 1993, it was estimated that 4,750,000 Sudanese found refuge in other countries, excluding the greater than 1,300,000 who died in the flight. From these camps, refugees from Sudan have been accepted for resettlement in the
United States since 1990.
Cultural Background: There are several different types of refugees from Sudan. The largest number in the
United States are refugees from the south of Sudan, composed of various minority ethnic groups fleeing religious and political persecution, warfare, and starvation. Additionally, there are political dissenters from the north who escaped from the oppressive Muslim fundamentalist regime in Khartoum. Many of these fled to neighboring countries, especially Ethiopia, to escape forced conscription, or in fewer cases, religious persecution, in particular against Bahai’s. There are at least ten different ethnic groups from the south that are represented as resettled refugees in the U.S. (this is by no means an exhaustive list), including the Nuer and the Dinka. For the most part, these are agriculturalists, and predominantly Christian.
Linguistically, Sudan is quite diverse, especially in the southern regions, where each tribe has its own language and sometimes several dialects. However, rudimentary Arabic language is spoken by almost all
Sudanese, as it is the common language of commerce and discourse between tribes. In southern Sudan,
English is only spoken by the educated minority. Literacy is very low, especially since schooling has been disrupted by chronic warfare.
In terms of social etiquette, there are some generalized distinctions between the Islamic north and the
African south. The separation between man and woman is more acute in the north than in the south.
Respect should always be afforded to the man as the household head, but typically mothers will be more knowledgeable about children's health and can be addressed directly, especially with southern families, where the rules of interaction are less rigid. Age also defines social interactions.
About 70% of the population of Sudan is Sunni Muslim, the vast majority in the north. About one-quarter of the peoples practice only "indigenous beliefs”, and the remainder Christian; both these groups are found mainly in the south. This Christian community is disproportionately represented in the resettled population, as their claims to asylum were the most well-founded.
19

Medical Background: There is widespread belief in Sudanese culture, especially among southerners, in the spiritual realm and its manifestations on health and illness, although the beliefs vary greatly from one tribe to the next. These spiritual beliefs and practices are observed mostly by non-Christians in the south and are sometimes sources of contention with the Christian community. In most cases, other available medical resources are resorted to when spiritual healing does not bring about the desired outcome.
There are multiple herbal and "traditional" remedies used by the Sudanese (although lack of availability limits their use here in the U.S.). For example, a widely-used cure for migraine headaches is a certain chalky compound (clay, mixed with certain leaves and water) which is rubbed over the head. To relieve the symptoms of malaria, there is a certain root chewed like a stick. One common form is called " visi ri ," a bitter shrub that bends its shoot to follow the sun. There are also certain leaves that are boiled and consumed to relieve malarial sweats; the same mixture can also be used to treat stomach disorders. For wounds, there are special leaves found in the bush which are tied over the wound like a plaster. These leaves may sometimes be burned and the ashes spread over the wound site.
Parasitism is very common amongst the Sudanese, especially tapeworms, amoebas, bilharzia (schistosoma), and roundworm (Ascaris). To cure infection from Ascaris, leaves and roots are boiled to produce a bitter liquid, which when swallowed expels the worms. Thread worm infection, under the skin, is treated by slowly rolling the emerging worm on a stick until the whole worm comes out.
All these curative measures are particularly relied upon where there is no access to clinics. Most of these cures are not commonly used by resettled refugees, as they are not readily available here, nor are the specialists who are sometimes required to carry them out.
In the United Sates, resettled Sudanese experience numerous difficulties in accessing medical care, such as the language barrier, but also name and birth date discrepancies. Most Sudanese have not had medical checkups in Sudan and therefore present with medical conditions of which they were previously unaware.
Common undiagnosed cases include diabetes, hypertension, food allergies, severe cases of depression, vision and hearing loss, and parasitism. Dental problems are also significant. Sudanese routinely share over-the-counter medications or borrow prescription medicines from others for cases of similar symptomatology. Similarly, Sudanese also tend to discontinue Western medicines as soon as symptoms resolve rather than completing the full course of treatment. Education on self-treatment and the importance of completed therapy is imperative for this population.
Health Risks

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
20

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