A refugee is considered one of the world’s most vulnerable people, someone who has been forced to flee his or her country due to war, violence, or oppression. A refugee has a well-founded fear of being persecuted for reasons including nationality, religion, race, political opinion, or social group membership, and for this reason must cross national borders to find asylum; staying in or returning to their home country would likely result in death. Many spend several years in refugee camps awaiting resettlement, wherein they are faced with copious other dangers, hardships, and disease exposure. According to the UNHCR, the UN Refugee Agency, there are approximately 22.5 million refugees worldwide, over half under the age of 18 (United Nations, n.d.). Since congress passed the Refugee Act of 1980, from which came the national refugee screening and admissions standards as part of the development of the Federal Refugee Resettlement Program, approximately 3 million refugees have settled in the United States (Krogstad & Radford, 2017).
In the year 2016, approximately 85,000 refugees resettled in the United States, with the majority being woman and children. That number dropped to under 54,000 in 2017 (Radford, 2017). In 2016, Rochester welcomed approximately 1,200 refugees from 30 different countries, the majority from Somalia, Cuba, Bhutan, Iraq, and Burma, with an increasing number from Syria (Sharp, Murphy, & McDermott, 2017). Although this number declined in 2017, Rochester still has a large population of resettled refugees, including those that are newly arrived and ones that have been living here for decades.
The provision of quality and accessible healthcare to these members of our community is of great importance both during the initial resettlement process and for years after. The Center for Refugee Health, part of Rochester Regional Health, is the only agency exclusively for refugees in Monroe county, and plays an invaluable role in improving the health of the refugee community. Having one location for refugees to go for their healthcare needs allows them to receive more individualized and culturally specific care and allows the time and resources of the agency to be directed entirely to refugees (K. Morris, personal communication, February 23, 2018).
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Refugees resettling in the United States face innumerable challenges when coming to their new country. Receiving any type of medical care especially as new arrivals can be hard for various reasons. These include cultural shock and acclimation obstacles (especially for older generations), language barriers, uncertain or inconsistent access to medical insurance, and the difficult navigation of the United States healthcare system, which is for many is confusing and overly complicated (Philbrick, Harris, Shaft, & Van Vooren, 2017). Other challenges include lack of reliable transportation, distance to healthcare centers, distrust of providers and treatments, and differences in cultural expectations about healthcare. In addition, refugees may not utilize the services that are available, and of which are eligible for due to a lack of awareness or understanding about them (Pace, Al-Obaydi, Nourian, & Makimura, 2015).
The Center for Refugee Health was established in 2014 to meet the increasing healthcare demands of the refugee community in Rochester. It was initially established as a practice for adults and soon after evolved into family primary care practice, treating refugees of every age. The center, which relies on grants and federal funding to operate, is small due to financial constraints; it currently has two doctors, one physician assistant, one registered nurse, and four licensed practical nurses who provide care. On a typical day one doctor will see 20 to 22 patients; yearly it sees between 5,000 and 8,000. On average the center welcomes 14 new patients weekly. Even though this number is half the amount seen in previous years, the center is always full.
Daily appointments are limited and are often full by the afternoon, so over the phone triage utilizing a call center interpreter is an important aspect of the nurse’s job. The nurse must use clinical judgment to determine if and how soon the refugee needs to be seen by a doctor. This is especially tricky as it is common for refugees to exaggerate their problems, as they tend to worry about common health problems such as the common cold and nausea and seek out medical attention for them. Symptoms not usually thought of as serious were likely symptoms of life-threatening problems in their home countries (K. Morris, personal communication, February 23, 2018).
According to the program coordinator at the Center for Refugee Health, there is no special training needed to work at the agency, and a registered nurse employed there does not need to have a certain level of education. Instead, the major qualification for anyone working there is having passion and respect for the work they do and the population they serve. Nurses must be subjective and trust the patients, and understand the extra steps required for even the smallest of tasks. It is a tough, demanding job and a nurse must love it to do well, as the turnover and burnout rates are high. However, those that find purpose and enjoyment working at the center and build a strong rapport with the patients consider it very rewarding and fulfilling. In addition to enthusiasm for the job, staff must be able to provide culturally appropriate health care to the diverse patient population (K. Morris, personal communication, February 23, 2018).
Currently at the Center for Refugee Health the largest refugee population they provide care to is the Nepali, as they were the earliest arrivals to Rochester, although the demographic of their patient population shifts yearly according to worldwide refugee trends. Their services must be individualized to the patient; for example, the attitudes and health care needs of the Nepali are different than those of Syrians which are different than those of the Cubans, and as such the health care provided to them is much different.
Nurses at center must be competent about many cultures to properly serve the many different groups and must also be able to provide appropriate healthcare to every age group. The refugee community is very family centered, so the center typically sees entire families together. Because of the usually large numbers of children these families have, there are many pediatric patients. Many of their current adult patients were once pediatric patients there, and they now bring in their own children; it is very much a multigenerational practice (K. Morris, personal communication, February 23, 2018).
The health status of these children has many variables, including whether they were born in their host country or country of departure, the environment they were living it before departure, and whether the children lived in refugee camps before coming to the United States (Yun et al., 2016). For refugee children, it is important for them to have scheduled well visits which address psychosocial and school issues, helping prevent them from “falling through the cracks” (K. Morris, personal communication, February 23, 2018).
One of the biggest barriers refugees face during the resettlement process is not knowing the language of their new country. At the center, only five percent of patients can go without interpreter services. The staff relies on the services of third party interpreters via phone and iPad, as live interpreter service is too costly. These interpreters must be certified and speak the correct dialect of the patient and must also understand the peculiarities of culture and ethnicity which varies greatly amongst groups (McNeely & Morland, 2016).
Three important health equity goals for the refugee population are initial health screenings, building a strong relationship with their “medical home”, and catch-up to preventative care (McNeely & Morland, 2016). Upon arriving to the country, the center gives the refugees their first initial health screening, typically within 30 to 90 days, and identifies any acute or chronic issues, many of which have been neglected for some time. It is at this screening that they also tested for any infectious or communicable diseases and receive necessary immunizations.
Common health problems include heart disease, hypertension, and type 2 diabetes, in addition to prevalent mental health issues including anxiety, depression and PTSD. Occurrence of health issues are varied among the groups. For example, mental health problems are commonly seen in Syrians due to the current war and traumatic events in their home country, as well as time in refugee camps, and type two diabetes in the Nepali due to lack of knowledge about nutrition and physical activity (Pace, Al-Obaydi, Nourian, & Makimura, 2015).
The most important part of a nurse’s role at the Center for Refugee Health is thorough and ongoing education. Patient education and follow-up is imperative, especially about things such as medications and medication compliance, preventative healthcare measures, nutrition, and making home environments healthier. The biggest challenge identified by the nurse is teaching patients that although it is difficult they can become independent members of society. It is a fine balance between helping and enabling the patients, especially since acclimation can be a difficult and lengthy process (K. Morris, personal communication, February 23, 2018).
Since there are requirements for refugees as part of the resettlement process, for example they must obtain their green card after and be employed after one year of resettlement, encouragement by nurses of self-sufficiency and cultural adjustment is important. Many newly resettled refugees find it difficult to be self-sufficient in the short-term for several reasons including physical and/or mental health problems, limited employment opportunities, language barriers, and lack of resources (Pace, Al-Obaydi, Nourian, & Makimura, 2015).
Refugees build strong relationships with agency staff and rely on them for both medical and non-medical assistance. The staff becomes knowledgeable about other facets of their patient’s daily lives other than their health, and as such act as social workers, counselors, and community advocates. This can help lead to the patient’s overreliance on them (K. Morris, personal communication, February 23, 2018).
This writer could very much envision working as a nurse at the Center for Refugee Health. The primary incentive the nurse faces in her role there now is how rewarding it is to see refugees move forward and succeed in their new home (K. Morris, personal communication, February 23, 2018). After all the unfathomable hardships they have endured, and all the challenges they have encountered just to get to the United States, refugees deserve to have as much support and compassion as needed to successfully resettle and live happy, safe, and healthy lives. The ability to be a part of that would be a privilege.
According to the American Nurses Association, ‘nursing is committed to both the welfare of the sick, injured, and vulnerable in society and to social justice. The ANA Code of Ethics…establishes the ethical standard for the profession in its fervent call for all nurses and nursing organizations to advocate for the protection of human rights and social justice.” (ANA President Responds, 2017). It is the responsibility of all nurses, no matter what field they are working in or people they are serving, to remember this.
