Immigrant Health Matters

Abdi Hassan, his wife, and four children are looking forward to their first trip back to visit family members in East Africa. The family arrived in Michigan seven years ago as refugees, and this is their first opportunity to see relatives in Kenya and Somalia. They are excited to introduce the extended family to their three youngest children who were born in America. Both he and his wife are taking three weeks off work during the older children’s school summer break. The cost of the trip weighed on their minds, as well as wondering whether any medical preparation was required. “I am not sure we need to see a doctor for this trip, as we are just going home,” he mused. His wife, Faduma, urged them to be seen, “Remember our friend Salah who went back and got malaria? At least I think we need malaria pills.”

Dr. Susan Clausen had a busy day at her refugee and immigrant clinic in southwestern Detroit. As a family medicine provider, she particularly enjoyed seeing families. When the Hassan family arrived, she asked if the children might be coming for camp physicals. Mr. Hassan answered, “We are here for malaria pills and any other required shots for a trip to Kenya and Somalia. We are not sure about getting shots that are not required.”¹ 

“When are you leaving?” asked Dr. Clausen. “In ten days,” came the reply. Dr. Clausen thought to herself, what can I do with so little time before they leave? I have heard about the measles outbreaks worldwide; at least I can be sure the kids are up to date with their MMR vaccines.²

Perhaps the single biggest challenge in this setting is misperception of risk, both on the part of the traveler and their health care provider. Abdi and Faduma may feel their risk is low for travel-related illnesses, having been born and raised in Somalia and Kenya. They worry more about risks for their children becoming ill than themselves. And Dr. Clausen may not be aware that the immigrant returning home – termed the VFR (visiting friends and relatives) traveler, is much more likely to develop travel-related illnesses than the tourist traveler. The data is impressive: 8.3x risk of malaria, 7.0x risk of typhoid fever, 5.6x risk of influenza, 4.8x risk of systemic febrile illness, and 3.8x risk of non-diarrheal intestinal parasites.³ Reasons for this are complex, and include last-minute travel, cost issues, risk perception, length of travel, and itinerary.^4,5 

A significant hurdle had already been overcome: Abdi and Faduma had come in to clinic with their children for advice. Always begin by thanking the family for coming in and acknowledging that they do have some unique risks. 

Dr. Clausen smiled as she explained, “Your heart may be Somali, but your bodies are now very American, so I am glad you came in.“ Realizing she only has one hour to counsel six family members, Dr. Clausen decided to focus on the issues of greatest risk, and to try to get the family in to her local travel medicine clinic in the next few days, recognizing they may choose not to go:

1. She updated selected routine vaccines for the family, including counseling on influenza, COVID, and tetanus boosters. The clinic carried hepatitis A vaccine, and she gave that as well.
2. Consulting the CDC travel medicine website, she realized the family may need yellow fever vaccine, available only at travel clinics, and had her staff start working on obtaining an urgent appointment.
3. After reviewing the CDC website, she realized she needed to avoid giving live virus vaccines, including MMR, as they could interfere with yellow fever vaccine to be given in travel clinic.
4. Once she learned the family was able to be seen in travel clinic, she knew they would be counseled on other vaccines, including yellow fever, typhoid and rabies, as well as malaria and traveler’s diarrhea prophylaxis and management. 
5. For malaria prophylaxis, she reassured the family each person would be given medications in travel medicine clinic, which would be dosed by weight, and focused her counseling on bed nets and repellents. She made certain she was confident that the family would indeed keep their travel clinic appointment. She understood that malaria in the returning VFR traveler is a significant cause of morbidity and mortality, and was prepared to give anti-malarials if necessary.
6. Lastly, she focused on a key issue in travel related morbidity and mortality: accidents. She reminded Abdi and Faduma to bring car seats, to wear seatbelts, and to avoid travel by motorcycle or at night.

Key resources

• CDC Yellow Book 2024: Visiting Friends & Relatives: VFR Travel
• Global TravEpiNet: Pre-Travel Providers’ Rapid Evaluation Portal (Pre-Travel PREP)
  A free clinical tool that guides you through preparing a U.S. traveler for a safe and healthy international trip
• International Society of Travel Medicine: Clinic Directory
  Global directory of travel and tropical medicine clinics
• Travel.State.Gov: U.S. Government Fact Sheet on Female Genital Mutilation or Cutting (FGM/C)
  Fact sheet with available translations

When Dr. Clausen realized the entire family was there to prepare for an extended trip to Kenya and Somalia, she was grateful that she had a direct connection to colleagues at her local travel medicine clinic. She began working on routine vaccine updates (avoiding live virus vaccines) while her staff secured an appointment for the family in travel medicine within the next few days. She explained to Abdi and Faduma that her clinic would begin the work of preparing the family for the trip, but that a specialized clinic is the best place to get certain vaccines recommended by the Kenyan government, particularly the yellow fever vaccine. This helped Dr. Clausen feel more confident that the family would indeed go to their travel clinic appointment.

When the family came to travel clinic, they received yellow fever vaccine, (which is now adequate for most patients lifelong), along with typhoid and MMR. Each family member was given a WHO Yellow Book and told to keep this with their passports the rest of their lives. Because the parents were visiting family in refugee camps in Kenya where there was a cholera outbreak, they were offered the oral cholera vaccine. After a discussion about the risk of rabies, particularly for young children, and the new recommendation for two shots 7 days apart for high-risk last-minute travelers, with a follow up third dose after the trip, Abdi and Faduma decided to forego the rabies vaccine and keep the children away from dogs. The provider asked if the parents knew how malaria was transmitted and reviewed ways to reduce the risk of mosquito bites, including use of bed nets and insecticides. Abdi and Faduma were relieved that all the children would receive anti-malarials. In addition, because their oldest daughter was 10 years old, the provider asked about and proactively addressed legal and medical issues in the U.S. around female genital mutilation/cutting (FGM/C). The visit ended on a positive note, thanking the family for coming in, and urging them to tell other friends and family to be seen before trips back home in the future.

Back in primary care, Dr. Clausen reviewed several articles on the VFR traveler, and realized the clinic could have a more proactive approach to this higher risk patient population. Being very interested in health equity issues, she was amazed to learn that nearly half of all travelers from the U.S. are VFR travelers, and that the proportion of VFR travelers requiring inpatient management upon return is double that of other travelers.⁶ She learned that for primary care providers who asked immigrants at an annual exam, “Are you planning on traveling home to visit within the next year?” the answer was above 60%. She decided to start asking this as a routine question on annual exams for immigrants, to proactively refer her patients to travel medicine, and to ask leadership to develop a poster to hang in clinic asking about planned international travel along with local resources in multiple languages.⁷ 

1. Daniels D, Imdad A, Buscemi-Kimmins T, Vitale D, Rani U, Darabaner E, Shaw A, Shaw J. Vaccine hesitancy in the refugee, immigrant, and migrant population in the United States: A systematic review and meta-analysis. Hum Vaccin Immunother. 2022 Nov 30;18(6):2131168. doi: 10.1080/21645515.2022.2131168. Epub 2022 Nov 4. PMID: 36332155; PMCID: PMC9746503.
2. Minta, AA, Ferrari M, Antoni S et al. Progress Towards Measles Elimination – Worldwide, 2000-2022. MMWR Morb Mortal Wkly Rep 2023;72:1262-1268
3. Leder, K. S., Tong, S., Weld, L., Kain, K. C., Wilder-Smith, A., von Sonnenburg, F., Black, J., Brown, G. V., & Torresi, J. 2006. Illness in travelers visiting friends and relatives: a review of the GeoSentinel surveillance network. Clinical Infectious Diseases, 43(9), 1185 - 1193. 
4. Barriers to malaria prevention among immigrant travelers in the United States who visit friends and relatives in sub-Saharan Africa: A cross-sectional, multi-setting survey of knowledge, attitudes, and practices. Volkman HR, Walz EJ, Wanduragala D, Schiffman E, Frosch A, Alpern JD, Walker PF, Angelo KM, Coyle C, Mohamud MA, Mwangi E, Haizel-Cobbina J, Nchanji C, Johnson RS, Ladze B, Dunlop SJ, Stauffer WM. PLoS One. 2020 Mar 12;15(3):e0229565. 
5. Bacaner N, Stauffer B, Boulware DR, Walker PF, Keystone JS. Travel medicine considerations for North American immigrants visiting friends and relatives. JAMA 2004; 291:2856–64.
6. Travel-associated disease among US residents visiting US GeoSentinel clinics after return from international travel. Stefan H F Hagmann,a,* Pauline V Han,b William M Stauffer,c et al for the  GeoSentinel Surveillance Network. Fam Pract. 2014 Dec; 31(6): 678–687.
7. Anita E Heywood, Nicholas Zwar. Improving access and provision of pre-travel healthcare for travelers visiting friends and relatives: a review of the evidence, Journal of Travel Medicine, Vol 25 (1) 2018, tay010, https://doi.org/10.1093/jtm/tay010

"We want to start seeing refugees in our clinic but don't know how to begin..."

April Garcia, RN, clinic manager for a small community clinic in central Indiana, wondered what to do about feedback she had just heard at an all-staff meeting. “I know there are lots of refugees coming to Indiana, but we aren’t seeing very many here in clinic, and we really want to do so,” said one provider. Staff discussed the constant stream of news reports about newly arriving Ukrainians, Afghans, and now even Rohingya refugees from Myanmar. The clinic social worker echoed her interest in helping, knowing the multiple stressors for new arrivals. Pharmacy staff said they would like to gear up and stock medicines which might be needed. Everyone worried about how to find professional interpreters for new arrivals. 

Additionally, resident physicians in this teaching clinic were keen to learn more global health. “What isn’t lacking is enthusiasm,” April mused, “but where do I even begin to connect to refugees and become known as a welcoming clinic? Do we have the necessary staff and expertise to take good care of new arrivals? And how do I approach this issue with clinic leadership, who are focused on our finances? I think I need to get some advice.”

How to garner support for the idea of caring for refugee, immigrant, and migrant (RIM) communities in your clinic

Ms. Garcia began with gathering information about refugee new arrivals in Indiana, seeking information from the State Refugee Health Program and resettlement agencies. She learned that 30,000 Burmese had settled in the Indianapolis area, and 10,000 more elsewhere in the state. She learned about 2023 State Department refugee quotas, primary and secondary migration, and expected arrivals to Indiana. She spoke with the State Health Department and was told that new clinics were needed to accept refugee new arrivals. She did not realize that patients come with overseas health screening and immunization records, and the state reimburses for the new arrival screening examination. Once she felt prepared, she held a meeting with the other key members of her clinic leadership: the clinic administrator and medical director. Her presentation was clear, concise, and to the point:

“The medical providers have expressed a strong interest in expanding our services for refugees; other staff are supportive and excited to do so as well. We have a lot to learn and preparations to make, but I think there is a business, legal, and quality case for providing services for refugees. On the business side, they will be our patients whether we are ready for it or not, given the demographic trends in Indiana. On the legal side, we need to be prepared to provide professional interpretive services for limited English proficient patients; studies have shown that interpreters save health systems money and improve quality of care. And we should be able to bill some health plans for the cost of providing interpreters. On the quality side, our clinic has always focused on health equity, and we can be proactive by learning more about major health issues facing refugees.”

How to assess your clinic and staff readiness for caring for RIM communities

Four key best practices define effective clinics for new arrivals:

1. Hire staff who reflect the communities served
2. Hire providers with expertise in refugee and immigrant health
3. Utilize professional interpreters for interactions with limited English proficient patients
4. Provide multidisciplinary care

These best practices can take decades to achieve, but with sustained focus, are attainable. Advertise in bilingual media outlets, including local settings where immigrants attend religious services, or at multicultural markets. Ask your bilingual staff for networking ideas. Hire providers who have received specific training in refugee and immigrant health, including in their residency training or postgraduate work. To ensure multi-lingual team members are sufficient for a health care context, consider testing their language skills through the American Council of the Teaching of Foreign Languages proficiency tests. Set a clinic rule about only using of professional interpreters, and teach staff a standard phrase to use, such as: “Thank you for offering to interpret for your family member, but we have a clinic policy to use professional interpreters whenever an interpreter is needed.” Remember that there are different options for interpreting, including phone, video, and in person. Multidisciplinary services are critical, including having a clinic social worker, community health workers if possible, and a wide range of adult, women’s health, and pediatric services. On-site pharmacists, and on-site psychiatry and psychology services are ideal. Liaison with resettlement agencies, the health department, and transportation companies for the first few visits is critical. Remember that having bilingual bicultural staff and professional interpreters is the key to attracting non-English-speaking patients.

How to make connections with RIM communities

Many state health departments have a refugee health program, and searching for specific information on state health department websites may be helpful. Your State Refugee Health Coordinator can help connect you to resources and answer questions. Find yours at HHS Office of Refugee Resettlement (ORR): Key State Contacts.

Do an internet search for refugee resettlement agencies and local refugee nonprofits; hold informational interviews with their staff and encourage their clients to consider your clinic for newcomer friendly services.

Review resources specific to best practices in care for newcomer RIM communities

This chapter provides excellent suggestions for caring for immigrants, from the specific perspective of policy makers, administrators, educators, researchers, clinicians and immigrant advocates:

Action Steps to Improve the Health of New Americans. Ohmans, P. Immigrant Medicine, Ch 4, pp 27-35. Ed Walker and Barnett, Elsevier, 2007.

Learn more about new arrivals

• Migration Policy Institute
  The Migration Policy Institute is an outstanding, authoritative resource for detailed information on migration, addressing many myths and misconceptions.
  • Refer to their excellent recent overview article, Refugees and Asylees in the United States, with updated numbers and definitions as of June 2023.
• ECHO Colorado: Newcomer Health
  This series is for health care providers who want to expand their knowledge of resettlement and health issues of newcomers, including refugee, immigrant, and migrant (RIM) populations.

Clinical resources

• CareRef is an online tool that guides clinicians – based on patient age, gender, and country of origin - through conducting a routine post-arrival medical screening of a newly arrived refugee or other immigrant to the U.S.
• VaxRef is an online tool that helps people and providers translate their vaccinations into English. It is currently available in five languages, including Ukrainian and Russian. 
• CDC: Guidance for the U.S. Domestic Medical Examination for Newly Arriving Refugees includes information on what screening and treatment, as well as vaccines, may have occurred on U.S. military bases for Afghans.
• UpToDate: Medical care of adult immigrants and refugees is a guideline for the refugee new arrival screening examination.
• There is a thriving network of clinicians, nurses, social service staff, and national experts who connect through their professional society. This includes a very useful listserv where a helpful Q&A occurs: Society of Refugee Healthcare Providers.
• Alternating between Canada and the United States annually is the premier academic event for refugee and immigrant health professionals: North American Refugee Health Conference.
• The American Academy of Pediatrics has a Council on Immigrant Child and Family Health and an active listserv. You must join the AAP to be able to access this Council’s listserv.
• UMN Medical School: Introduction to Immigrant and Refugee Health Course
  For more in-depth learning, Global Medicine at the University of Minnesota offers a free seven-hour introductory course on refugee and immigrant health care.

Connect to other national resources

• CDC: Immigrant, Refugee, and Migrant Health
• MDH: Center of Excellence in Newcomer Health
• National Resource Center for Refugees Immigrants and Migrants (NRC-RIM)
• CDC: TB Centers of Excellence for Training, Education, and Medical Consultation

April Garcia, RN was excited to present an update at her all-staff meeting, one year after connecting with the State Health Department and beginning to see more refugee new arrivals. At the onset of the outreach, she had implemented a new, more granular demographic data collection system, which went beyond race/ethnicity to include country of birth and preferred language for interacting with the health care system. They utilized the Ask Where (PDF) guidance to help staff feel more comfortable with asking country of birth. Because of this, all their clinic business and quality data could be interpreted with a health equity and business planning lens. 

“We are on our way to our goal of 40% of our staff being bilingual and bicultural – we had one staff retire and two move to other cities. We were able to hire bilingual staff to fill their positions. We hired two new providers with specific training and experience in refugee health. We also implemented the Refugee Health Decision Support tool in Epic to assist the providers still learning about refugee health. Thirty percent of our patients prefer a language other than English for interacting with our care system – and we know those languages, so we can plan interpretive services. We have been able to schedule longer appointments for more complex patients and ensure additional time needed for interpretation services. Staff retention and satisfaction with their work has gone up. Best of all, looking at our quality data, we are narrowing the gap in vaccine coverage and lead screening. We still need to focus specifically on Burmese and Somali patients and their preventive health screenings; that is a good focus for next year. We will keep focusing on achieving those four best practices, knowing it takes time to achieve that ideal. This has felt like a very fulfilling and fun year! Thanks everyone, for the great team effort!”

Mrs. Galyna Karpenko and her two children, Liliya (age 12) and Anton (age 8), had just arrived from Poland in January of 2023 to Rochester, New York. It was a world away from her home in Kyiv, Ukraine. Galyna had connected with a long standing Ukrainian American immigrant family in Rochester, who agreed to sponsor her under the U.S. government Uniting for Ukraine Program. Her husband, Ivan, stayed back to help with the war effort, and she was feeling both anxious and depressed about how he was doing, as well as overwhelmed by the myriad of administrative and social hurdles in the U.S., despite the help of her sponsoring family. As she got in to the rideshare van with her children for her first clinic visit, she wondered whether “public” medical care was any good in America and worried about what shots might be required for her children. 

Dr. Ann Wilson has her usual busy schedule in her family medicine clinic in Rochester, New York today. She has been seeing immigrants for years, including Ukrainians who have lived in the area for decades. After Russia’s invasion of Ukraine in February of 2022, her clinic began to see a surge of Ukrainian new arrivals. “I feel comfortable with the Ukrainian patients I have seen here the last decade or more, but I wonder if there are any special issues which might be impacting this newest wave of arrivals?” she mused.

Developing trusting relationships with patients

Dr. Wilson’s clinic had a good relationship with the state refugee health program and resettlement agencies, and she had negotiated with her administrative leadership the ability to have 30-minute appointments with newly arriving refugees, instead of her usual 20-minute appointments. She knew that the first appointment was a critical one for beginning to develop a trusting relationship with new patients. She also knew trust between provider and patient develops over time and is based on both the clinic staff and the provider demonstrating trustworthiness, compassion, and good communication skills. Her clinic has bilingual/bicultural staff, including Ukrainian born nurses, professional interpreters, and the ability to call the clinic directly and leave messages in Ukrainian. She understood that taking the time to explain the U.S. health care training process (high school, college, medical school, residency) would be well worth the few minutes of explanation to Ukrainian patients dubious about the quality of public vs private medical care.

Keeping up with the literature

Ukrainians have been coming to the U.S. in significant numbers since the 1880s, reaching over one million arrivals as of 2020 (U.S. Census Bureau: More Than One Million Americans Report Ukrainian Ancestry). Some came after the Holodomor (a man-made famine in 1932 and 1933), with another surge after the collapse of the former Soviet Union in 1989. Many of these earlier arrivals were Jewish and settled in New York, Pennsylvania, and elsewhere. Wilson knew that the newest Ukrainian arrivals were potentially different from these previous waves of immigrants, and decided to do a quick literature search for medical issues of note. She discovered several things of interest:

“It looks like Ukrainians have a high prevalence of chronic disease including hypertension and diabetes. And of course, mental health issues including anxiety and depression.” What was a bit surprising was the lower level of completion of routine vaccinations compared with other countries in the European region (WHO: Immunization Coverage data) and significant vaccine hesitancy. “All the more reason to listen empathetically and engender trust,” she thought. In addition, she learned about:

• Higher prevalence of tuberculosis in the Ukraine, 71/100,000 in 2021 [WHO: Incidence of tuberculosis (per 100 000 population per year)], and higher rates of MDR tuberculosis (13-32.6%) [CDC: TB Dear Colleague Letters].
• One of the fastest growing rates of HIV in Europe (WHO: HIV Country Profiles).
• Lower rates of vaccination coverage for many vaccines preventable disease (WHO: Immunization Data Portal | Ukraine).
• Significant vaccination hesitancy issues (Wilson Center: Vaccine Hesitancy in Ukraine: The Sign of a Crisis in Governance?), including fear of side effects, lack of information, and doubts about vaccine efficacy (NIH PubMed Central: Vaccine hesitancy among Ukrainian refugees).

For many Ukrainians, the U.S. approach to both acute and preventive health visits may require explanation. Many Ukrainians visit pharmacies and speak with pharmacy staff for acute illnesses. In cities, local well-known hotlines, similar to 911, are used to request home visits to assess acute symptoms. Pediatricians and well child checks are not generally available in Ukraine, and vaccines are given at school or dedicated vaccine clinics. Providers should spend time explaining to patients an overview of the U.S. health care system, including urgent care, use of 911 (which can be a very foreign concept), and preventive health care for children and adults.

Dr. Wilson’s internet search revealed a wealth of information and connection to local refugee health experts and resettlement agencies. Rochester, NY has a rich history with Ukrainian immigration, and many local agencies ready to help ease the transition for the newest arrivals (Deeply Rooted: Rochester’s Ukrainian Community, Part One). As is often the case, she learned their immigrant status was quite complex, including both humanitarian parolees and asylees, which impacts health benefits. She was grateful for the vital support provided by the clinic social worker.

Learn more about Ukrainian new arrivals

• UNHCR Data Portal: Ukrainian Refugee Situation
  Over 9 million Ukrainian nationals have fled their country, primarily to neighboring countries, for safety reasons. The situation is changing rapidly.
• CORE: Ukrainian Backgrounder (PDF)
  The Cultural Orientation Resource Exchange (CORE) has an excellent backgrounder which contains historical, political, and cultural information intended to cultivate a general understanding of refugees from Ukraine who are resettling in the United States.

Review resources specific to Ukrainian new arrival health issues

• Ukrainian Clinical Guidance
  Minnesota Center of Excellence in Newcomer Health clinical guidance for care of Afghan new arrivals
  • Guidance for Providers Caring for Newcomers Arriving through the Uniting for Ukraine Program (PDF)
    CDC Update Alert with recommendations; Aug. 25, 2022.
  • Interim Clinical Guidance for Providers Caring for Newcomers from Ukraine (PDF)
    CDC Update Alert with recommendations; May 10, 2022.
  • Vaccination Coverage and Record Translation Guidance for Health Care Providers Serving Ukrainian Newcomers (PDF)
    Center of Excellence guidance highlighting differences between U.S. and Ukrainian childhood immunization schedules, review of overseas vaccination records, samples provided by community partners, and resources.
• Health Requirements for Arrivals with Humanitarian Parolee Status
  Humanitarian Parolees may have health requirements associated with their parole status within 90 days of arrival.
• Immunity Community: Fostering COVID-19 Vaccine Confidence in Russian- and Ukrainian-Speaking Communities
  This free online continuing education course is designed to help providers better understand vaccine hesitancy and develop strategies to initiate conversations about the COVID-19 vaccine with Russian- and Ukrainian-speaking patients.

Review the approach to the refugee new arrival screening exam

• CareRef is an online tool that guides clinicians – based on patient age, gender, and country of origin - through conducting a routine post-arrival medical screening of a newly arrived refugee or other immigrant to the U.S.
• VaxRef is an online tool that helps people and providers translate their vaccinations into English. It is currently available in five languages, including Ukrainian and Russian. 
• CDC: Guidance for the U.S. Domestic Medical Examination for Newly Arriving Refugees includes information on what screening and treatment, as well as vaccines, may have occurred on U.S. military bases for Afghans.
• UpToDate: Medical care of adult immigrants and refugees is a guideline for the refugee new arrival screening examination.

Connect to colleagues

• Many state health departments have a refugee health program, and searching for specific information on state health department websites may be helpful. Visit Office of Refugee Resettlement: Key State Contacts.
• There is a thriving network of clinicians, nurses, social service staff, and national experts who connect through their professional society. This includes a very useful listserv where a helpful Q&A occurs: Society of Refugee Healthcare Providers.
• Alternating between Canada and the United States annually is the premier academic event for refugee and immigrant health professionals: North American Refugee Health Conference.
• The American Academy of Pediatrics has a Council on Immigrant Child and Family Health and an active listserv. You must join the AAP to be able to access this Council’s listserv.

Connect to other national resources

• CDC: Immigrant, Refugee, and Migrant Health
• MDH: Center of Excellence in Newcomer Health
• National Resource Center for Refugees Immigrants and Migrants (NRC-RIM)
• CDC: TB Centers of Excellence for Training, Education, and Medical Consultation
• Migration Policy Institute
  The Migration Policy Institute is an outstanding, authoritative resource for detailed information on migration, addressing many myths and misconceptions.
• ECHO Colorado: Newcomer Health
  This series is for health care providers who want to expand their knowledge of resettlement and health issues of newcomers, including refugee, immigrant and migrant (RIM) populations.
• UMN Medical School: Introduction to Immigrant and Refugee Health Course
  For more in-depth learning, Global Medicine at the University of Minnesota offers a free seven-hour introductory course on refugee and immigrant health care.

When the Karpenko family arrived, a pre-scheduled Ukrainian interpreter was there for the entire appointment. Dr. Wilson spent the first half of the visit asking Mrs. Karpenko to share the story of her journey to the U.S., her fears for her husband’s safety, and trouble sleeping. She prescribed medicines for Galyna’s hypertension and referred her to the clinic’s Russian-speaking psychologist. Hesitant at first, when Dr. Wilson did a soft hand off, inviting her colleague to briefly say hello and welcome Galyna to his practice, she seemed relieved to meet him and agreed to follow up. Dr. Wilson then asked about Liliya and Anton’s medical and vaccination history. She learned that Galyna deeply mistrusted the safety of vaccines in general and the ability of Ukraine’s health care system to safely administer vaccines. The children were behind on routine vaccines, and Galyna was very reluctant to start vaccinations at this clinic visit. Dr. Wilson explained the requirements for childhood vaccines for school in general and recommended a follow-up visit for the family next week to review lab results and continue the conversation about vaccinations. Galyna left the clinic feeling as though she had been listened to and genuinely cared about and decided to come back the next week for follow up.

Physician assistant Roberto Castillo has a busy schedule in his primary care clinic in Houston, Texas. He has been seeing immigrants for years, but in late 2021 started to see an influx of Afghans. “This is a patient population I don’t know anything about,” he thought to himself. On his schedule today was a family: father Saboor, wife Salma, and their five children, ranging in age from 3 months to 12 years old (those who viewed the November 2022 ECHO Newcomer Health: Afghan Health Considerations webinar will recognize this family was discussed in detail).

Mr. Castillo felt simultaneously interested in seeing someone from a country about which he had no knowledge and anxious about how to best care for the family. He had kept up on the humanitarian crises following the U.S. withdrawal from Afghanistan. Other than that, he knew many Afghans were coming to Texas and wondered about where he could find more information about their health issues.

Salma and Saboor were also anxious about the upcoming appointment: “How will we all get there? Will the provider be kind? Will they know anything about us and why we came to America? And why do we have to have more health checks, when we have been through so many already? We are actually more worried about finding a job for Saboor and school for our children.”

Time constraints

PA Castillo was accustomed to seeing large immigrant families, and his clinic had a good relationship with the state refugee health program and resettlement agencies. His entire morning was blocked out to see the family. A ride had been arranged and a Pashto interpreter pre-scheduled. This greatly helped with time management, and he had a few minutes to read about Afghan new arrivals while the family was being roomed.

Lack of knowledge about health issues specific to Afghans

Even though Roberto had seen refugees before, as he quickly realized from reading the rapidity of the Afghan exodus meant the usual overseas screening protocols had not been able to be followed. Many arrived at military bases in the U.S. and Europe without medical pre-screening and vaccinations. A herculean effort to house and feed over 120,000 was rapidly put together via Operation Allies Welcome. Several localized outbreaks of chickenpox, measles, and SARS-CoV-2 occurred on the bases. Vaccination programs were rapidly instituted, and tuberculosis screening began. Evacuees began leaving Afghanistan in August 2021, and the last U.S. bases housing Afghan arrivals completed their work sending Afghans on to resettlement states in October 2021.

He learned quickly that Afghanistan had poor childhood vaccine coverage, estimated by the WHO to be 60%. He also learned he should be aware of diseases including leishmaniasis, malaria (particularly Plasmodium vivax), and tuberculosis.

PA Castillo’s quick internet search revealed a wealth of information and connection to local refugee health experts and resettlement agencies. He learned that Texas was the top receiving state for newly arriving Afghans in FY2021-2022, followed by California and Virginia, and that their immigrant status was quite complex, including both parolees and special immigrant visa (SIV) holders; parolees could also become asylum seekers. He knew this would impact health benefits, and knew he would have to involve the clinic social worker for assistance.

Learn more about Afghan history and cultures

• Register to access the Caring for Newly Arrived Afghans course hosted by the University of Minnesota for an excellent brief overview of recent Afghan history and cultural issues, including a talk by Afghan-American physician, Dr. Mehria Sayad-Shah.
• CDC: Refugee Health Profiles has select refugee health profiles which can help clinicians learn more about the history and culture of patients whom they are seeing.
  • An interim Afghan Refugee and Humanitarian Parolee Health Profile is available through the Minnesota Center of Excellence in Newcomer Health.
• EthnoMed: Caring for Afghan New Arrival Community has compiled an excellent list of resources.
• The Migration Policy Institute is an outstanding, authoritative resource for detailed information on migration, addressing many myths and misconceptions.

Review resources specific to Afghan new arrival health issues

• Guidance for Clinicians Caring for Individuals Recently Evacuated from Afghanistan
  CDC's Emergency Health Alert from September 2021.
• Afghan Clinical Guidance
  Minnesota Center of Excellence in Newcomer Health clinical guidance for care of Afghan new arrivals.
• ECHO Colorado: Newcomer Health
  This series is for health care providers who want to expand their knowledge of resettlement and health issues of newcomers, including refugee, immigrant and migrant (RIM) populations.

Review the approach to the refugee new arrival screening exam

• CareRef is a tool that guides clinicians – based on patient age, gender, and country of origin - through conducting a routine post-arrival medical screening of a newly arrived refugee or other immigrant to the U.S.
• CDC: Guidance for the U.S. Domestic Medical Examination for Newly Arriving Refugees includes information on what screening and treatment, as well as vaccines, may have occurred on U.S. military bases for Afghans.
• UpToDate: Medical care of adult immigrants and refugees is a guideline for the refugee new arrival screening examination.

Connect to colleagues

• Many state health departments have a refugee health program, and searching for specific information on state health department websites may be helpful, particularly if you would like to receive copies of overseas examinations that occurred as well as domestic medical examinations of refugees. Visit Office of Refugee Resettlement: Key State Contacts.
• There is a thriving network of clinicians, nurses, social service staff, and national experts who connect through their professional society. This includes a very useful listserv where a helpful Q&A occurs: Society of Refugee Healthcare Providers.
• Alternating between Canada and the United States annually is the premier academic event for refugee and immigrant health professionals: North American Refugee Health Conference.
• The American Academy of Pediatrics has a Council on Immigrant Child and Family Health and an active listserv. You must join the AAP to be able to access this Council’s listserv.

Connect to other national resources

• CDC: Immigrant, Refugee, and Migrant Health
• MDH: Center of Excellence in Newcomer Health
• National Resource Center for Refugees Immigrants and Migrants (NRC-RIM)

Lastly, for more in-depth learning, Global Medicine at the University of Minnesota offers a free seven-hour introductory course on refugee and immigrant health care: UMN Medical School: Introduction to Immigrant and Refugee Health Course.

Saboor, Salam, and the children were able to attend the appointment with a ride arranged by their refugee resettlement agency. The clinic had arranged an in-person female Pashto interpreter, who was very welcoming. Saboor had been an interpreter for the U.S. Army and did not understand why an interpreter was needed. PA Castillo explained that the clinic has a policy that all adults are seen with a professional interpreter, and this was accepted. The clinic staff seemed kind and caring, asking about their journey to America, taking time to establish rapport, and explaining the concept of having a primary care provider and clinic for the family. Greatly appreciated at the end of the visit was time spent with the clinic social worker, who helped review housing and educational opportunities in the neighborhood. The family left the clinic feeling as though they had made a connection with a health care team in America and were on to their next challenge.

Dr. Olivia Russo looked at her schedule, and knew she was in for a busy day. After rounding at the local 20 bed hospital this morning, her afternoon was fully booked. Running her own private practice in rural Ohio, this was not unusual, often seeing 30 or more adults, children, and families in a day.

Today’s schedule, however, held something different. The name Banzalina Ilunga was unfamiliar. When she asked the nursing staff, the reply came, “That is a newly arriving refugee family – a mother and her five children.” Dr. Olivia felt simultaneously interested in seeing someone she had never met before and anxious about how to best care for Banzalina and her family. Realistically, she also had very little time to research the Democratic Republic of the Congo, it’s history and culture, and what kinds of health challenges such patients might face. She decided to do a quick internet search for “Refugees in Ohio” to learn more.

Banzalina was also anxious about the upcoming appointment: How will we all get there? Will the provider be kind? Will they know anything about me and my history, my culture, my journey to America? And what about all the vaccinations and taking so much blood? We have been through so many health checks already; why do we need more when we feel well?

Time constraints

Many providers may view a patient with limited English proficiency as a burden in their day, perhaps requiring more time with a professional interpreter, or facing the reality of no professional interpreter being available.

A state-wide group of experts in refugee and immigrant health in Minnesota surveyed providers to ask “How long would you take to answer a clinical question which may impact your health care decisions about an immigrant patient you are seeing during a busy day of scheduled patients?” The sobering answer for the majority of clinicians: “I am able to take no more than three to five minutes.”

Lack of knowledge about refugee and immigrant health issues

“Where were you born?" and "Where have you traveled?” are critical questions to ask of many patients, yet the question often is not asked, in part because the provider may not know what to do with the answer.

Lack of knowledge about available resources

Many clinicians, particularly those with few immigrants in their clinical practice, are not aware of the growing and robust body of knowledge which encompasses refugee and immigrant health. They also may not know that resources are available to guide the screening of newly arriving immigrants, as well as ongoing primary care issues more specific to immigrant groups. Such lack of knowledge may contribute to health disparities and should not be considered acceptable given the abundance of readily available resources which can be found within that three-to-five-minute reality of time available to search for answers.

Dr. Russo’s quick internet search revealed a wealth of information and connection to local refugee health experts and resettlement agencies. She learned that Ohio was one of the top 10 states receiving newly arriving refugees in FY2020 and was interested to learn more.

Learn more about refugee history and cultures

• CDC: Refugee Health Profiles has select refugee health profiles which can help clinicians learn more about the history and culture of patients whom they are seeing.
• EthnoMed: Other Cultures also has cultural profile pages.
• The Migration Policy Institute is an outstanding, authoritative resource for detailed information on migration, addressing many myths and misconceptions.

Review the approach to the refugee new arrival screening exam

• CareRef is a tool that guides clinicians – based on patient age, gender, and country of origin - through conducting a routine post-arrival medical screening of a newly arrived refugee or other immigrant to the U.S.
• CDC: Guidance for the U.S. Domestic Medical Examination for Newly Arriving Refugees includes information on what screening and treatment, as well as vaccines, may have occurred internationally for refugees (something Banzalina was worried about).
• UpToDate: Medical care of adult immigrants and refugees is a guideline for the refugee new arrival screening examination.

Connect to colleagues

• Many state health departments have a refugee health program, and searching for specific information on state health department websites may be helpful, particularly if you would like to receive copies of overseas examinations that occurred as well as domestic medical examinations of refugees.
• There is a thriving network of clinicians, nurses, social service staff, and national experts who connect through their professional society. This includes a very useful listserv where a helpful Q&A occurs: Society of Refugee Healthcare Providers.
• Alternating between Canada and the United States annually is the premier academic event for refugee and immigrant health professionals: North American Refugee Health Conference.
• The American Academy of Pediatrics has a Council on Immigrant Child and Family Health and an active listserv. You must join the AAP to be able to access this Council’s listserv.

Connect to other national resources

• CDC: Immigrant, Refugee, and Migrant Health
• MDH: Center of Excellence in Newcomer Health
• National Resource Center for Refugees Immigrants and Migrants (NRC-RIM)

Lastly, for more in-depth learning, Global Medicine at the University of Minnesota offers a free seven-hour introductory course on refugee and immigrant health care: UMN Medical School: Introduction to Immigrant and Refugee Health Course.

Banzalina and her family were able to attend the appointment with a ride arranged by her refugee resettlement agency. The clinic had arranged an in-person Lingala interpreter, whom Banzalina had met previously, greatly reassuring her. Dr. Russo and the clinic staff seemed kind and caring, asking about her journey to America, taking time to establish rapport. Dr. Russo even spoke to Banzalina about the stress of resettlement and hopes for the future of her children. She acknowledged that this was only the first of several future visits in which they could address further concerns. Not everything must be done or addressed at the first appointment! The shots and blood tests were hard, but Banzalina and the children were strong and left the clinic feeling as though they had made a connection with a health care team in America.

Mohamed Abdi came home from work tired, as was often the case after putting in a long day as a line worker at a turkey factory in rural Minnesota. “I am worried about what is happening at work,” he told his wife. “Many people seem to be getting sick with COVID.” She was also worried about the vaccine and it’s potential side effects, including infertility.

Mr. Abdi hadn’t decided yet whether to get the COVID-19 vaccine that many people seemed to be discussing. “I am worried about how quickly the vaccine was developed, and whether or not they worked and were safe,” he said. “Plus, I wondered about severe or long-term side effects of the vaccine, and whether I would miss more wok because of them.”

After outreach by the Health Department years earlier, he had learned that autism was not caused by the MMR vaccine but was still wary of how a COVID-19 vaccine might affect his children. “I don’t really know if our kids will qualify for the vaccine or if they should take it.”

A few weeks later, he developed symptoms, and was found to have COVID-19. Isolation and quarantine were unrealistic because of living with his large extended family, despite having a three-bedroom home. He wasn’t sure if there were treatments available to him, and he worried about the loss of income related to being away from work. He wasn’t sure where to turn with his many questions for his own health, and the health of his family.

Mr. Abdi’s experiences, while fictional, speak to many issues facing immigrant workers. Many first-generation immigrants work in essential jobs where they are in close contact with coworkers and the general public. This includes work in factories, farming, and long-term care facilities. Fields of employment, limited access to COVID-19 vaccines and healthcare more generally, health co-morbidities and other factors may have played roles in the early disproportionate toll of COVID-19 on communities of color. Many refugee and immigrant communities don’t have access to printed information and video messages in their primary language.

Of note, in the first months of the pandemic, Black people in the United States were significantly more likely to die from COVID-19 compared to white, Asian, and Latino people.¹

The remarkable good news is that the uptake of vaccines in communities of color has improved dramatically, thanks to intensive, local outreach by multiple partners. Refugee, immigrant and migrant communities brought many strengths to the work, including trusted messengers such as religious leaders, as well as local refugee organizations. The ability to ask questions in their native language was one key to acceptance.

As a recent report in MMWR² noted:

“Asian and non-Hispanic White adults had the highest COVID-19 vaccination coverage by the end of April 2021. By the end of November 2021, disparities in vaccination coverage for some racial and ethnic groups narrowed, and coverage was similar for non-Hispanic Black (78.2%), Hispanic (81.3%), Native Hawaiian and other Pacific Islander (75.7%), and non-Hispanic White (78.7%) adult.”

According to recent CDC data, within the last year, the death rate for white people is 14% higher than for Black people, and 72% higher than for Latino people.³ This is a notable public health turn around.

Ultimately, Mr. Abdi fully recovered from COVID, and after encouragement from his Imam, and discussions with his primary care provider, his family has been vaccinated and boosted.

Don’t forget the basic tenets of effective immigrant health work⁴

Help patients access health insurance; use professionally trained medical interpreters, hire providers with expertise in refugee and immigrant health; hire staff who reflect the communities they serve; provide multidisciplinary care that includes community health workers/care navigators; and establish clinics in close proximity to immigrant communities.

Connect to the community

Provide intensive outreach efforts by partnering with local community organizations, including schools and religious organizations; bring Mobile Clinics for vaccination and health outreach to areas where immigrants live and hire culturally and language- matched care navigators or other community health workers to staff these mobile clinics. Provide barrier free testing and vaccination.

National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM):

• Working with Interpretation Companies to Facilitate COVID-19 Vaccine Sign Up
• Convenient Vaccine Access for Communities
• Vaccine Campaign Partnerships with Faith-Based Organizations
• Community Health Workers
• Partnerships with K-12 Schools Serving RIM Communities
• Mobile Vaccine Units to Serve Communities

Utilize COVID-19 resources that are available in multiple language

This includes translated materials and recorded messages for those immigrants who are pre-literate:

• NRC-RIM Get the Facts Campaign
• NRC-RIM Translated Materials Library

Assure universal phone system access for non-English speaking immigrant patients

This may include, as one example, prerecorded messages in multiple languages for patients who call in to access care.

Connect to refugee and immigrant health experts

• Minnesota Center of Excellence in Newcomer Health
• Society of Refugee Healthcare Providers
• North American Refugee Health Conference
• National Resource Center for Refugees Immigrants and Migrants (NRC-RIM)

1. Covid and Race. David Leonhardt. New York Times June 9, 2022.
2. COVID-19 Vaccination Coverage by Race and Ethnicity – National Immunization Survey Adult COVID Module, United States, December 2020-November 2021, MMWR, June 10, 2022 / 71(23);757–763.
3. CDC: Coronavirus Disease 2019 (COVID-19)
4. Action Steps to Improve the Health of New Americans, P. Ohmans, in Immigrant Medicine, Editors Walker, PF and Barnett, ED, Elsevier Publishing, 2007, pp.27-35.