Refugees and COVID-19
By Aniyizhai Annamalai MD , Bryan Brown MD, Lilanthi Balasuriya MD, Camille Brown MD
Forcibly displaced populations around the world are particularly affected by the current COVID-19 crisis. Resettlement has been suspended and asylum seekers are threatened by return to home countries. Globally, millions of refugees are housed in crowded camp-like conditions with inadequate sanitation and limited medical care. They are overrepresented in the homeless population in the European Union. Refugees who are already resettled through the U.S. Refugee Resettlement Program are better situated but still face many challenges compared to the host population. We describe our experiences addressing some of these challenges.
The Issues
Refugees frequently have limited English proficiency (LEP) and low health literacy and are at risk of poor understanding of public health recommendations for social distancing, hand hygiene and care of sick family members at home. Refugees and other migrants are known to use emergency rooms more often than non-migrants for low acuity presentations. During this pandemic, this exposes them to risk of COVID-19 infection and transmission to others. Newly arrived refugees who have not yet received their domestic health assessment are not established with primary care. They lack knowledge of local health systems and awareness of how to seek medical advice. Refugee children face delays in receiving age-required vaccinations raising the risk of communicable diseases in the coming months. Refugee children cannot enroll in school and their families cannot be referred to the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) without a clinical evaluation.
Our Approach
We formed a leadership group of refugee health care providers in Connecticut five years ago for better communication among those who treat refugees. This forum has proved helpful to us during this crisis to review best practices on COVID-19 in refugees. We collated available multilingual resources about COVID-19 for refugees with LEP and distributed within the group. Examples of information sources are Society of Refugee Health Care Providers and Centers for Disease Control. We organized a group of medical student volunteers from the Yale Medical Student Navigator Program to reach out to recently resettled refugee families and provide education on COVID-19 prevention, an important component of which is avoiding unnecessary emergency room visits while at the same time seeking care when necessary. Volunteer students coordinated with resettlement agency staff to arrange for delivery of common over-the-counter medications for refugees who would not know to obtain them.
Our clinical practices are severely limiting new patient evaluations but we were able to advocate with leadership for an exception for new refugees to establish them in care, so they could access primary care rather than emergency rooms for medical care.
Our clinics strongly encourage us to utilize video visits for new patient telehealth visits but we obtained special permission to utilize telephone visits as we have not been successful linking interpreter services to the video platform. We arranged for children to be brought in for vaccinations singly by one parent, rather than as a family, which is different from the family based visits we normally conduct for new refugees.
We have also been able to perform selected physical examinations for very young children. With deployment of providers to hospital based care, our clinic staff capacity is reduced. So we maintain an open line of communication with our local resettlement agency so their staff can directly reach us when refugees contact them for medical concerns.
When we learned that some refugees are afraid to report symptoms for fear of separation from families, we reached out to those families to evaluate and educate. We are also doing telehealth follow up visits for refugees with mental health problems, and while this is suboptimal for new patients, it allows us to maintain contact and engage them in care.
Refugee families struggle financially as they are unable to seek employment during this time. Resettlement workers continue to work remotely to help new refugees access food stamps and other social assistance whenever possible. While our coordinated outreach efforts focused on needs of newly arrived refugees, we are also actively reaching out to individual refugee patients who are established in our practices.
Proactive Outreach to Refugee Populations
We want to remind providers that refugees are an especially vulnerable population that may be overlooked in public health efforts. Proactive outreach and interventions will reduce not only reduce their risk of COVID-19 infection, but decrease their potential for being vectors of transmission. Close communication with volunteers and health coordinators at the refugee resettlement agency has been key in our prevention efforts.
Authors: Aniyizhai Annamalai MD, Department of Internal Medicine, Yale School of Medicine; Bryan Brown MD, Department of Internal Medicine, Yale School of Medicine; Lilanthi Balasuriya MD, Department of Psychiatry, Yale School of Medicine; Camille Brown MD, Department of Pediatrics, Yale school of Medicine
