Refugee health in the United States

A nurse tends to a woman in an Arizona migrant camp, 1961.

Refugee health or migrant health focuses on the health of individuals who have relocated from their country of origin, often because of factors such as political instability, war, or natural disaster.[1] Special considerations are needed to provide appropriate medical treatment for these individuals, who often face extreme adversity, violent and/or traumatic experiences, and travel through perilous regions.[2] Such considerations include screenings for communicable diseases, vaccinations, posttraumatic stress disorder, and depression.[3]

The United States has rigorous health screening guidelines for refugees and immigrants entering the country. The 1980 Federal Refugee Act enabled the US Public Health Service to facilitate health screenings for all immigrants and refugees before they depart their country of origin.[4] The screening effort is overseen by the Office of Refugee Resettlement (ORR), housed in and funded by the U.S. Department of Health and Human Services (HHS).

Both in their countries of origin and after arriving in the U.S., refugees often face obstacles in accessing medical care.[5] In their countries of origin, weak healthcare infrastructure and a scarcity of medical resources may prevent them from obtaining needed care prior to their departure. Upon arrival in the U.S., cultural and linguistic barriers can limit access to timely, appropriate care.[6]

Special health considerations for refugees

Because of the often hasty circumstances of their departures from their origin countries, refugees usually lose access to their medical records, and continuity of care is difficult to establish upon entry to the United States.[7] This is a significant problem, especially for refugees with chronic and mental health conditions.[7] Further, after arrival in the U.S., refugees may face obstacles to accessing care because of limited English proficiency and uncertainty of how to navigate the U.S. healthcare system.

For improving refugee health, individuals who can act as "cultural brokers" could help refugees to access medical services, locate pharmacies, learn about their medications, and schedule follow-up treatment.[8] Establishing communication between policymakers, frontline providers of refugee medical care, and refugees can allow for improvements in refugee health policy outcomes.[8] Also, making sure that refugees receive continuing, thorough assessments of their mental and physical health, health promotion materials in their own language, and access to specialist services (especially in cases of torture or violence) can improve the standard of health among refugee populations.[7]

In 2013, a study done by Tod Hamilton was looking to find if the post-migrant health of black immigrants to the United States varied across their countries with different conditions. The study found that their health was more favorable when migrating from a country with relatively higher ratio of enrollment in primary, secondary, and tertiary education, where tertiary education is any education pursued after high school. Immigrants who were migrating from countries with relatively lower levels of income inequality and higher life expectancies at birth were more likely to experience more favorable health than individuals born in the receiving country. After the researcher controlled for country conditions, African immigrants to the United States reported better health than non-African immigrants.[9]

A longitudinal study found that late life immigrants were less likely to suffer from cancer and also had less chronic conditions that individuals born in the U.S.. Late life immigrants were defined as individuals who were 70 years or older and had only been in the immigrant-receiving country (United States) for less than 15 years. However, these late life immigrants had worse self-reported health than the native-born individuals.[10]

Mental health

As of 1997, states are required to provide a comprehensive health screening for all newly arrived refugees in the United States, which includes a mental evaluation, as well as a physical examination. This approach has resulted in a significant number of mental health referrals and treatments, indicating a need for increased psychological support for newly-arrived refugees.[11] The most frequently diagnosed mental condition in refugee populations is post-traumatic stress disorder (PTSD), which is commonly a result of violence. Experts have found that drug therapy, through the use of serotonin uptake inhibitors, as well as cognitive therapy have been effective treatments during resettlement. However, there still exists a lack of culturally appropriate psychiatric care that prevents adequate treatment.[12]

The mental health of refugees remains an issue long after their resettlement in the United States. Refugees often experience further mental trauma after migrating due to hostility from native citizens, or even authorities at detention centers and ports of entry, which is further exacerbated by long wait times for asylum application decisions. This process generally takes anywhere from 18 months to well over two years.[13] In a study of Cambodian refugees (one of the largest refugee groups in the United States), it was found that, despite the passage of more than two decades since the end of the Cambodian civil war and refugee resettlement in the US, members of the group continue to suffer from high rates of psychiatric disorders associated with trauma.[14] Within the Cambodian refugee group, higher rates of PTSD and major depression were associated with factors such as old age, having poor English-speaking proficiency, unemployment, being retired or disabled, and living in poverty.[14] Researchers have identified a number of factors contributing to mental illness in refugee populations, including language barriers, family separation, hostility, social isolation, and trauma prior to migration. However, few doctors in the US are equipped to address these issues, and thus, there have been calls for a refugee-specific strategy for health care that ensures equal access to services for refugees, as well as universal training for physicians to handle refugee-specific conditions and circumstances.[13] Several barriers prevent Western mental health protocols and categorizations from effectively evaluating and treating refugees. For example, bereavement and demoralization are often labeled as depression in Western mental health. Moreover, access to mental health resources is often time-limited for newly-arrived refugees, which poses another challenge health professionals attempting to deliver effective and culturally appropriate care, which takes into account the unique history and cultural diversity of the refugee population.[15]

According to a study in 2013, Latino (Mexican, Cuban, Puerto Rican, or Other) women were significantly affected by pre-migration measures (migration itself and unplanned migration) that resulted in higher levels of psychological distress, but not Latino men. The study also found that both men and women were more likely to report fair or poor physical health if they migrated to the United States in an unplanned manner.[16]

Dental health

Poor oral health is the most common health-related issue among refugee children and is the second most common health issue among refugee adults.[17] Refugee children in the U.S. have been shown to have poorer oral health on average, due to lack of access to dental care.[18] As with medical care, dental care is difficult to obtain by refugee families with limited English language proficiency and limited education about proper dental hygiene.

Lead poisoning

Lead poisoning is an important health issue for children all around the world. The prevalence of elevated blood lead levels (i.e., BLLs ≥ 10 µg/dL) among newly resettled refugee children is substantially higher than the 2.2% prevalence for US children.[19] A 2001 Massachusetts study found as many as 27% of newly arrived refugee children with elevated BLLs, making refugees one of the highest risk groups.[20] Refugees may be exposed to lead from a number of sources which can include: leaded gasoline, herbal remedies, cosmetics, spices that contain lead, cottage industries that use lead in an unsafe manner, and limited regulation of emissions from larger industries.[21] The detrimental effects of lead on children may occur with no overt symptoms and blood lead testing is the only way to determine exposure or poisoning. Lead poisoning is typically treated by identifying the lead source, eliminating that source, and regularly receiving testing to ensure that blood lead levels are decreasing.[22] For extremely high blood lead levels (i.e., BLLs ≥ 45 µg/dL), chelation therapy may recommended for refugee children.[23] The CDC recommends lead testing for newly arrived refugee children younger than 16 years of age.[19] Guidelines for testing vary among states, ranging from testing children younger than six years of age to the CDC age limits of testing those younger than 16 years of age.

Infant Mortality

A study done in 2007 found that infants born to Mexican-immigrant women in the United States had a 10% lower mortality rate than infants born to non-Hispanic women in the United States. This research further support for the Hispanic paradox.[24]

Diet

A study that based its research on the New Immigrant Survey (NIS) found that Hispanic immigrants that have been in the United States the longest have experienced greater changes in their diet. Of these Hispanics with the greater change in their diet since moving to the U.S., the ones who have reported the worst health are the ones who have spent more time in the United States. Also, Hispanic immigrants who have spent the most time in the U.S. and reported worse health were also more likely to report the use of English language in their workplace. These findings demonstrate some correlation between Hispanic-immigrant health and their assimilation to American behavior in the United States.[25]

Medical screening for entry to the United States

The Centers for Disease Control and Prevention provides two major categories of refugee health guidelines:

  • The overseas medical screening guidelines provide panel physicians guidance on the overseas pre-departure presumptive treatments for malaria and intestinal parasites. These screenings are usually conducted days to weeks before the refugee departs from his or her country of asylum.[26]
  • The domestic medical screening guidelines are provided for state public health departments and medical providers in the United States who conduct the initial medical screening for refugees. These screenings are usually conducted 30–90 days post-arrival in the United States.[27]

Overseas protective actions

Three medical interventions are either required or recommended in order to contain infectious disease and reduce the medical burdens that may be associated with refugee resettlement. First is a mandatory overseas screening for all refugees and immigrants, then a recommended domestic screening for refugees, and finally a required medical component to the Adjustment of Status (Green Card) process.

These medical exams are performed by approximately 400 physicians [called Panel Physicians] selected by the US Department of State (DOS) consular officials. The CDC Division of Global Migration and Quarantine (DGMQ) provide the technical instructions and guidance to the physicians conducting the overseas exams. The screening is primarily aimed at detecting infectious diseases of public health concern. The overseas exam includes a medical history inquiry, physical exam, chest x-ray for persons older than 14 years of age (Southeast Asian refugees older than 2 years of age), and specific lab tests. Testing routinely includes screening for syphilis and HIV in people over 15 years of age.

Laws

The CDC's Division of Global Migration and Quarantine is responsible for providing the US Department of State and the United States Citizenship and Immigration Services (USCIS) with medical screening guidelines. The guidelines are developed in accordance with Section 212(a)(1)(A) of the Immigration and Nationality Act (INA), which outlines the reasons an alien is ineligible for a visa or admission to the United States, specifically based on health grounds. "The health-related grounds include those aliens who have a communicable disease of public health significance, who fail to present documentation of having received vaccination against vaccine-preventable diseases, who have or have had a physical or mental disorder with associated harmful behavior, and who are drug abusers or addicts."[28] Medical conditions recognized in refugees are categorized as Class A or Class B and are described below. If a refugee is found to have an inadmissible health-related condition, a waiver is required for the applicant to come to the US.

Class conditions

The health-related grounds for exclusion of refugees and immigrants set forth in the law are implemented by a regulation, "Medical Examination of Aliens" (42 CFR, Part 34). The regulation lists certain disorders that, if identified during the overseas medical examination, are grounds for exclusion (Class A condition) or represent such significant health problems (Class B condition) that they must be brought to the attention of consular authorities.

The purpose of the medical examination is to determine whether an alien has 1) a physical or mental disorder (including a communicable disease of public health significance or drug abuse/addiction) that renders him or her ineligible for admission or adjustment of status (Class A condition); or 2) a physical or mental disorder that, although not constituting a specific excludable condition, represents a departure from normal health or well-being that is significant enough to possibly interfere with the person's ability to care for himself or herself, or to attend school or work, or that may require extensive medical treatment or institutionalization in the future (Class B condition).

Class A conditions Class B conditions
Conditions which preclude entry to the US, including communicable diseases of public health significance, mental illnesses associated with violent behavior, and drug addiction Conditions identified as amounting to a substantial departure from normal well-being.
If a Class A condition is indicated, refugees must undergo treatment before they are eligible for entry to the U.S. If a Class B condition is indicated, refugees will likely receive treatment prior to departure from their country of origin, as well as follow-up care upon arrival in the U.S.

Domestic preventative actions

When refugees enter the United States, they must enter through one of the authorized ports of entry that have Quarantine Stations. At these locations, US Public Health Service personnel review refugees' medical documents and perform limited inspections to look for obvious signs of illness. Through an electronic notification system maintained by the CDC, state health officials in the destination state are notified and sent copies of the overseas medical exam.

Upon arrival in the US, it is recommended that refugees complete a domestic health screening that seeks to reduce health-related barriers to successful resettlement and protect the health of the US population. Domestic health exams focus on infectious disease screening, but can also offer diagnosis and treatment for other health conditions identified. The parameters of the screening are based upon the 1995 Office of Refugee Resettlement Medical Screening Protocol, but new guidance is forthcoming.

Laws

The Refugee Act of 1980, which amended the Immigration and Nationality Act to establish a domestic refugee resettlement program, has outlined several public health activities with regards to refugee resettlement. First, all state or local health officials are to be notified of each refugee's arrival so that they can provide timely treatment for health conditions of public health significance identified overseas. The Director of ORR has the authority to make grants to state or local health agencies to help them meet the costs of providing medical screening and initial medical treatment to refugees. In this way, states can provide domestic health assessment services with federal refugee funding support. To qualify for this funding, the state health assessments need to be in accordance with ORR requirements and approved by the ORR director. It is recommended that a refugee receive a health screening within 90 days of entering the United States. The screening protocols are left to state health officials with the approval of ORR.

Domestic health assessment

A Medical Screening Protocol for Newly Arriving Refugees was developed by ORR in collaboration with CDC in 1995. Many states have added requirements in addition to the ORR protocol. DHHS is now drafting guidance for an expanded domestic protocol for screening refugees. The scope of the domestic health exam includes:

  • Follow up (evaluation, treatment and/or referral) of Class A and B conditions identified during the overseas medical exam
  • Identification of persons with communicable diseases of potential public health importance that were not identified during, or developed subsequent to the overseas exam
  • Introduction of incoming refugees and eligible clients to the US health care system, and
  • Identification of conditions that could present a barrier to self-sufficiency

Adjustment of status exam

Refugees are eligible to apply for adjustment of status after one year in the US.[29] While most immigrants are required to have a full medical exam at the time of applying for adjustment of status, refugees are an exception. Refugees who arrived without a Class A condition only require vaccinations with their adjustment of status; the full medical examination is not required.[30] A full medical exam is only required for refugees if a Class A condition existed prior to arrival in the US.[31]

Sample U.S. programs

Because each state is responsible for coordinating refugee health screenings, protocols vary by state. A sampling of information about various state Refugee Health Programs are listed below:

References

  1. ↑ "Home | Immigrant and Refugee Health | CDC". www.cdc.gov. Retrieved 2017-03-24.
  2. ↑ A, Bigot; L, Blok; M, Boelaert; Y, Chartier; P, Corijn; A, Davis; M, Deguerry; T, Dusauchoit; F, Fermon. "Refugee health: an approach to emergency situations".
  3. ↑ Porter, Matt; Haslam, Nick (2001-10-01). "Forced displacement in Yugoslavia: A meta-analysis of psychological consequences and their moderators". Journal of Traumatic Stress. 14 (4): 817–834. doi:10.1023/A:1013054524810. ISSN 1573-6598.
  4. ↑ "Full text of "Refugee act of 1980 : [an act to amend the Immigration and nationality act to revise the procedures for the admission of refugees, to amend the Migration and refugee assistance act of 1962 to establish a more uniform basis for the provision of assistance to refugees and for other purposes]". archive.org. Retrieved 2017-04-08.
  5. ↑ "WHO | Overcoming migrants' barriers to health". www.who.int. Retrieved 2017-03-24.
  6. ↑ Morris, Meghan D.; Popper, Steve T.; Rodwell, Timothy C.; Brodine, Stephanie K.; Brouwer, Kimberly C. (2017-04-08). "Healthcare Barriers of Refugees Post-resettlement". Journal of Community Health. 34 (6): 529–538. doi:10.1007/s10900-009-9175-3. ISSN 0094-5145. PMC 2778771. PMID 19705264.
  7. 1 2 3 Feldman, R. (September 2006). "Primary health care for refugees and asylum seekers: A review of the literature and a framework for services". Public Health. 120: 809–816.
  8. 1 2 McNeely, Clea A.; Morland, Lyn (2017-04-09). "The Health of the Newest Americans: How US Public Health Systems Can Support Syrian Refugees". American Journal of Public Health. 106 (1): 13–15. doi:10.2105/AJPH.2015.302975. ISSN 0090-0036. PMC 4695930. PMID 26696285.
  9. ↑ Hamilton, Tod G. "Do Country‐of‐Origin Characteristics Help Explain Variation in Health among Black Immigrants in the United States?" Social Science Quarterly, vol. 95, no. 3, 2014, pp. 817-834, doi:10.1111/ssqu.12063.
  10. ↑ Choi, Sunha H. "Testing Healthy Immigrant Effects among Late Life Immigrants in the United States: Using Multiple Indicators." Journal of Aging and Health, vol. 24, no. 3, 2012, pp. 475-506, doi:10.1177/0898264311425596.
  11. ↑ Savin, Daniel; Seymour, Deborah J.; Littleford, Linh Nguyen; Bettridge, Juli; Giese, Alexis (2005). "Findings from Mental Health Screening of Newly Arrived Refugees in Colorado". Public Health Reports (1974-). 120 (3): 224–229.
  12. ↑ Adams, Kristina M; Gardiner, Lorin D; Assefi, Nassim (2004). "Healthcare challenges from the developing world: post-immigration refugee medicine". BMJ: British Medical Journal. 328 (7455): 1548–1552.
  13. 1 2 Karmi, Ghada (1992). "Refugee Health: Requires A Comprehensive Strategy". BMJ: British Medical Journal. 305 (6847): 205–206.
  14. 1 2 Marshall, Grant N. (2005-08-03). "Mental Health of Cambodian Refugees 2 Decades After Resettlement in the United States". JAMA. 294 (5). doi:10.1001/jama.294.5.571. ISSN 0098-7484.
  15. ↑ Murray, Kate E.; Davidson, Graham R.; Schweitzer, Robert D. (2010-10-01). "Review of refugee mental health interventions following resettlement: Best practices and recommendations". American Journal of Orthopsychiatry. 80 (4): 576–585. doi:10.1111/j.1939-0025.2010.01062.x. ISSN 1939-0025.
  16. ↑ Torres, Jacqueline M., and Steven P. Wallace. "Migration Circumstances, Psychological Distress, and Self-Rated Physical Health for Latino Immigrants in the United States."American journal of public health, vol. 103, no. 9, 2013, pp. 1619-1627, doi:10.2105/AJPH.2012.301195.
  17. ↑ Cote, S.; Geltman, P.; Nunn, M.; Lituri, K.; Henshaw, M.; Garcia, R.I. (2004). "Dental caries of refugee children compared with US children". Pediatrics. 114: 733–740. PMID 15574605.
  18. ↑ Reza, Mona; Amin, Maryam S.; Sgro, Adam; Abdelaziz, Angham; Ito, Dick; Main, Patricia; Azarpazhooh, Amir (2016-02-01). "ORAL HEALTH STATUS OF IMMIGRANT AND REFUGEE CHILDREN IN NORTH AMERICA: A SCOPING REVIEW". Journal (Canadian Dental Association). 82: g3. ISSN 1488-2159. PMID 27548669.
  19. 1 2 "CDC Recommendations for Lead Poisoning Prevention in Newly Arrived Refugee Children" (PDF). Centers for Disease Control and Prevention. Retrieved April 10, 2017.
  20. ↑ Geltman PL, Brown MJ, Cochran J. Lead poisoning among refugee children resettled in Massachusetts, 1995-1999" Pediatrics 2001; 108:158-162
  21. ↑ Zabel, E., Smith, M.E., O’Fallon, A. Implementation of CDC Refugee Blood Lead Testing Guidelines in Minnesota. Public Health Rep. 2008 Mar-Apr;123(2):111-6.
  22. ↑ Health, National Center for Environmental. "CDC - Lead - Lead Poisoning Prevention in Newly Arrived Refugee Children: Tool Kit". www.cdc.gov. Retrieved 2017-04-10.
  23. ↑ "Oral Chelation Therapy for Patients with Lead Poisoning" (PDF). World Health Organization. Retrieved April 10, 2017.
  24. ↑ Hummer, Robert A., et al. "Paradox found (again): Infant Mortality among the Mexican-Origin Population in the United States." Demography, vol. 44, no. 3, 2007, pp. 441-457, doi:10.1353/dem.2007.0028.
  25. ↑ Akresh, Ilana R. "Dietary Assimilation and Health among Hispanic Immigrants to the United States." Journal of Health and Social Behavior, vol. 48, no. 4, 2007, pp. 404-417, doi:10.1177/002214650704800405.
  26. ↑ "Overseas Guidelines | Immigrant and Refugee Health | CDC". www.cdc.gov. Retrieved 2017-04-08.
  27. ↑ "Guidelines: Domestic Medical Exam Newly Arriving Refugees | Immigrant and Refugee Health | CDC". www.cdc.gov. Retrieved 2017-04-08.
  28. ↑ "Immigration and Nationality Act". USCIS. Retrieved 2017-03-05.
  29. ↑ "Green Card for a Refugee". USCIS. Retrieved 2017-04-08.
  30. ↑ "Adjustment of Status". USCIS. Retrieved 2017-04-08.
  31. ↑ Centers for Disease Control and Prevention Division of Global Migration and Quarantine (DGMQ), www.cdc.gov/ncidod/dq/civil.htm
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