A Proposal for the Follow-Up Care of Muslim Refugees in Massachusetts
What actions should the Massachusetts Office for Refugees and Immigrants (ORI) undertake to ensure proper follow-up for identified physical and mental health issues among Muslim refugees? This question was explored over the Summer of 2019 at MCPHS University, and the recommendations are surprisingly feasible.
Background
In accordance with the United Nations High Commissioner for Refugees (UNHCR) protocols, refugees are first identified and designated as such before being given preadmission to an identified nation. Those with medical needs are among the prioritized and “considered prime candidates for resettlement” (Dooling, 2017). The Office of Refugee Resettlement (ORR), a part of the U.S. Department of Health & Human Services, then coordinates with state offices after the UNHCR-cleared individuals likewise pass Department of Homeland Security and State Department screenings and assessments (Administration for Children and Families, 2019).
Given this process, support for Muslim refugees in Massachusetts is still sorely needed. Even prior to the Syrian War and worldwide diaspora of its people beginning in 2011, there were already a dearth of extended efforts to care for Muslim refugee populations, particularly children, following initial medical and psychological assessments (Eisenberg et al, 2011). Depending on the current status of fluctuating budgets, the United States government funds official refugee offices in between 4–6 states, with 28 individual cities and countless nonprofit organizations, committees, and commissions providing further services (de Graauw, 2015). The ORI in Massachusetts was created by the state legislature in 1992, following the 1985 creation of the Massachusetts Office of Refugee Resettlement by MA Executive Order (Commonwealth of Massachusetts, 2019a).
As a state with an official office, Massachusetts has the ORI, along with the Department of Public Health, to help conduct additional health screenings primarily through the Refugees Health Assessment Program (RHAP).
Refugees and Islamophobia
Though the world has made efforts, the global community has been unable to respond fully to the needs detailed by on-site medical practitioners like Alghothani, Alghothani, & Atassi (2012) calling for international health intervention for Syrians at refugee camps. In turn, the Centers for Disease Control and Prevention (2017) highlight a number of additional complications, this time cultural differences, that accompany Syrian refugees who have somehow managed to make it to the U.S. after durations in these camps. The U.S. healthcare system already struggles in terms of its understanding of Muslim patients’ needs and preferences (Padela & Curlin, 2013); this majority-Muslim Syrian population comes with its own history of PTSD, depression, separation anxiety, and host of physical ailments, especially women’s health issues (Javanbakht, 2018; Samari, 2017). In the words of R.F. Harbut (2019) writing for the AMA Journal of Ethics, this is a population with “unique health needs” (p. E77).
It is not being suggested that all Muslim-majority countries are the same nor that all Muslim refugees needs the exact same manner of health care and aid. However, as Padella & Curlin (2013) note, in accord with Hacker et al’s (2011) interviews with Everett, MA-based Muslim refugees, they all do share in the hostile cultural climate and politics of the U.S. currently. Islamophobia in the U.S. has grown precipitously since the September 11th attacks in 2001, in turn affecting Muslims’ health across the country: “Islamophobia challenges health equity and population health” (Samari et al, 2018, p. e1).
This problem has worsened even as the Trump administration has further limited refugees in the United States. In March 2017, President Trump directed the implementation of Executive Order 13780, a revision of Executive Order 13769 informally termed the “Muslim Ban”; after challenges in the courts, his administration produced Presidential Proclamation 9645 that September which could be upheld by the Supreme Court that next year (Hurd & Schwartz, 2018). The Department of Homeland Security would, with these orders, shut down nearly all immigration from five Muslim-majority countries — Chad, Iran, Libya, Syria, and Yemen — along with North Korea and Venezuela (Presidential Proclamation 9645, 2017). Figure 1 illustrates the decrease in all admitted refugees to Massachusetts over the last ten years, Muslim or otherwise (Mattos et al, 2019).
The decrease in numbers has not resulted in an increase in care. Quite the opposite, Muslim refugees, like their Latino complement, “worried that by disclosing their legal status they would be vulnerable to ICE or law enforcement action and as a result some immigrants avoided using the health care system” (Hacker et al, 2011, p. 591). The fear of immediate political violence or religious persecution against the wider backdrop of increased Islamophobia in the U.S. has been shown to heighten depression and anxiety among Arab[1] refugees, even as compared to U.S.-born Arabs (Pampati et al, 2018). The flowchart (Figure 2) suggests how the climate negatively impacts health outcomes for refugees (Hacker et al, 2011).
Of course, this increase in refuge anxiety and fear is not specific to the northeast region, with Lopez et al (2017) reporting much the same for the Midwestern United States as well.
The limits of RHAP
While the Refugee Health Assessment utilized for RHAP does provide information on Health Education (Section 3.10) and Referrals (3.11), it does not appear to have any overt apparatus, only guidelines, for follow-up with its refugee clientele (Commonwealth of Massachusetts, 2019b). This is particularly problematic given the reticence, documented above, by recent refugees to maintain healthcare treatment. Given the specific communities to which many of these refugees are relocated, such as Springfield and Worcester (Dooling, 2017), additional contact with them appears left to local civic and charitable organizations.
Efforts have been undertaken in states like New York (Alarcon et al 2014) and Minnesota (Dicker et al, 2010) to safeguard patients’ transitions to primary care, and San Diego County likewise had identified refugees experiencing a barrier in accessing regular health services (Morris, M.D. et al, 2009). In their literature review of refugee challenges for health care, Brandenberger et al. (2019) emphasized the 3C model: Communication, Continuity of care, and Confidence. At present, neither Massachusetts generally nor ORI specifically have a program for the central Continuity of Care, likely diminishing the opportunities for Communication and any sense of patient Confidence.
New efforts, like those by the Boston Center for Refugee Health and Human Rights (BCRHHR) clinic at the Boston Medical Center, are being developed to address this gap, but this seems to occur outside the governmental system and its responsibilities. Coalitions like Health Care for All emphasizes this increased need to reach refugee communities as their impetus for forming: “In early 2017, medical providers and community organizations began reporting that immigrant patients were avoiding or delaying health care services due to fears of intensified immigration enforcement. Since that time, the federal government’s threatening rhetoric and actions toward immigrants — both perceived and actual — have further ratcheted up fear in our communities” (Health Care for All, 2018).
Smock et al (2019) already identified the systemic failure of Massachusetts’ Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program from 1998–2010, so it is not unreasonable to fear that RHAP is challenged in avoiding a similar fate, particularly after assessment has been concluded and the refugee looks for a new stability.
Stakeholders
The ORI, funded by the Office of Refugee Resettlement (ORR), has been unable to meet the challenge stated in its own Massachusetts New Americans Agenda from ten years prior: “[I]mmigrants still face many challenges in accessing adequate health care. The most basic challenges are inability to enroll in healthcare programs due to financial or status-based restrictions, linguistic access, and cultural competency of providers” (Egmont et al, 2009, p. 33). As it is split into five divisions, the ORI having an extended engagement with health refugee beyond the RHAP would bridge its entire structure, requiring buy-in from all; as a secondary beneficial effect, a new program to aid in healthcare follow-up and treatments might also strengthen the ORI by creating interdivisional synergy (and, in turn, arguing for additional funding from the ORR).
MA-based refugee support organizations. ORI lists almost three dozen Refugee Service Providers in addition to the BCRHHR in its overview materials (Massachusetts Office for Refugees and Immigrants, 2018), however that number should not prove reassuring. Not only can a new refugee get lost in the multitude of organizations and different priorities, but this also suggests that these organizations are having to put their own resources to unmet Continuity of Care (Flynn, 2018). The efforts of these organizations may help to paper over the disconnect between refugee and state government concerning health issues, but their efforts can undoubtably be tasked to a number of other priorities (e.g. education, legal services, childcare assistance, etc.).
Muslim refugees based in MA. The research center at the Boston Foundation estimates that, in the ten-year period between 2007–2017, over 16,000 refugees came to settle in Massachusetts (Vance, 2017). With nearly 5,000 from Iraq, over 2,000 from Somalia, and several hundred more from other Muslim-majority countries, it would be safe to estimate a population of approximately 10,000 Muslim refugees are living within the state, in addition to children born to these families over that time period. Any barrier to health and medical service among this group would likely be compounded within their growing families. Therefore, an increased action and implementation would not only serve the newer arrivals but also those who previously arrived but could not engage in follow-up care themselves.
Policy Options
Option 1:
Rather than outsourcing the responsibility to non-governmental groups, the ORI could develop its own Refugee Outreach division tasked to continue culturally sensitive contact with resettled refugees well after their health assessments. This would be in keeping with the “Amsterdam Declaration” that emerged among global health leaders in 2004, emphasizing “the need for comprehensive training of health care providers to understand the specific requirements of migrants and refugees” (Brandenberger et al, 2019). More immediately, this effort matches those recommendations put forward by the refugees in Everett, MA themselves: “Many felt that training in cultural competency for police, health care workers and city hall staff would improve relationships with immigrant communities” (Hacker et al, 2011, p. 593). Such an effort would require a sizeable financial pledge from the state (or ORR at the federal level, which seems less likely), significant training, and extensive deployment across the ORI’s professional environment. The BCRHHR could prove invaluable in implementing such training in Eastern MA, with additional recognized training organizations needed in central and western MA.
Option 2:
One potential solution can be gleaned from the Refugee Health Partnership (RHP) developed at Johns Hopkins, where pairs of trained predmedical students meet with refugees during monthly home visits (Bernhardt et al, 2019). With the abundance of medical schools in the Commonwealth, what prevents the Massachusetts polity, rather than nonprofit organizations or hospital institutions, from doing likewise? RHP provided Johns Hopkins medical students with a daylong orientation and materials, then matched them with a suitable refugee family based on stated preferences (e.g. gender, language, prior experience). This patient-centered approach met families in the comfort of their homes or community centers, incorporated narrative medicine, and engaged in best practices for refugee treatment. A similar program based out of any one of Massachusetts’s many teaching hospitals or medical universities could be enacted to aid refugees and future medical professionals alike. ORI could, with Johns Hopkins’s expertise, develop its own affiliated program with locals schools for orbiting refugee communities; Bernhardt et al (2019) intend to scale up the program, with Boston University School of Medicine beginning to incorporate the Johns Hopkins model represented in Figure 3 (p. 546).
Recommendation
Option two appears most clearly the policy that should be put into effect. First, from a pragmatic perspective, it is more likely that the ORR will decrease its funding of the ORI than raise it for new initiatives, citing the drop in incoming refugees. Of course, this decrease comes as an effect of political actions, not inherent need. Moreover, the refugee Muslim populations that arrived prior to the Trump policies are still present in Massachusetts, with 35% of all the state’s refugees from 2009–2013 coming from Iraq and another 11% from Somalia (Massachusetts Office for Refugees and Immigrants, 2018). Just three years ago, Syrians were the fastest-growing population of incoming refugees to Massachusetts (Vance, 2017). The ORI noted that barriers for these previous waves of refugees included “substantial medical issues” as well as “trouble navigating the U.S. systems,” therefore it is unlikely that the ORR will now suddenly rush to support additional programs for previously known issues.
On a more hopeful and encouraging note, the Option 2 RHP model was obliquely suggested in the ORI’s own 2009 Massachusetts New Americans Agenda, encouraging the deployment of medical students in aiding refugees (though it emphasized translator certification over any cultural training). Just as the International Rescue Committee of Baltimore and its Special Health Needs Program worked with Johns Hopkins to enlist motivated, fresh medical students, so too would ORI be consistent in its mission to do likewise with the universities in the Commonwealth. Notably, a number of schools, such as MCPHS University, have been highlighting their own first-generation student populations with “First Flight” programs, and likely have a population of culturally sensitive future health professionals eager for such an opportunity.
[1] Author’s note: As suggested above, “Arab” is not synonymous with “Muslim,” nor are all Arab countries and cultures monolithic. However, the shared persecution and bigotry aimed jointly at these groups unifies them for the purposes of this report.
References
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