This is a corrected version of the Medicine and Society that appeared in print.
Am Fam Physician. 1998;57(6):1245-1256
One cannot pick up a newspaper or turn on the television without confronting the seemingly unending dramas of wars and conflicts between nations. These conflicts produce long lines of starving women and children waiting to receive food or medical treatment from organizations under the guidance of the office of the United Nations High Commissioner of Refugees. Although the countries that produce refugees may change, the pain and suffering of individuals do not. The Geneva Convention of the United Nations provided the following definition of a refugee:
Refugees of every race and religion are found in every part of the world. Because they fear for their lives, they give up everything—home, belongings and family—for an uncertain future in a strange land. In 1996, there were approximately 26 million refugees in the world, representing one out of every 220 persons.2
A small percentage of these refugees are granted political asylum and permanently relocated to other countries, including the United States and Canada. Within one year of arrival, refugees are required to have a physical examination. Although the medical needs of refugees often differ from those of the general U.S. population, and while the needs may be individual and regional, there are common principles of practice that can be used in the provision of their health care. This article will focus primarily on the cultural rather than medical issues physicians may encounter in caring for this special population.
Refugee assistance involves a complex web of collaboration between individuals and agencies.3 Most new refugees have a sponsoring agency in the community to assist with the resettlement process, and this agency is a valuable resource for the physician. Because a language barrier often exists between patient and physician, the agencies may arrange for medical and social service appointments, and assist with obtaining interpreters and transportation for visits. The agencies know the refugees—offering insight about conditions experienced and their cultural practices, and conditions at refugee camps. Because practicing physicians may not be aware of these factors, networking between the refugee agency, the physician and the community or governmental resource is essential in the provision of health care.
Background Factors in Caring for Refugees
Situations That Cause Refugees to Flee
As described in the definition, refugees have fled from hostile situations including lack of food. Knowledge of specific situations can assist physicians in determining the focus of the office visit. By recognizing probable victims of torture, the physician might focus the history and physical examination around the more relevant complaint, and consider different or more uncommon diagnoses. For example, while beating is the most common type of torture, thermal and chemical burns, electrical torture, rape, sexual abuse, environmental manipulation, pharmacologic torture, asphyxiation and suspension by wrists are among other forms of torture used.4 Because torture may leave no telltale physical markings, careful history-taking provides relevant information to the physician.
Refugees in Camps
Many refugees, before entering the United States, have resided in United Nations camps located in countries adjacent to their homelands. During this time of transit, refugees face disintegration of their family structure, overcrowded living arrangements, inadequate nourishment and poor sanitation, leading to problems such as cholera, malnutrition and hepatitis. Rape, torture or other physical suffering, such as land mine accidents, are also a reality of life affecting refugees during times of war and conflict.5–8 Although camp conditions are often poor, high crude mortality rates of refugees have drastically been reduced because of the services provided by the world community.9 Before acceptance as political asylum claimants, refugees receive an overseas examination by public health advisors and/or physicians, although it may be inadequate and not timely.10,11
Problems Encountered at the Physician's Office
Cultural barriers between physician and refugee patients can affect the outcome of the encounter. In some cultures, it is not proper to ask an authority figure, such as a physician, any questions. Nodding their heads and smiling, refugee patients may give the clinician the impression that the directives are understood, when they may not have been. In some cultures, it is considered improper to maintain eye contact while talking to authority figures, and patients may avoid eye contact even when interested in the discussion.12 Although this behavior may be related to cultural differences, it may also be related to fear that a health problem may affect residence status in the host country.5
Frequently, problems arise when medical procedures are conducted. In some cultures, certain body parts are considered “sacred” or blood loss “irreversible.”12 Therefore, it is worth exploring patients' belief systems regarding illness, as sickness is often believed to arise from physical as well as metaphysical and supernatural forces. The clinician might uncover a hidden agenda and cause of ailments when questioning a patient's perception of illness.13,14
Regardless of cultural differences, it is critical to maintain respect for the patient while providing health care according to the standards of the host society. For example, in many cultures, the patient's family, not the patient, is told the diagnosis, in direct contrast to usual practice in this country.15 Another example of cultural difference is female circumcision (also known as female genital mutilation), present in some African refugees. While some cultural practices should be respected, education needs to be implemented to assure health according to the standards of this society.
Trained medical interpreters, preferably the same gender as the patient, are valuable partners in health care delivery to refugees.14 Because of the sensitive nature of some health issues, it is least desirable to use children or the spouse of a patient. Medically trained interpreters are preferable to family members or nontrained interpreters, because the latter may express his or her own views, emotions and beliefs during the translation.15 To minimize these occurrences, physicians need to monitor patients' facial expressions.
When interpreters are not available, or when the patient does not want an interpreter, the physician needs to speak slowly, repeat often and in different ways, and ask the patient to repeat back the directives to assess understanding.
Refugee Expectations for Treatment and Compliance
Refugees often expect Western physicians and medicine to cure everything and that the cure will be immediate.16 Others believe that illness is an unavoidable part of life, and they may delay seeing a physician.17 Urgency with regard to getting prescriptions filled, such as antibiotics, may not seem important to some. These interpretation difficulties may arise when the newcomers first come in contact with Western physicians while maintaining their previously held beliefs and expectations of the healing roles of witch doctors and priests from their homelands. In addition, cultural beliefs regarding the etiology of illness (e.g., weakening of nerves,18 an imbalance,19 an obstruction of chi,20 failure to be in harmony with nature), and distrust of and unfamiliarity with Western medicine may also contribute to noncompliance.
Noncompliance with medication and treatment protocol is often a problem. Supervised administration of some medicine (i.e., tuberculosis prophylaxis) has proven effective in several cities and may be helpful for certain noncompliant patients. When prescribing an antibiotic, the clinician needs to tell the refugee or parent to finish the medicine, especially since the usual custom is to take medicine only until the pain or symptom is gone. It may be preferable to prescribe as few medicines as possible at a single visit, with extra time given to help the patient understand the treatment protocol.
Special Aspects of Caring for Refugees
Spousal and Child Abuse
Domestic violence is a common occurrence in many cultures, with refugee families at increased risk for experiencing abusive situations for several reasons. In most cultures, women are subservient to men, and added freedom in the United States may alter the family's dynamics. In the United States, men may be expected to help out more within the home, and women may be required to work. Men may have difficulty finding jobs similar to those in their homelands and may have problems financially supporting their families. Alcohol abuse related to the new freedom and the prevalence of alcohol in our society may add to the problem.
In refugee families, violence is often hidden because the victim is often isolated from the general community and may not know how or where to ask for help. Some refugee groups may be small and may lack the support of their fellow compatriots in times of difficulty. Women's shelters may not be an option since some shelters may not be able to provide services because of language and cultural barriers. Additionally, women with children may be reluctant to go to shelters, because they are an unfamiliar setting.
The disciplining of children varies between cultures, and in some, children may be hit on the head, slapped or hit with a tree twig. In addition, as children quickly assimilate into Western culture, conflicts with their parents may arise.
Physicians need to be cognizant of the possibility of abuse in refugee families and identify resources in the community to assist these families. Networking with schools is important because teachers may recognize problems within the refugee's home. Adequate time needs to be spent explaining to the family alternate ways of disciplining children and informing them that spousal and child abuse is prohibited by U.S. law. Women at risk need to be told about actions to take and phone numbers to call if they need to leave their situation.
Preventive Health and Safety Issues
Preventive health care may be a new concept for refugees. It is an issue especially with regard to immunizations. This may be because of cultural differences or the day-to-day survival routine while fleeing their countries. Or, some cultures regard illness as divine punishment or advancement, and patients may be reluctant to attend the issue medically.21
Safety issues are of major concern for refugees. Physicians may need to discuss with parents the topics of children and traffic hazards, the risk of letting children run barefoot outside, the risks associated with electrical outlets, the proper clothing required for inclement weather, and the safe storage of medicines and cleaning supplies. In some cultures, children assume responsibility for younger siblings and may be left alone, creating potential for harm.
Pediatric and Obstetric Concerns
Refugee women and children are at a particularly high risk of medical problems and represent the majority of persons within groups entering the United States. Younger children suffer more because of wars and conflicts, suffering from conditions such as malnutrition, dehydration and infections. One study reported that 17 percent of the pediatric refugees had weights below the fifth percentile, and that only 39 percent of the pediatric refugees had adequate immunizations.11 Also, children are not immune to the trauma, including sexual trauma, related to the refugee experience. They may also have witnessed torture or death of their neighbors, relatives and even parents, which may affect their mental well-being.
Another special group is pregnant refugees. A study of obstetric histories among Hmong refugees showed the presence of greater parity, delayed prenatal care and lower hematocrits in pregnant patients when compared with Caucasian counterparts, although the refugees had fewer complications than other indigent pregnant patients.22–24
The prevalence rate of female genital mutilation is between 5 and 99 percent in the 26 African countries where this practice is used.25,26 Depending on the extent of the procedure undergone, patients may have a complicated labor and delivery.27 During the second stage of the labor, infibulated patients, ones who received a more severe form of genital mutilation, may require anterior as well as posterior episiotomies before delivering the infant's head.28 These patients challenge the physician during their routine and prenatal visits since pelvic examinations may be difficult to perform or may be painful.
Infectious and Endemic Diseases
Many of the infections and diseases seen in Third World countries are not freqently seen in the United States, and physicians may feel insecure treating these conditions. These diseases include tuberculosis and parasite infections. For example, malaria is endemic in many countries. Practitioners should consider the risk of malaria in pregnant women, with the possibility of congenital transmission to the fetus and newborn.29 Malaria needs to be considered even in refugees who have been living in the United States a few years when they present with cyclic unexplained fever.
Human immunodeficiency virus (HIV) infection is a major concern for refugees. Although adult refugees are screened for HIV prior to their U.S. entry, they may become infected just before coming to the United States or become infected soon after entering the country. Most refugees know very little about sexually transmitted diseases (STDs) and HIV. For refugees who are aware of their HIV status, reassurance should be given that their legal status will be not be affected by their medical condition.
Although refugees want to become assimilated into the U.S. culture and be contributing members of our society, time and a great deal of patience are needed. Adjustment is very difficult the first year, with other problems surfacing years after arrival in the United States.
Some refugees are from nomadic societies and create problems in this country when they move from one place to another seeking different areas in which to live. By moving, they are separated from their sponsoring agency who provided assistance with shelter, food, clothing, and enrollment in social services and schools. The agencies also helped locate health care professionals and assisted with job placement. Frequent moves may impede the continuity of medical care and increase the public health concerns about communicable diseases such as tuberculosis, STDs and intestinal parasites, or may affect conditions that need follow-up, such as pregnancies, malnutrition, domestic violence and psychiatric disorders. Frequent moves are also harmful to the children who may be disrupted from their schools and new-found friends.
Mental Health Concerns
Mental health problems can arise from several different situations. There may be preexisting conditions or newly onset conditions related to situations from which they fled, or the stress of relocation may trigger a preexisting condition.
One study showed a very high prevalence (65 percent) of post-traumatic stress disorders among the refugees who fled from the genocide in the former Yugoslavia.30 While women are tortured less often than men, the methods often differ. In one report, women who were sexually tortured had more psychologic and sexual dysfunctions when compared with the ones who were not.31 Most torture victims experience some physical sequelae as a result, with headache reported in 65 percent of torture victims.32
Another study showed that among the Cambodian refugees with psychiatric diagnosis, 57.9 percent had depressive disorders, 23.7 percent had anxiety and post-traumatic stress disorder and 3 percent had adjustment disorders.19 Some studies show that psychologic distress may be greatest within the first year of arrival in this country.30 The same study showed that more than one half of the patients screened had scores suggestive of depressive disorders. Unfortunately, a general physician may have difficulty detecting this diagnosis in their refugee patients.
For physicians and others to effectively provide services to refugees, a needs assessment should be done. There may be an infinite number of variables that exist between and within the different groups of refugees. The main factors that need to be addressed in an assessment are listed in Table 1.
While these efforts by the host health care professionals are essential, physicians need to weigh the risk of causing dependency and passivity, or a take-it-for-granted attitude on the part of the refugee. These behaviors may be a result of the few opportunities for active participation by refugees in expressing their needs, especially over the long term. Once their immediate basic health and social needs are met, refugees should be encouraged to participate in the provision of support for others in the community.5 The model of using focused group meetings may offer a non-threatening means for the newcomers to express their concerns and needs in their new country.16
Taking time to talk with patients, allowing them to express their concerns and actively listening help make these cross-cultural experiences worthwhile. Family physicians have a unique opportunity to enrich their medical practices by learning about different cultures and endemic diseases and conditions, while providing quality health care to an at-risk population. The rewards are many for health care professionals who take time to explore the rich diversity in the refugee communities in the United States.