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Refugee 101 for Healthcare Providers. Refugees from Rwanda arrive in Tanzania. Photo by UNHCR/ P. Moumtzis. Overview. Who is a refugee Refugee resettlement in Tucson Predominant groups and background Resettlement process and agency roles Refugee health Health screenings - PowerPoint PPT Presentation
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Refugee 101for Healthcare Providers
Refugees from Rwanda arrive in Tanzania. Photo by UNHCR/ P. Moumtzis
Overview• Who is a refugee• Refugee resettlement in Tucson
– Predominant groups and background– Resettlement process and agency roles
• Refugee health– Health screenings– Common health issues and resources
• Language interpretation services• Community resources
•
What does it mean to be a refugee?
What would you do right now if bombs were falling around you?
What would you do if people of your faith or ethnic group were being singled out, tortured, and slaughtered?
What does it mean to be a refugee?
• If you had 15 minutes to
evacuate your home…
what would you take ?
What does it mean to be a refugee?
Where would you go?
Who would help you?
If you could not return
home - would you hope
that someone would
help you?
Who is a Refugee?A refugee is a person who "owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, isunwilling to avail himself of the protection of that country…"
Article 1, The 1951 Convention Relating to the Status of Refugees
Pictures: Courtesy of pubrecord.org and japanfocus.org
Who is a Refugee?This definition of a refugee does not include:
• Economic migrants• Asylum seekers• Persons displaced by natural disasters• Internally displaced persons (IDPs)
Refugees in the WorldRefugees in the World ~ 11 million
Women/Children ~80%
In the Refugee Camps ~70%
Time in Camps > 10 years
Resettled in the 3rd countries (incl. USA)
< 1%
Refugees in USA
South Asia47%
East Asia23%
Africa21%
Latin America/The Carribean
7%
Europe/Central Asia3%
`80,000 Arrivals in FY 2010
Refugee in Tucson
0400800
1200985 973 676 362 243 214 177 154 111 104
Top 10 Nations – 6 years summary
Total: 4,376
Iraq• About the size of CA
Baghdad (Capital ~5.7 million
(2004)).
• Nationality: Iraqi(s).
Population (07/09): 28,945,657.
Ethnic groups: Arab 75%-80%,
Kurd 15%-20%, others ~ 5%.
Religions: Muslim 97%, Christian
and others ~ 3%.
Languages: Arabic/Kurdish
Iraqi Refugees
Bhutan• Location: Southern Asia, between
China and India• Population: `710,000• Constitutional Monarchy• Languages: Dzongkha (official),
Tibetan dialects, Nepalese dialects (among Nepalese)
• Ethnicity/race: Bhote 50%, ethnic Nepalese 35%, indigenous or migrant tribes 15%
• Religions: Lamaistic Buddhist 75%, Indian- and Nepalese-influenced Hinduism 25%
Bhutanese Refugees
Somalia• Population (2010 est.): 10,112,453
(growth rate: 2.8%); infant mortality rate: 107.4/1000;
• life expectancy: 50• Capital: Mogadishu • (~ 1,208,800)• Languages: Somali (official),
Arabic, English, Italian• Ethnicity/race: Somali 85%, Bantu
and others 15% (including Arabs 30,000)
• Religion: Islam (Sunni)
Somali/Somali-Bantu Refugees
Democratic Republic of Congo• Population: 67 million
(2010) • Capital: Kinshasa • Languages: French,
Lingala, Kiswahili, Kikongo, Tshiluba
• Major religions: Christianity, Islam
• Life expectancy: 47 years (men), 50 years (women) (UN)
Refugees from Congo
Eritrea• Population: 5.2 million (UN,
2010) • Capital: Asmara • Languages: Tigrinya (official),
Arabic (official), English (official), Tigre, Kunama, Afar, others
• Major religions: Muslim, Coptic Christian, Roman Catholic, Protestant
• Life expectancy: 59 years (men), 64 years (women) (UN)
• Infant Mortality Rate: 41.3/1,000
Eritrean Refugees
How Do Refugees Reach the US?- Application for resettlement in a third country - Rigorous screening (medical and security)
- Interviews- Cultural orientations
Waiting time: several months to many years
Picture: www.worldreliefmn.org/the-story-in-pictures/
Refugees in the US• Once approved, refugees are assigned to various
sponsoring voluntary agencies in the United States• 12 Nationwide Refugee Resettlement Agencies• 4 in Phoenix• 3 in Tucson (see handouts)
PRE-ARRIVAL:Locate & Furnish Apartment
Connect utilities
ARRIVAL:Pick up at Airport Home Safety Orientation
WEEK 1:DES Interview (Food
Stamps/AHCCCS)Social Security Card
RMAP card
FIRST 30 DAYS: CORE SERVICES• Ongoing cultural/home orientations• Financial/MG orientations• Health Screening (including TB
screening and Immunizations)• Begin initial doctor visits• Register adults for ESL at Pima• Bus passes• School Enrolment• Employment Assistance
6 MONTHS:Start paying onIOM Travel Loan
1 YEAR:Apply for Permanent
Residency (Green Card)
5 YEARS:Apply for Citizenship
Resettlement in Tucson
• Insufficient financial assistance for the first 90
days ($900 per person)
• Shortage of Staff
• Caseload
Challenges of Resettlement
Common challenges for new arrivals:• Living in poverty• Securing employment• Learning the language• Getting around Tucson• Navigating the healthcare system and
other government services• Adapting to American culture (time,
individualism, the status of women, etc.)
Resettlement in Tucson
Before going to USA:• Medical assessment by International Organization of
Migration/IOM:• TB-screening, Chest X-ray, RPR tests, and general
physical exam;Upon arrival to USA:• TB-screening within first 30 days• Initial medical screening within 30 days after arrival
unless stated differently;• Initial dental screening within first 30 days
REFUGEE HEALTH CARE REQUIREMENTS
Health InsuranceRMAP
• Federally-funded temporary public benefits program for new refugees
• Covers medical costs during first 8 months not covered by AHCCCS
• Also covers immunizations and dental and eye exams for refugees including over 21 years
AHCCCS• Arizona/Federal Medicaid
health insurance program for qualified low-income residents
• Coverage for medically necessary care with limitations
• Broader coverage for children under 21 years and ALTCS members
• Mandatory for all refugees within 30-60 days after arrival • Funded through RMAP• Screening for communicable diseases, mental health,
undiagnosed chronic conditions• Screening tests including TB, Hepatitis B, HIV, Syphilis,
GC/Chl, and Pregnancy test• Vaccinations for children and adults• Follow-up immunizations for adults to fulfill I-693
requirements• Immediate referrals to Center for Well-Being, OB Intake at
FMC, Infectious Diseases Providers at UMC
Preventive Health Screening
PainHeadache
Neck pain
Back Pain
Abdominal Pain
Female Pelvic Pain
Mental Health
PTSD
Depression
AnxietyAdjustment
DisorderSocial Isolation
Chronic Condition
sAnemia
Asthma
Diabetes
Dyslipidemia
COPD
Hypertension
Vitamin D def
Vitamin B12 def (Bhutanese)
Common Refugee Health Issues
Vaccine Requirements for Green Card
Language barrier
Differences in health beliefs Differing beliefs regarding causes of health and ill health (e.g.
viruses, organ systems) Concept of chronic (vs acute) disease Concept of preventive care (e.g. CA screenings tests)
Difficulty navigating health care system Understanding medication refills Keeping set appointment times Following up with referrals to specialists
Healthy Living: Nutrition, hygiene, sanitation
Patient and Provider Challenges
• Pre-migration: exposure to infectious & parasitic diseases, physical & psychic trauma
• During flight & refugee camps: malnutrition, exposure to the elements, exposure to infectious & parasitic diseases, physical & psychic trauma
• Post-migration/Resettlement: increasing susceptibility to chronic diseases, problems & stressors of resettlement (unemployment, language, etc.)
Source: Globalhealth.gov
Link between Migration & Resettlement Health Burden
Mental HealthConsiderations
Triple Trauma ParadigmPre-Flight
Disruption, secrecy, fear, traumatic eventsFlightFood insecurity, separation, lack of trustResettlementCultural isolation, loss of status, limited social support
Pre-flightKidnappingsRapesThreats of harmFamily members tortured and killedTortured by militia or government officialsWitnessing and experiencing shootings and bombingsLong term discrimination and oppression
Flight
Limited resourcesLack of statusDiscrimination Family still in home country or no knowledge of their whereabouts
Post-flight• New town• Foreign Country• New language• New Culture• Unemployed• New Apartment• New neighbors• New school
• Crowded locations• Heavy traffic• Financial difficulties• No friends• No extended family• Unable to communicate• Role reversal• Changing Gender Roles• Impact of Torture
Services at Center for Well-Being
Clinical Services: Individual, Family and groups counseling for depression, anxiety, and severe trauma
Refugee Well-Being Project: In-home wellness promotion and informational sharing
Survivors of Torture Program: Intensive case management services for those who fit the definition of a survivor of torture
Language and Communication• Tucson Refugees Speak:
Acholi, Amharic, Anywak, Arabic (several dialects), Bosnian (Serbian/Croatian), Dari, Dinka, English, Farsi, French, Karen, Kinyarwanda, Kirundi, Krahn, Kurdish, Lingala, Mandingo, Maay-Maay, Nepali, Mende, Ndogo, Oromo, Pushtu, Russian, Turkish,
Somali, Spanish, Swahili, Tigrinya, Uzbek, Vietnamese…
Telephone Interpretation• Cyracom
• Language Line
Telephone Interpretation Services: Typical Process
• Call the specific health plan’s Member Services number• Request interpretation services and specify language• Be prepared to provide the patient’s:
– Name– AHCCCS ID#– DOB– Address
• Also be prepared to provide the doctor’s:– Name – Location– NPI #
Telephone Interpretation Tips• Specific process and required information
for each health plan varies• See handouts• Contact the applicable health plan’s
Customer Service for any questions or problems
What To Expect When Working With Refugees:
Refugees who speak limited EnglishRefugees who speak excellent English
A family that is less educatedA family that is highly skilled and educated
People that seem very conservative or foreignPeople that seem very liberal or westernized
Slides from The IRC
A Few Tips:• Release your expectations• Develop Self-Awareness
– Be aware of your worldview, values, and behaviors
– Be aware of your prejudices • Develop Awareness of Different Cultures
– Listen & Learn & Appreciate– Address Misconceptions
• Keep trying and don’t be afraid of mistakes
Slides from The IRC
Contact Information
• International Rescue Committee (IRC): 319-2128
• Lutheran Social Services: 721-4444• Catholic Social Services: 623-0344• See handout form for referrals to IRC’s
Wellbeing and Survivors of Torture Programs
• See handout on community resources
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