International Editorial: Healthcare for Immigrants and Refugees:
Alfred T. Kisubi,
Ph.D.
International Editor, Human Services Today University of Wisconsin Oshkosh Oshkosh, Wisconsin, USA
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Introduction
Who’re Immigrants
and Refugees?
In this International Editorial I wish to highlight the mental, physical,
and social health issues among refugees and call upon all human service and
healthcare workers to pay attention to the refugees’ problems and try to solve the mental health needs
of the new arrivals in their community. As the healthcare bill snakes toward
final legislation, there are those who point out that it should not cater
to “illegal immigrants.” That has been happening in this country
for some time.
Immigrants have long been on the fringes of medical care. But, in the last
decade, and especially since the terrorist attacks of Sept. 11, 2001, steps
to include them have faltered in a political climate increasingly hostile
to those who face barriers of language, cost and fear of penalties like
deportation, say immigrant health experts, providers and patients. More
and more immigrants are delaying care or retreating into a parallel universe
of bootleg remedies and unlicensed practitioners.
Here ‘refugees’ and ‘new immigrants’ mean people who have legally just come here to stay as permanent residents and naturalized citizens or just for a little while as students, visitors to new immigrants. ‘Refugees” are the core of our discussion. These are people, who the United Nations High Commission for Refugees (UHHCR) has relocated to the U.S. as a third country as mandated by international Convention and Protocol Relating to the Status of Refugees (UNHCR, 1951 Convention, and 1967 Protocol), which the U.S. ratified. Usually the refugees include people that fled from their country to avoid the chaos caused by wars that the U.S. and allies do frequently sponsor or wage directly such as in Vietnam, Afghanistan, Iraq, or by proxy, such as Somalia, Sudan, Congo, Uganda, Ruanda, Angola, and Bosnia.
When the refugees arrive in the U.S. they are received
by some U.S. settlement agency, such as Catholic Charities who sponsored
the lost boys and their families from South Sudan to Oshkosh, or Shelter
Now that sponsored the Kurds also in Oshkosh, Wisconsin. Therefore, the refugees
are not
‘illegals’. They are the aftermath of America’s international
(foreign) policy coming home, where their welfare, particularly healthcare,
ought to be part of the healthcare debate at national, state and local community
levels.
Milwaukee Self-help
Response
In Milwaukee the Pan-African Community Association, Inc in response to the mental, physical and social issues, organizes free medical screening for diabetes, and high blood pressure. They disseminate culturally sensitive healthcare information for ethnic minorities, including refugees and immigrants, in Metro Milwaukee. Also they promote modern and traditional best practices such as learning about health care challenges and opportunities faced by ethnic minorities, including refugees and immigrants, in Metro Milwaukee. Alternative healthcare strategies for ethnic minorities, including refugees and immigrants, are encouraged and the role of culture and spirituality in healing are recognized and promoted.
Response
to the Problem by the Sebastian Family Psychology Practice, LLC
Also in response to refugee mental health needs, Sebastian
Family Psychology Practice, LLC (A New Immigrant Psychologist-owned business)
is well poised for refugee mental health issues. The proprietor, having experienced
the throws of leaving ones country and living in another, decided to focus
a great deal of his practice on the needs of the new immigrants in his community.
Accordingly, a special refugee project was set up under the CY 2005 grant
activities, continuing into CY 2006. In 2005, over 300 clients received services. This caseload
included Americans and refugee clients, who consumed services in direct mental
health services programs. 85% of the clients had a dual diagnosis of major
mental disorders, such as depression, mood disorders, anxiety, and agoraphobia
in addition to AODA issues. Only 15% were in the pure AODA category. Of the
major mental health disorders found, at least 40% of the refugee clients
had major disorders, such as post-traumatic stress disorder, adjustment disorder,
affective disorders, and domestic abuse. A total of 172 cases received services in CY 2006. Of these,
there were about 20 torture cases, primarily from Sudan, Liberia, Ivory Coast
and the Congo. There were 10 referrals to resources, which included severe
psychiatric hospitalizations, alternative medicine referrals, as well traditional
healers, providing a needed recourse. Table 1 shows the number of refugees
targeted and served in FFY 2005 and FFY 2006.
Table 1 # And Ethnicity Of Refugees Served In 2005 And 2006 |
||||
Refugee Group |
FFY 05 Target |
# Served in 05 |
FFY 06 Target |
% to be served in 06 |
Afghans |
|
5 |
10 |
5.88 |
Africans |
35 |
38 |
50 |
29.41 |
Barmese |
None |
5 |
10 |
5.88 |
Bosnians/Serbians/ Croatians |
None |
7 |
15 |
8.82 |
Hmong/Laotian/Cambodians |
47 |
40 |
75 |
44.12 |
Russians |
None |
2 |
10 |
5.88 |
Total |
82 |
97 |
170 |
100 |
In order to ensure active involvement by all parts of the community in the resettlement and orientation of the refugees, the Sebastian Family Psychology Practice, LLC runs a Community Education Service with the following activities: 1) Outreach, 2) Group education workshops on issues affecting refugees to sensitize the community and workplaces to understand refugee problems that might impact performance and adjustment, 3) Group orientation for elementary, middle and high school refugee children. They also study the problems that afflict refugee pupils in school and educate teachers and other school authorities about the needs of their refugee pupils.
The task of reaching out to the refugees is about a third of the entire clinical and case management activities of the office per year. Generally, the office has experience in serving a diverse group of clients, including children, youths and families experiencing emotional distress, psychological traumas and negative effects of extreme poverty, as well as AODA effects of alcohol and other drugs. Here is why.
The Refugee
Issues
Demographics and
Issues:
Between 2001 and 2005, 1564 refugees arrived in the Milwaukee area.
[1]
An estimated 603 more refugees settled in the area between
October 1, 2005 and September 30, 2006.
[2]
Of those who settled in the area between
2004 and July 2005, 650 refugees were Hmong, 231 refugees were African
and 57 refugees belonged to the category “other,” forming a
total of 1245 refugees.
[3]
Wisconsin saw a 31% increase in the number of foreign-born
residents between 2000 and 2004. They
arrived from Central America, Asia, Europe, as well as Russia and Africa. The entire nation has seen a 10.1% increase
in the number of the foreign-born over the same period (Milwaukee Journal
Sentinel, February 22, 2005)
[4]
.
Milwaukee County, which boasts of a long immigrant history, has become “home” to a new wave of additional Hmong new arrivals, making the Southeast Asian refugee community the largest of the recent arrivals, followed by refugees from Ukraine, Bosnia, Croatia, Serbia, Russia, and various African countries, such as Somalia, Sudan, Congo, Liberia, Ivory Coast, Uganda, and Eritrea (The Milwaukee Catholic Herald, November 21, 2002). [5]
Fennely and the Minnesota Health Taskforce (February 2004) in their study of the health needs of African immigrants and refugees found the following general needs: Housing 71%, health 67%, jobs/poverty 64%, education 55%, language 51% and transportation 14% (Refugee Health Taskforce, 2/04). H. Gerson Jones in his special to the Voice and Viewpoint article entitled “Health Needs and Language barriers Facing African Immigrants Now Documented” outlines the findings of the Summit Institute for Research and Education in their report Giving Voices to the Voiceless. The report concludes that recent African immigrants face formidable barriers to health care access due to limited English skills, lack of resources, and the absence of healthcare insurance and lack of awareness of how to get through the healthcare system.
Mental Health and Orientation
Issues
Newly arriving refugees come with anticipation of their new lives.
They come burdened with the traumas of war, torture, persecution and conflicts
that have torn the fabrics of their lives. They also have difficult adjustments
with the resettlement experience. Some arrive having experienced severe trauma
related to their flight.
[6]
The phenomenon of mental illness among recent refugees
has been highlighted by recent publicized events. The
shooting spree during the 2004 hunting season, implicated a Hmong male
with alleged mental health issues. In
Milwaukee, police shot a Hmong male under circumstances involving mental
illness and cross-cultural misperceptions.
Current observations by the Sebastian Family Psychology Practice, LLC office and shared information with the Milwaukee Area Refuge Resettlement Agencies (MARC) reveal increasing numbers of complex symptoms among various African, Hmong, other S.E. Asians refugees, and those in the Bosnian/Croatian/Serbian, African and Burmese refugee (B/C/S) communities. These problems include physical health problems, sleep and appetite pattern disruptions, work and ESL related stressors as well as marriage and family relationship pressures. Children and youths present with a variety of emotional and mental health problems that include personal disorientation, homesickness, fear, anxiety and depression. Adjustment pressures for some of the Somali Bantu and Hmong children have led to conflicts within their host school settings. Often the urban neighborhoods and schools they are resettled into have additional environmental pressures that overwhelm their psychological security.
Like mainstream U.S. popular views, refugee communities struggle with misperceptions of mental health challenges and attitudes. Therefore, there is a need to educate both the general public and the refugees about the mental health issues among the refugee and immigrant communities of Wisconsin as a whole, and Milwaukee County in particular.
The Minnesota study concluded that healthcare needs for the African immigrants and refugees included: Health insurance, information about services and eligibility, mental health care and treatment, dental and eye care, and preventive services. Factors impacting how immigrants relate to and use or not use the U.S health care and welfare systems were reported to be: culturally based belief systems, values, traditions and practices culturally defined needs and attitudes toward seeking help. The Summit Institute for Research and Education reported in 2005 that the American lifestyle works against protective elements within the various cultures that promote health status. Barriers to health care mentioned in most studies are: lack of awareness about preventive medicine, language, translation/interpretation needs and communication problems, limited or no insurance, and dissatisfaction with the care received (Ibrahim, 2005). Other barriers unique to health care include frustration with long waits for doctors and interpreters in hospitals or clinics, concerns about inadequate or incorrect translation and mistakes made in diagnoses and treatment, and fear that confidentiality would be violated by interpreters. (Qamar Ibrahim, 2005).
Language Barriers
Language barriers were significant. The Summit Institute for Research and Education, (2005) reports that language barriers have a huge impact on the entire range of social function especially education, employment, housing, politics and law. Immigrants and refugees had a hard time finding a job because of language barriers. Therefore, this leads to isolation. Adults who don’t speak English remain in the home. African immigrants and refugees with limited English skills are generally unable to assist children with educational efforts. Those who had a trade could not afford re-certification costs. According to the Summit Institute for Research and Education (2005), African immigrant health care workers lack the opportunities to obtain additional training and credentialing to utilize their skills in the United States. The stress and complexity of every-day life in a foreign country engulfed with discrimination and lack of economic opportunities for adequate income manifest themselves in mental illness and depression (Summit Institute for Research and Education, 2005). Most studies found mental issues to be significant in the African immigrant and refugee population. Mental health afflictions included: depression, post-traumatic stress disorder and domestic violence. Anita Wadhwani (2005) concluded that the language gap hurts mentally ill immigrants and attributed it to cultural conflicts and mistranslations due to the poor training of the translators.
Education for Immigrant/refugee
and for Health workers
Education or the lack of it is a significant barrier to refugees and immigrants. Some didn’t finish school in their home country. Therefore, they cannot sign forms and get what they need from the System. So, learning English will open opportunity to work or socialization outside the house. Education programs must also target American health workers to educate them about the health needs of the African immigrants and refugees. The Summit Institute for Research and Education, (2005) reported that there are very few health care providers in the United States who understand the various African cultures and how to communicate and interact with these patients.
Of course the process and task of resettling persons who
have fled persecution from their countries of origin, is hard and complex,
but someone ought to do it. That
is what Sebastian Family Psychology Practice, LLC is bent to do in collaboration
with several community agencies that know and appreciate the need for an
integrated approach to assist the refugees rebuild their lives in honor. They see it as appropriate that the State
of Wisconsin Department of Workforce Development has regarded mental health
services as an integral part of refugee resettlement.
Response to the Problem process
Bilingual professional staffing
patterns:
The Sebastian Family Psychology Practice, LLC, agency has a diverse
multilingual and multiethnic pool of mental health and AODA providers.
These providers possess long clinical experience, each in their category
of expertise. All clinical staff is hired on contract and thus are not
agency employees but they are dedicated to the mission of serving the diverse
clientele of this office. Presently, the agency has 13 bilingual staff
where 2 males and 1 female Hmong, 1 male and 2 female are bilingual Caucasians,
3 males and 4 females are African immigrants with African multilingual
skills. The other mainstream American born clinical staff is improving
cultural competence so that they can serve the diverse target clients.
Ethnic community counselors:
Also, the agency in 2007 recruited and trained a cadre of crisis community
counselors for each of the targeted ethnic groups. This approach was based
on the rationale that, in addition to trained clinicians, the lay crisis
community counselors would greatly fit their ethnic communities. They received
fundamental coursework in youth counseling training via the U.W. Milwaukee
youth worker program. The 6-10 week program targeted a total of 10 such lay
crisis counselors. These individuals were drawn from the Hmong, Bosnian/Croatian/Serbian,
African and Burmese refugee communities.
It is understood that all contracted bilingual/bicultural clinicians who
have their credentials have vested professional interest in remaining in
this community and with this agency. The fact is that all current agency
contracted clinicians are also actively involved at civic levels within their
sub ethnic communities. Thus, it is safe to assume that they are here in
the community to stay. Each
of the credentialed staff is already enrolled in some of the mainstream reimbursement
systems that fund mental health and AODA services. For example, all current
clinicians, parent assistants and case aides are also enrolled in Wraparound
Milwaukee, the Bureau of Child Welfare, the Wiser Choice Programs, and other
funding sources. Some of the refugee clients may qualify for these services,
thus their care would then be shifted to the appropriate payer entity.
Other community partners such as Access Mental Health, Islamic Social and
Community Services, and the MARC agencies, have a mechanism of enrolling
their clinical staff into the funding channels mentioned above. This agency
has all credentialed staff enrolled in at least all the local HMOs of the
Milwaukee Metropolitan area. The agency energetically seeks funding through
the local, Federal, private and collaborative means, to secure adequate funding
of the program year after year.
Outreach Process: Mental Health and AODA Services:
Currently, outreach efforts include regular communication with the resettlement
agency directors and their case managers. All MARC and case managers’ monthly
meetings are attended by agency staff. Other outreach efforts include: contact
with school officials, religious leaders, ESL programs, primary care providers
as well as ethnic community leaders among Hmong, African, and Bosnian/Croatian/Serbian
and Burmese communities.
Other proposed outreach efforts include:
1. Hmong American Women Association, Hmong American Friendship Association, Lao Family and Burmese community leaders;
2. Engagement of Hmong radio stations that targets the youth, young adults, and the elderly;
3. African national groups via their grassroots organizations with the help of Pan –American Community Association;
4. Identification of work sites that employ significant (i.e. 10) workers from the designated populations;
5. Continued engagement of mainstream media (print, radio, T.V, Website sites to educate on issues effecting refugees; and
6. Engagement of the professional training programs of medical and mental health providers including the Medical College of Wisconsin nurse training programs as well as education and human service worker training programs.
It is anticipated that
the increased awareness of refugee issues will increase understanding, and
later, service delivery.
Referral and Termination Process:
The referral process involves:
1. Self or relative referral to agency ;
2. MARC agency case managers;
3. Referral form is filled by the referring person/agency that serves the elderly;
4. Clinic director reviews all referrals and assigns appropriate providers within 24 hours;
5. If the case is approved, treatment plan guides the level and frequency of care.
The length of interventions
is contingent upon need and HMO authorization. Those without insurance are
covered by the refugee grant funds. Cases are closed or transferred according
to the acceptable standards of care for Mental Health and AODA services.
Transfer of clients to another agency is done according need or at end of
the grant period. The agency is a mandated outpatient mental health and AODA
clinic and as such, it is bound by State laws to ensure patient care continuity
in the event of service disruption. This could be due to an end of funding
and/or contract termination for the agency.
In anticipation of the grant termination the agency assesses its capability to continue care. They check the payment patterns, problems and solutions for each of the HMOs and T-19. They also check grant revenues from funded proposals. They have careful resource allocations to each case on a monthly basis. Thus, each clinician or case aide receives “Authorized Units” per month, per case. Thus subsequent utilization is based on case needs. After 3 months of continuous services, cases will be evaluated for discharge.
Transfer of cases to competent providers is facilitated with the consent of the client or guardian. Since the agency is staffed by independent clinicians who are free to move on with their clients who so choose, the case transfer can be seemless. The agency follows a similar model presently used by Wraparound Milwaukee and Bureau of Child Welfare in Milwaukee County.
A Humanist Proposal
Cultural Sensitivity:
We (new immigrants)
should work with native-born Americans in recognizing the existence of
immigrant groups, whose specific vulnerabilities are the outcome of both
individual behavior and of high risk social and economic situations. It
means stressing the importance of such co-factors of vulnerability to infection
as poverty, exclusion, obstacles to information and prevention, lack of
access to care and to drugs, and lack of facilities for care and support.
Human Services workers should recognize that each refugee or immigrant has
unique problems to present. Africans from various nations and background
are not to be seen as the same. In addition to the differences between ethnic
groups, each person is a unique individual, whose beliefs idiosyncrasies
and values mix with cultural background and personal experiences to influence
their health care needs and wants.
In order for the health care providers to provide culturally sensitive care, they must be given culturally sensitive training/education in all health care training institutions. Efforts must be made to improve communication between immigrants/refugees and their health providers.
A wide, culturally sensitive, and appropriate education program about the importance of preventive health care practices and screening for all African immigrants and refugees must be designed and implemented in every community hosting new immigrant.
In order to treat cultural practices with empathy, health providers must
be knowledgeable about each and every practice and treat it as normal to
the client, instead of reacting with shock or ethnocentric disapproval
they should give their new immigrant patients ‘Hull House’ treatment.
Delivery
Strategies: Health in Our Communities
Community human service organizations
should make a public commitment to the following seven resolutions to combat
disease and promote health for individuals, families and the community:
1.
Support a greater involvement of people living
with any disease at all levels.
2.
Promote community collaboration for research on
common diseases among us.
3.
Strengthen community collaboration for physical,
mental, social, political, economic and spiritual health and safety.
4.
Encourage a community care initiative.
5.
Mobilize community, state and federal organizations
at all levels for a movement for the our children.
6.
Support initiatives to reduce the vulnerability
of women.
7.
Strengthen the community mechanisms concerning
human rights and biomedical ethics with reference to diseases common among
us.
We should implement these noble resolutions in our advocacy, education,
research, and service. This effort necessitates our empowering everyone
concerned in this effort.
References
Fennely, K. and the Minnesota Health Taskforce. (February 2004). Listening to experts: Provider Recommendation on the health Needs of Immigrant and refugees. Hubert Humphrey Institute of Public Affairs, University of Minnesota.
Jones, H.G. (2005). Health Needs and Language Barriers Facing African Immigrants Now Documented. The Voice and Viewpoint. California Black Health Network: A consortium of Community Based Agencies Promoting Improved Health Status of Black Americans.
Ibrahim, Q. (2005). Health Perceptions and Knowledge of Preventive Health Care of East African Women. LEAD: Helping African Immigrants and Refugees to Become Leaders in America.
State of Wisconsin Department of Workforce Development, (September 19, 2005). Volag Refugee Arrival Projection FFY 2006.
State of Wisconsin Department of Workforce Development, (September 19, 2005). Attachment 1 – Wisconsin Refugee Chart.
State of Wisconsin Department of Workforce Development, Bureau of Migrant, Refugee and Labor Services. (October 18, 2005) Attachment 2 – Estimated Total Eligible Refugee Population by County/Workforce Development Area.
Summit Institute for Research and Education (2005). Giving Voices to the Voiceless.
The Milwaukee Catholic Herald (November 21, 2002), Pan-African Association welcoming African refugees, immigrants.
UNHCR, (August 2007). Text of the 1951 Convention Relating to the Status of Refugees. Resolution 2198 (XXI) adopted by the United nations General Assembly. Geneva Switzerland: UNHCR. Retrieved on November 19, 2009 at http://www.unhcr.org/3b66c2aa10.html
UNHCR, (August 2007). Text of the 1967 Protocol Relating to the Status of Refugees. Resolution 2198 (XXI) adopted by the United Nations General Assembly. Geneva: Switzerland: UNHCR. Retrieved on November 19, 2009 at http://www.unhcr.org/3b66c2aa10.html
U.S. Department of Health and Human Services (2001), Annual Report to Congress, p.3.
Wadhwani, A. (Thursday, 2003). “Language gap hurts mentally ill immigrants.” The Tennessean. A Gannet Co. Inc. newspaper.
[1] State of Wisconsin Department of Workforce Development, Bureau of Migrant, Refugee and Labor Services. (October 18, 2005) Attachment 2 – Estimated Total Eligible Refugee Population by County/Workforce Development Area.
[2] State of Wisconsin Department of Workforce Development, (September 19, 2005). Volag Refugee Arrival Projection FFY 2006.
[3] State of Wisconsin Department of Workforce Development, (September 19, 2005). Attachment 1 – Wisconsin Refugee Chart.
[4] Milwaukee Journal Sentinel, February 22, 2005.
[5] The Milwaukee Catholic Herald (November 21, 2002), Pan-African Association welcoming African refugees, immigrants.
[6] U.S. Department of Health and Human Services (2001), Annual Report to Congress, p.3.
This editorial was published in Human Services Today, Fall
2009 ,
Volume 6, Issue 1 .
http://hst.coehs.uwosh.edu This article
may be freely distributed for educational purposes provided above copyright
information is included.