#61: Refugee Health, Part 1 – Entry to the United States: Resettlement, Intake, and Screening

August 24, 2022 | By Sam Masur

Summary

With the recent forced displacement of communities from Afghanistan, Ukraine, and beyond, it is more important than ever to understand how to care for refugee populations. Dr. Jamie Robinson and Dr. Mark Troyer discuss components of initial intake and medical screening upon entry to the United States, including: the long and vetted road to refugee resettlement, the importance of trauma-informed mental health screening and oral health, and the rewarding nature of their work.

Credits

• Executive Producer: Max Cruz
• Showrunner: Sam Masur
• Writer, Producer, Infographic: Angela Y. Zhang
• Cover Art: Chris Chiu
• Hosts: Chris Chiu, Justin Berk, Angela Y. Zhang
• Editor:Justin Berk; Clair Morgan of nodderly.com
• Guest(s): Jamie Robinson, Mark Troyer

Refugee Health, Part 1: Pearls

1. Refugee healthcare takes a team! Work with your interdisciplinary colleagues.
2. Don’t feel pressured to do everything at the first visit. Take time to access records to avoid duplicate work, and focus on the time-sensitive and patient-expressed agenda items.
3. Although you may provide anti-parasitic presumptive treatment, much of refugee health centers less around tropical medicine or infectious disease and more around creating a medical home and providing trauma-informed care.
4. Consider your patient’s pathway to entry to guide what medical screening they may have received or may need. Oftentimes they have already gone through a rigorous process to enter the United States.
5. Trauma-informed mental health screening, vaccinations, and oral health screening are vital to refugee healthcare.
6. Work with a medically certified interpreter whenever possible and offer as the default option; find compromises to preserve your patients’ autonomy.

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Refugee Health Part 1 (Resettlement, Intake, and Screening) Notes

Laying the Groundwork – Definitions

For more terms and details, refer to the UN’s page on refugees and migrants. 

Refugees are people outside their country of origin because of feared persecution, conflict, violence, or other circumstances that have seriously disturbed public order, and who, as a result, require ‘international protection’.  Their situation is often so perilous and intolerable, that they cross national borders to seek safety in nearby countries, and thus become internationally recognized as ‘refugees’ with access to assistance from states, UNHCR, and relevant organizations.  They are so recognized precisely because it is too dangerous for them to return home, and they therefore need sanctuary elsewhere.  These are people for whom denial of asylum has potentially deadly consequences.

Asylees/Asylum seekers are individuals seeking international protection. In countries with individualized procedures, an asylum seeker is someone whose claim has not yet been finally decided on by the country in which he or she has submitted it. Not every asylum seeker will ultimately be recognized as a refugee, but every recognized refugee is initially an asylum seeker. As Dr. Troyer clarifies, an asylum seeker is either seeking protection at the border or once they have already entered the country of refuge (e.g. the US) – therefore, their first point of contact is with the refuge country, not with a refugee camp.

All migrants obtain a temporary visa that allows them to enter the country. In order to stay indefinitely they need a green card, which is much harder to get.

A note on the Afghan refugee evacuation: Given the urgent need for exodus, President Biden initiated Operation Allies Welcome which allowed Afghanis to temporarily relocate to a “lily pad” city near a foreign U.S. military base for processing before coming to the United States. Some Afghanis who worked with the U.S. in some capacity (e.g. interpreter) were able to be admitted to the U.S. as a parolee, which means they have a different path to entry and might have had different health screening requirements than what is covered in this episode.

Required Medical Exams for Refugees

Panel Physician Evaluation (abroad) 

Prior to being resettled, refugees have to get extensive background checks, be interviewed on the nature of their persecution, and undergo extensive health and security clearances, which means that on top of regular immigration vetting, they receive even more scrutiny. 

For the purposes of this episode, we will be discussing refugee healthcare in the United States only with guidelines from the Center for Disease Control. The first health clearance comes through an evaluation by a “panel physician”, during which time the refugee can be waiting at a refugee camp (usually in a different country than their own) or living in another city, for up to years or decades. 

The workup consists of:

• Standard workup of medical problems, and referral as needed.
• Tuberculosis: >15 yo gets chest x-ray; 2-14 yo living in a country with endemic TB gets quantiferon gold assay.
• Syphilis and gonorrhea for those aged 18 to 44.
• COVID testing (significantly delayed admission process in 2020).
• HIV is no longer an inadmissible disease and so does not need to be tested for.
• Prior to admission, refugees may also receive presumptive anti-parasitic treatment based on the country of origin.

Inadmissible conditions include: physical or mental health conditions with associated harmful behavior; substance use disorder; active tuberculosis, leprosy, syphilis, gonorrhea, or COVID-19.

Medical Screening (domestic)

Next, the goal is to have a domestic medical screening with a physician vetted through Immigration Services within 90 days of arrival to the United States.

Expert practice: If you find out where your refugee patient first arrived in the United States, you can obtain records from their domestic medical screening through the corresponding department of health. Contact the Department of Health for access to the panel physician form.

Many refugees will have received presumptive treatment for parasitic infections. Per Dr. Robinson, obtaining 3 sets of ova and parasite stool studies can be a big barrier to care, especially with limited access to transportation. In addition, many of the parasites found in O&Ps can be non-pathogenic and clinically insignificant. Given that the CDC recommends presumptively treating if not treated overseas, pursue treatment even without confirmation studies.

What to do about vaccinations?

• Obtaining a green card for permanent residence requires fully vaccinating, if age-appropriate, against 16 diseases: MMR, polio, tDAP, H. influenza, rotavirus, hepatitis A, hepatitis B, meningococcal, varicella, pneumococcal, and COVID. HPV is not required. 
• In some countries of origin, people may have received duplicate vaccines. You need documentation to waive these vaccines – because many vaccination records are inconsistent, it’s important to gain access to the panel physician exam and medical domestic screening to avoid excess vaccination. Expert practice: Obtain varicella and MMR titers and empirically vaccinate the rest. 

Interpretation

• In-person interpreters are ideal, but the demand for interpretation often outweighs supply. In these cases, use a video or audio interpreter. Expert practice: Build your interpretation skills assuming the interpreter cannot see your actions.
• Sometimes, a family will decline an interpreter. Expert practice: Start with a default “opt-out” option. Instead of asking if they want an interpreter (which can create a stigma around “needing” an interpreter) say, “We use interpretation for all people who prefer a language other than English”. Can also frame it as being for yourself as the provider to make sure your words are being communicated.
• If a patient is insistent, accommodate their autonomy. Compromises include allowing a family member to interpret while having an interpreter in the room as back-up for clarification.
• For pediatric patients who speak English: often their parents do not, so you will need an interpreter so that the parents can make informed medical decisions.
• Medical interpreters are trained to bridge not only the language gap, but also the cultural gap. Therefore, sometimes what you say will not be interpreted verbatim as your interpreter colleague navigates these gaps with the patients.
• Follow standard best-practice interpretation skills, such as speaking directly to the patient and only having the interpreter work with a few key points at a time.

Primary Care Considerations

• Make sure to welcome your patient to the United States! Expert practice: Offer a brief orientation to the medical system: scheduling is required for appointments, patients in the US come to the doctor for well visits.
• Review records beforehand and incorporate them into your EHR.
• Trauma-informed mental health screening is vital. Use the PHQ-9 with a medical interpreter even if the form is written in the patient’s preferred language; the interpreter can help adapt cultural differences in symptom description. 
• Use the Refugee Health Screener 15 (RHS15), an emotional distress and trauma screener validated specifically in refugee populations.
• Even if screening has been done initially, follow up regularly. Many refugees have trouble finding work, have to be held back in school with their education gap, and/or have to pay back the travel costs of resettlement.
• A note on insurance: Refugees only receive eight months of medical assistance, after which point they have to find insurance. Lack of insurance is a big barrier to care. In addition, for many refugees there is a delay between arrival to the U.S. and insurance coverage activation, resulting in yet another barrier.
• Expert pearl: You don’t have to do it all at once! The to-do list may seem overwhelming but the benefit of primary care is that you establish a longitudinal relationship with your patients. Ask your patient what they want to accomplish to help set an agenda. 

Oral Health

• • Many patients have never seen a dentist in their country of origin. 
  • Depending on water fluorination status and amount of sugary or processed foods, refugee patients may present with a heavy burden of dental caries (Cote et al., 2004).

• Expert practice: Examine gums and buccal mucosa. Ask if your patients are brushing with fluoride toothpaste. Counsel on nutrition, especially with the Western processed diet. Assess for tobacco use. Apply fluoride.

• Expert pearl: Be aware of further barriers to care. Many dentists, especially pediatric dentists, do not take Medicaid. The small subset that does may not use an interpreter. Use wrap-around services to help work with your patients through these roadblocks.

Want to get more involved?

• Attend the NARHC Conference | Society of Refugee Healthcare Providers (June 23-25th, 2022 in Cleveland, Ohio) to learn more about refugee health and connect with other providers. You may even get to meet Dr. Robinson and Dr. Troyer in person!
• Find a local asylum clinic – healthcare professionals can train to provide legal affidavits to support a patient’s fear of persecution and trauma history.

Goal

Listeners will explain the process of refugee resettlement as it pertains to the first medical screening upon arriving in the United States, and considerations for refugee populations for equitable primary care.

Learning objectives

After listening to this episode listeners will…  

1. Explain the process of refugee resettlement to the United States.
2. Recognize the importance of using interpreters responsibly and in a patient-centered manner.
3. Feel comfortable approaching vaccination status in a refugee patient.
4. Learn about the importance of oral health, components of a basic oral exam, and barriers to oral care for refugees.

Disclosures

Dr. Robinson and Dr. Troyer report no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Zhang AY, Robinson J, Troyer M, Cruz M, Masur S, Chiu C, Berk J. “#61: Refugee Health, Part 1 – Entry to the United States: Resettlement, Intake, and Screening”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ August 24, 2022.