The world is experiencing a refugee crisis. For the United States, that means about 85,000 adults and children from Africa, the Middle East, Asia, and elsewhere fled from major conflicts in their homelands and resettled here during fiscal year 2016, according to the U.S. State Department. With President Trump’s Jan. 27 executive order on immigration, it is unclear how many refugees will arrive this year. But doctors at several institutions are prepared to treat new refugees and those who are already in the country.
Doctors are discovering that refugees come with a wide range of health needs that some communities are not prepared to address. All refugees are examined and cleared overseas for active infectious diseases or untreated psychiatric disorders before they come to the United States. Still, many arrive with undiagnosed diseases, pregnancy, chronic conditions, or emotional trauma that can be compounded by previous inadequate medical care, poverty, limited education, or language barriers. Once settled, refugees may experience care that is compromised by health care providers who lack an understanding of their cultures.
In addition, refugees are required to have basic health screening within 90 days of arrival, but few U.S. clinics who administer the screening offer patients ongoing care. “In a lot of cases, they’re screened, then given a list of primary care providers written in English and [told] ‘Good luck!’” said Jeffrey Walden, MD, an assistant professor of family medicine at the University of North Carolina (UNC) School of Medicine.
Walden directs the Refugee and Immigrant Health Clinic for the Cone Health Family Medicine Residency program in Greensboro. More than 800 refugees—including those from Congo, Sudan, Iraq, and Syria—are resettled each year in Guilford County, where the clinic is located. The area has few primary care options for new arrivals or settled refugees. UNC medical residents and students who train at the clinic have seen about 200 refugees since the clinic’s opening in late 2014.
“Our underserved safety-net clinics collapsed, and that’s where the majority of refugees were going,” Walden said. As a result, there’s a backlog of patients waiting for care. “That’s a nationwide problem,” he added.
The Greensboro clinic is one of several efforts by medical schools and teaching hospitals around the country that are addressing the urgent need to provide primary care for refugees.
Excellent training ground for students and residents
As the son of two ethnic Palestinians who immigrated to the United States from Jordan and Kuwait, fourth-year UNC medical student George Alyateem speaks Arabic and is interested in surgery and global health. He chose the Greensboro clinic for a one-month elective, during which he took patients’ social and medical histories, conducted physical exams, and conferred with Walden, who saw the patients as well. Alyateem also accompanied community-based nurses on visits to refugees’ homes.
Resident physicians rotate through the half-day weekly clinic for six weeks and remain the primary care providers for patients throughout their residencies. Both residents and medical students attend lectures on the refugee experience and related health issues.
Alyateem spoke Arabic with some patients but used the clinic’s medical interpretation service for clinical discussions. He found this clinical experience a little more demanding than others, but said the training about immigration was helpful. “If you don’t know what [refugee patients have] been through, you’re not going to know where to start and how to help,” he said.
Many patients do not know they have conditions such as diabetes or hypertension. Some have generalized abdominal pain, which may be a symptom of psychiatric illness. Sometimes, the clinic has found undiagnosed HIV, hepatitis, intestinal parasites, or latent tuberculosis.
Time and cost constraints affect refugees’ access to care, Walden said. The patients receive Medicaid at first, but it ends after several months. Non-English-speaking patients usually need more time during an office visit than other patients do. Some states pay for interpretation services, but North Carolina does not. Those factors and others are why private physicians often don’t take refugee patients, Walden said.
“My goal is to serve a need for this population but also serve our residents’ and students’ educational needs,” said Walden. “So when they graduate, they’re more open to seeing other refugees, other immigrants, and other underserved patients.”
Culturally sensitive care
The refugee health clinic at the Family Health Center of Worcester, a teaching center affiliated with the University of Massachusetts (UMass) Medical School, recently created a transitional primary care clinic. From the first visit on, patients are seen by the same provider—either a family medicine global health fellow or a family medicine attending physician, and receive help in navigating the health system. Clinic staff, providers, and learners are trained to provide culturally sensitive care.
“Refugees often come from countries where primary care, as a thing, doesn’t really exist,” said director Olga Valdman, MD. “Our system is very different and pretty complex.” The twice-weekly clinic began in 2015 and has served about 280 patients.
Families are seen together, to help them feel comfortable and reduce transportation and language difficulties. According to Valdman, medical students, residents, and fellows become skilled in recognizing and treating infectious diseases not commonly found in the general U.S. population; in this way, they learn to respect different health beliefs, cultural norms, and practices, too. Patients stay with the clinic until their medical conditions stabilize and they can make their own appointments, get referrals, use insurance, and refill prescriptions.
The refugee clinic draws on the health center’s 11 full-time staff interpreters, who are certified both as medical interpreters and patient navigators. They speak 43 languages, including Albanian, Arabic, Nepali, Somali, and Vietnamese. The interpreters help refugees ask questions, understand what is happening during the medical visit, and follow information from the health care providers.
Collaborations strengthen care
Refugee clinics often work with resettlement agencies that have case managers or volunteers to help refugees adjust and access care. The Department of Family and Community Medicine at Thomas Jefferson University created a refugee health clinic, now known as Jefferson Center for Refugee Health, in 2007 by partnering with the Nationalities Services Center (NSC), a local resettlement agency. “Our goal was to get each refugee connected to a primary care physician and have those residents or attendings become their primary care doctors,” said clinic director Marc J. Altshuler, MD, who is also associate director of Jefferson’s residency program.
Soon, the clinic and resettlement agency began addressing health-related needs beyond medical visits. “When we started seeing refugees from Bhutan, we noticed they had a deficiency in vitamin B12,” which is not part of the Bhutanese diet, Altshuler said. “NSC went into the community, to different stores, to increase B12-rich foods so the refugees could increase supplementation in their diet.”
Jefferson and NSC met with other institutions that wanted to set up clinics based on the Jefferson Center model. Altshuler talked with residents and faculty about refugee health, while the NSC provided training about immigration and resettlement. Through this collaboration, the Nemours Pediatric Refugee Clinic at Jefferson was launched. Then clinics opened at the University of Pennsylvania Health System, Drexel University College of Medicine, and Children’s Hospital of Philadelphia, among others.
To provide a coordinated system throughout the region, the Philadelphia Refugee Health Collaborative was formed in 2010. It now consists of eight refugee health clinics and three resettlement agencies. “What we have created in Philly [hasn’t been] replicated anywhere else,” said Altshuler. Members meet regularly, share best practices, and combine research efforts. The group offers training to organizations on refugee resettlement, health, cultural competency, and clinical resources.
“Everyone really put the competition aside to do what’s right and what’s best for our patients,” Altshuler said. “And working together as a collaborative was the best thing to do for them.”