Since 1975, the United States has resettled more than 3 million refugees. It was not until the Refugee Act (1980) that the US had an official and comprehensive immigration policy (Bon Tempo, 2008). According to Kerwin (2015) the Act sought to harmonize US law with the 1951 United Nations (UN) Convention Relating to the Status of Refugees and the 1967 Protocol Relating to the Status of Refugees. It sought to “revise and regularize” US refugee admission procedures and laid the foundation for federal immigration oversight and is the precursor to the current USRP -United States Resettlement Program- (Kerwin, 2015; Utržan et al., 2018).
As explained in detail by Utržan et al. (2018), to facilitate refugee resettlement efforts, the USRP developed a cooperative agreement with non-governmental organizations (NGOs) or voluntary resettlement organizations (VOLAGs). Referred to as Resettlement Support Centers (RSCs), they are: 1) Church World Services (CWS), 2) Ethiopian Community Development Council (ECDC), 3) Episcopal Migration Ministries (EMM), 4) Hebrew Immigrant Aid Society (HIAS), 5) International Rescue Committee (IRC), 6) Lutheran Immigration and Social Services (LIRS), 7) United States Committee for Refugees and Immigrants (USCRI), 8) United States Conference on Catholic Bishops (USCCB), and 9) World Relief (WR) (Utržan et al. 2018,128).
Resettlement organizations are supposed to provide refugees with critical services upon their arrival in the US. These include monthly cash benefits, employment services, and English language classes. There are nevertheless funding discrepancies between government agencies and an absence of oversight that severely impedes service delivery (Bruno, 2017).
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Kerwin (2015) explains the main challenge and source of tension for non-federal stakeholders in USRAP – the United States Resettlement Admissions Program- has been the federal government’s diminishing financial commitment to the program (Brown and Scribner 2014, 110-12; US Senate Committee on Foreign Relations 2010). Moreover, a survey of 59 resettlement cases in 2008 by Lutheran Immigration and Refugee Service (LIRS) found that federal funding covered 39 percent of the cost of required services during the crucial first 90 days of resettlement (LIRS 2009, 9) (Kerwin, 2015,225).
Refugee policy in the United States has undoubtfully given a turn in the last years. In September 2017, the Trump administration set a much lower refugee admissions ceiling of 45,000 for FY 2018, but this quota was not met by the actual number of admitted refugees most notably due to the travel ban imposed on Muslim-majority states. Other factors were the slowdown on the interview, screening, and admissions processes which have provoked a regression in the community-based infrastructure built for resettlement over the past decades (Miliband 2018).
The reduction in refugees has been felt in Chicago, for example, where some resettlement agencies have gone months with no new refugees. At their peak, agencies in Illinois helped acclimate more than 500 new arrivals a month. Now, some months they see fewer than 50 altogether. Of the 50 local affiliates of national agencies affected by the department’s decision, six stopped placements altogether, and 21 chose to suspend placement for the rest of the fiscal year (Weinberg & Husain, 2018).
With the new adjustments in programming affected by Trump’s policy, the refugee provider agencies are under strain. The key issue is that the amount of money given to refugee resettlement agencies by the federal government depends on the number of refugees these agencies serve, and these numbers keep falling due to the implementation of a more restrictive refugee policy (Bruno, 2017; Miliband, 2018).
In the United States, one of these key infrastructures that are affected by these new policies are the community health centers which work with the resettlement agencies. These are on the front lines of working with refugees. According to Taylor (2014) a community health center is a nonprofit comprehensive primary care facility that is federally mandated to provide services to underserved areas. Through the assistance of local agencies, the UN-designated refugee is connected to a local community health center that provides health and behavioral health care services (Bruno, 2015; Morland & Levine, 2016).
It is known that refugees have often survived traumatic events, leaving many with symptoms of depression, anxiety, and post-traumatic stress disorder. In addition, individuals and families may enter the United States with pre-existing health and mental health conditions that can complicate their resettlement (Burnett, 2016; Bustamante, Leclerc, Mari, & Brietzke, 2016; Ellis, Murray, & Barrett, 2014; Hansen & Huston, 2016; Moulton, 2016) (Dubus & Davis, 2018).
One of the biggest challenges refugees face is dealing with the US health system. The basic premise underlying the U.S. resettlement program is that refugees can benefit from institutional support as they begin to integrate into their new country and strive to reach economic self-sufficiency (Bruno, 2011; Newland, 1995; Schwartz, 2010).
Philbrick et al. (2017) explains that ideally, refugees rely on a voluntary agency to help them navigate the medical system. However, voluntary agencies are given very limited government financial assistance to aid refugee’s needs such as obtaining food, housing (including furnishings), clothing, English language education, employment counseling, education, and medical care. These organizations rely on volunteers and often face numerous obstacles to coordinate care effectively, including inadequate funding, lack of familiarity with the health care system, language barriers, and patients asking family or friends to help navigate the system (Philbrick et al. 2017,656-657).
Some of the barriers for refugees to access health care are shared by low-income Americans who also face limited transportation, financial restraints, and unstable housing. Refugees on the other hand also face barriers related to language, culture, unfamiliarity with the US health care system, and traumatic life experiences (Asgary, 2011). There is also a lack of trust in health care providers for refugees accessing health care and using preventive care (Elwell et al. 2014; Morrison et al. 2012).
A study by Worabo et al. (2018) mentioned the commentaries by an Eritrean man who asked why they are only provided with 8 months of Medicaid; since by the time he was able to schedule an appointment with his primary care provider, the Medicaid coverage had expired (Worabo et al. 2018,489).
In the same study, participants were asked what they do when they have a health problem, most of them stated that they would call “911” or “go to the emergency room.”. As noted by DeShaw who found that, for example, Somali immigrants and refugees in Minnesota tended to access health care through the emergency room more frequently than the general population. Similarly, as the refugees in Worabo et al., they reported the use of emergency rooms and that they would go to the hospital if they had a health problem (DeShaw, 2006).
Miscommunication between health care personnel and refugees is another big issue highlighted by this study. Sometimes, a lack of interpreter services and language barriers explain missed appointments and untreated health problems in the refugee population. There also is confusion when trying to navigate the health care system. The need for guidance to navigate this system is prevalent among refugees (Worabo et al. 2018,490).
Kennedy (1999) suggests resettlement agency caseworkers should partner with community health centers to provide health care system navigation. The study gives the example of the Colorado Refugee Service Program as a well-integrated system that includes refugee agencies, language services, a family medicine clinic, and voluntary agencies (Kennedy et al. 1999).
Another factor mentioned in Worabo et al. (2018) is the cultural factor which plays a role in shaping refugees’ perceptions of US health care services. For example, the Iraqi and Somali participants felt that US health care providers did not take enough time to listen to their concerns but “just give us medicine to keep us quiet.” (Worabo et al. 2018,493).
In short, miscommunication hinders all aspects of health care, including making appointments, obtaining transportation to appointments, disclosing personal health information, and understanding test results and treatment plans. This evidences the importance of English language classes for refugees (Also known as ESL) as well as building a partnership to establish streamlined interpretation services (Worabo et al. 2018,493).
Mishori (2017) points out how refugees from countries with inadequate or inefficient health systems may be “missing immunizations and routine recommended screenings for cancer and chronic diseases”. He then suggests a need of greater attention to women’s health, family planning, cancer screening (breast, colon, and cervical), oral health, vision, and chronic disease screening (hyperlipidemia, diabetes mellitus, hypertension, and hepatitis C). By doing so health providers can identify and address previously unmet health care needs (Mishori, 2017,118)
The literature evidences the struggles refugees already face when navigating the US health system: cultural barriers, trust issues, communication, unmet expectations, among others. To this we must add the funding and downsizing problems service providers are facing. The interruption of services due to a lack of funding poses an ethical dilemma this paper seeks to address.
As a result of these funding cuts, the infrastructure and social capital built to help refugees is destroyed and refugees are the principal victims. Many of them rely on case workers or case managers for appointments, transportation, and interpretation. But due to downsizing, refugees may have no way of getting in touch with their service providers for medical follow up, check up or further treatment.
This undermines the effective treatment of the patients and can have lasting negative health outcomes. This is particularly challenging when the patient is a child for whom earlier detection and treatment of diseases can mean the difference between compromised health and a path to healthy adulthood. This hard choice constitutes an ethical dilemma for the service providers who will live with the knowledge that they may have contributed to undermining a child’s future.
A solution to this problem is proposed by Spiegel et al. (2018) who suggest implementing innovative health funding from other situations and adapting them to refugee-specific contexts but also believe existing funding could be used more effectively. The use of additional funding from non-traditional sources such as the private sector and donors could also benefit national health systems as well as refugees (Spiegel et al., 2018,9).
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