Health Care for Refugees Resettled in the US
In the past 30 years, some three million refugees have fled their native lands, seeking resettlement in the United States. Those without high-risk infectious diseases may begin the resettlement process, but how many will visit your practice with chronic noninfectious illnesses, untreated traumatic injuries, or other conditions requiring diagnosis and management? Are you prepared to help these patients overcome potentially significant language and cultural barriers to effective health care?
It is estimated that three million refugees from all over the world—forced to flee their native countries for various reasons—have entered the United States since 1980.1,2 Prior to resettling in the US, refugees undergo health screenings for high-risk infectious diseases that preclude emigration; those free of such diseases may enter. However, the civil surgeon who conducts a refugee’s medical examination does not screen for chronic diseases that are not considered a threat to public health. Other infectious illnesses, previous traumatic injuries, and mental health issues may also go undetected at this exam.
Refugees may have had little or no access to health care before their arrival in the US, lived in conditions that increased their risk for exposure to various illnesses, and experienced traumatic events before fleeing their native lands. After their arrival, refugees may face access issues, including language and cultural barriers, health care ineligibility, and lack of transportation. This article seeks to increase awareness among primary care practitioners of the needs and issues of refugees who may be seen in their practices for conditions that developed before their arrival in the US and others emerging since their resettlement.
This activity will begin with an overview of who refugees are, how they come to reside in the US, and the medical process they undergo before resettlement. Next follows a discussion of medical issues that practitioners should be aware of among refugees, including conditions not commonly seen in the US. Finally, language and cultural issues will be addressed, including an explanatory model3 to help bridge discrepancies between practitioners of Western medicine and patients of non-Western traditions.
Man, 58, from Burundi
At age 55, the patient was resettled to the US with his family. Since then, he has had trouble holding a job, and his difficulties have been attributed to the stress of transition to life in the US. His current employer has sent him for an occupational examination. Findings are within normal limits except for visual acuity, which is tested at 20/25 in his right eye and 20/200 in his left. When asked, the patient reports having had “river blindness,” that is, onchocerciasis, as a child. Onchocerciasis is an uncommon cause of permanent blindness.
BACKGROUND AND DEFINITIONS
Refugees are defined by US Citizenship and Immigration Services4 as “people who have been persecuted or fear they will be persecuted on account of race, religion, nationality, and/or membership in a particular social group or political opinion.” The United Nations High Commission for Refugees (UNHCR)5 adds that a refugee “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.”
The man from Burundi came to the US through a long, complicated process. His family fled genocide in their native country to a refugee camp in Tanzania. Once there, they attained official refugee status, an essential part of the resettlement process. Refugees must fall into one of three processing priority categories:
(1) those referred by UNHCR, a US embassy, or a designated voluntary agency
(2) persons designated by a US refugee program as belonging to a “special humanitarian concern” group
(3) certain family members of refugees who currently reside in the US.6
The application generally involves biographical information and a family tree.7 Because they had fled their home, the family from Burundi had limited paperwork but were referred by UNHCR to the US for resettlement.
Once refugees become eligible for resettlement in the US, they undergo medical screening, security clearance, and cultural orientation. They are then placed by one of the sponsoring resettlement agencies listed in Table 1.8 This process can take from two months to several years.9 The medical screening may be performed by a panel physician, an overseas practitioner who examines refugees prior to their resettlement; or by a civil surgeon, who examines refugees after their arrival in the US—generally when the refugee applies for status adjustment.10
The man from Burundi represents a relatively common issue among refugees in the US. Many chronic conditions go untreated within this population because follow-up may be inadequate or absent, patients’ access to health care is insufficient, or the health care provider is unfamiliar with refugee issues. In this case, evaluation of the man’s vision was not part of the routine examination conducted in all refugees. Because he was never offered a subsequent vision check, his blindness went unnoticed, and his work difficulties were attributed to language and adjustment issues.
His visual problem could not be corrected, but once it was identified, accommodations were made in the workplace that facilitated his adjustment to the new work environment.
