Primary Health Care for Refugees—Introduction Meera Siddharth, MDa,b,c

Introduction s practitioners of refugee health, we often get asked many questions about what we do. Who are refugees? What is refugee health? How is it different than immigrant health? Are you giving free health care? In this publication, we hope to answer these questions, as well as concentrate on some of the important issues in refugee health, nutrition, infectious disease, and psychological trauma. So, who are refugees? Let us start with the definition as established by the United Nations High Commissioner for Refugees (UNHCR).1 A refugee is someone who has been forced to flee his or her country because of persecution, war, or violence. A refugee has a well-founded fear of persecution for reasons of race, religion, nationality, political opinion, or membership in a particular social group. Most likely, they cannot return home or are afraid to do so. War and ethnic, tribal, and religious violence are leading causes of refugees fleeing their countries. According to the UNHCR Global Trends 2012 Report, there were 45.2 million forcibly displaced persons worldwide at the end of 2012. Currently, the worldwide population of refugees is about 15.4 million, with 10.5 million of these refugees under UNHCR protection. There are 28 million Internally Displaced Persons (IDPs), these are people who are displaced from their homes, yet remain in their own country. Some IDPs may also receive protection or assistance from the UNCHR. A smaller subset of displaced persons is asylees, numbering about 900,000.2 These are people who fit the criteria of a

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From the aChildren's Hospital of Philadelphia Refugee Health Program, Philadelphia, PA; bCHOP Karabots Pediatric Care Center, Philadelphia, PA; and cUniversity of Pennsylvania School of Medicine, Philadelphia, PA. Curr Probl Pediatr Adolesc Health Care 2014;44:186-187 1538-5442/$ - see front matter & 2014 Mosby, Inc. All rights reserved. http://dx.doi.org/10.1016/j.cppeds.2014.03.001

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refugee, but reached another country by other means, such as a visitor, tourist, or student, and then made a formal application for asylum. Finally, there are about 10 million stateless persons who have no nationality or citizenship. According to the 2012 report, 46% of refugees are children, of which approximately 21,000 are unaccompanied (Fig).3 In 2012, the top countries of origin were Afghanistan, Iraq, Sudan, Somalia, and the Syrian Arab Republic.4 In 2012, the top two refugee hosting countries were Pakistan (1,638,500) and Iran (868,200), with Germany hosting the most refugees among high-income countries at 589,700.5 The three durable solutions for refugees are voluntary repatriation, local integration, and resettlement to a third country. Very few refugees have the third option; in 2012, less than 1% of refugees were resettled. The United States has a long history of taking in people who fit the above definitions. The previous century saw waves of refugees fleeing Europe, post World War II and then the Cold War. The 1970s saw the influx of refugees from Indochina. In 1980, The Refugee Act formally organized refugee resettlement, standardizing the process across the US, using a public–private partnership between nonprofit resettlement agencies and their local representatives. The United States takes in about 80,000 refugees a year. While this is a small percentage of the world's refugee population, it is also the largest number accepted by any country for permanent resettlement. Refugees begin the process abroad, in their camp, or the municipality to which they have fled. They apply to the UNHCR to prove their refugee status. Once through that process they undergo a security check by the Department of Homeland Security and a health screening overseen by the Centers for Disease Control and Prevention. Those chosen for immigration are then reviewed weekly by representatives of the nine resettlement agencies, who together have about 350 local affiliates

Curr Probl Pediatr Adolesc Health Care, August 2014

45.2 Million Displaced People

28.8 Million Internally Displaced Persons

15.4 Million Refugees

Nearly 1 Million Asylum Seekers

Fig. End of 2012 UNHCR statistics.

all over the country. They then decide who has the capacity to resettle the refugees at the local level. An individual or family may be placed in a specific city or area based on the presence of a local co-ethnic population or family members, or because of access to work, worship, and/or health care. Once they reach a locality, a member from the local resettlement agency meets them at the airport and takes them to their apartment, which has been furnished with the basics. They also receive assistance in settling in to their new life—applying for a Social Security card, applying for school and employment, life skills education (e.g., how to buy groceries), and other aspects of cultural orientation. Refugee resettlement agencies are expected to assist families for about three months, and receive a small lump sum from the State Department to help defray costs. Often they stay involved for longer than this. Refugees receive eight months of Medicaid and cash assistance, after which children typically remain eligible for welfare benefits but many adults become uninsured.6 Refugees are also able to obtain employment authorization, so that they may look for work when they arrive. Most find low-skilled, entry-level jobs. Before leaving their transition country, refugees receive an Overseas Medical Exam from a physician hired by the State Department. This is a general public health exam to screen for communicable diseases such as tuberculosis. Refugees may also receive a set of vaccines as well as geographically appropriate prophylactic treatment prior to departure. Once they arrive in the US, refugees undergo a Domestic Medical Exam. This varies depending on where they are seen, but in general, it consists of both a public health screening, as well as a personal health screen. The screening focuses on evaluations for infectious diseases, nutritional deficits, and mental health concerns, all of which will be discussed in more

Curr Probl PediatrAdolesc Health Care, August 2014

detail in this journal. Other important screenings include dental health and for children, development. Refugees as a group are a heterogeneous subset of immigrants in general, with diverse national origins and life experiences prior to fleeing their homes. They carry the burden of issues in their country of origin, as well as difficulties in their journey to resettlement. These burdens often manifest in both physical and mental health issues years down the line. It should be noted that this type of experience is not limited to refugees and other immigrants may suffer similar experiences. And, despite these challenges, most refugee children display remarkable resilience.7 It is the job of the medical practitioner to provide quality medical care to this diverse group. The field of refugee health has evolved over the years to encompass addressing public and personal health issues, trauma, and issues around assimilation. In all of this, the concept of providing compassionate, culturally effective care is at the forefront.

References 1. United Nations High Commission for Refugees. What is a Refugee? Retrieved November 3, 2013 from http://www. unrefugees.org/site/c.lfIQKSOwFqG/b.4950731/k.A894/What_ is_a_refugee.htm; 2013. 2. United Nations High Commission for Refugees. Displacement— The New 21st Century Challenge. Global Trends 2012. Geneva, Switzerland. Retrieved from http://unhcr.org/globaltrends june2013/UNHCR%20GLOBAL%20TRENDS%202012_V08_ web.pdf; 2013, p. 2. 3. United Nations High Commission for Refugees. Displacement— The New 21st Century Challenge. Global Trends 2012. Geneva, Switzerland. Retrieved November 3, 2013 from http://unhcr.org/ globaltrendsjune2013/UNHCR%20GLOBAL%20TRENDS%20 2012_V08_web.pdf; 2013, p. 2. 4. United Nations High Commission for Refugees. Displacement— The New 21st Century Challenge. Global Trends 2012. Geneva, Switzerland. Retrieved November 3, 2013 from http://unhcr.org/ globaltrendsjune2013/UNHCR%20GLOBAL%20TRENDS%20 2012_V08_web.pdf; 2013, p. 13. 5. United Nations High Commission for Refugees. Displacement— The New 21st Century Challenge. Global Trends 2012. Geneva, Switzerland. Retrieved November 3, 2013 from http://unhcr.org/ globaltrendsjune2013/UNHCR%20GLOBAL%20TRENDS%20 2012_V08_web.pdf; 2013, p. 14. 6. United States Department of Health and Human Services. A comprehensive review of immigrant access to health and human services. Chaudry and Fortuny. Urban Institute, Washington D. C. Retrieved January 7, 2014 from http://aspe.hhs.gov/hsp/11/ ImmigrantAccess/Review/index.shtml; 2011. 7. Betancourt TS, Khan KT. The mental health of children affected by armed conflict: protective processes and pathways to resilience. Int Rev Psychiatry 2008;20(3):317–28.

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Primary health care for refugees--introduction.

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