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Immigrant Health Matters

center of excellence in newcomer health logo Immigrant Health Matters is a quarterly series of brief vignettes focused on immigrant health and health equity. Articles are designed to be read in three minutes and to provide an immigrant’s perspective of challenges in achieving health equity.

Health equity is generally defined as a state in which every person can achieve their highest possible level of health. Each article presents a scenario, provides background on related concepts, and discusses action steps for providers and organizations caring for immigrants.

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Caring for Ukrainian newcomers

Rochester, NY

September 2023

The scenario

Mrs. Galyna Karpenko and her two children, Liliya (age 12) and Anton (age 8), had just arrived from Poland in January of 2023 to Rochester, New York. It was a world away from her home in Kyiv, Ukraine. Galyna had connected with a long standing Ukrainian American immigrant family in Rochester, who agreed to sponsor her under the U.S. government Uniting for Ukraine Program. Her husband, Ivan, stayed back to help with the war effort, and she was feeling both anxious and depressed about how he was doing, as well as overwhelmed by the myriad of administrative and social hurdles in the U.S., despite the help of her sponsoring family. As she got in to the rideshare van with her children for her first clinic visit, she wondered whether “public” medical care was any good in America and worried about what shots might be required for her children. 

Dr. Ann Wilson has her usual busy schedule in her family medicine clinic in Rochester, New York today. She has been seeing immigrants for years, including Ukrainians who have lived in the area for decades. After Russia’s invasion of Ukraine in February of 2022, her clinic began to see a surge of Ukrainian new arrivals. “I feel comfortable with the Ukrainian patients I have seen here the last decade or more, but I wonder if there are any special issues which might be impacting this newest wave of arrivals?” she mused.

The challenge

Developing trusting relationships with patients

Dr. Wilson’s clinic had a good relationship with the state refugee health program and resettlement agencies, and she had negotiated with her administrative leadership the ability to have 30-minute appointments with newly arriving refugees, instead of her usual 20-minute appointments. She knew that the first appointment was a critical one for beginning to develop a trusting relationship with new patients. She also knew trust between provider and patient develops over time and is based on both the clinic staff and the provider demonstrating trustworthiness, compassion, and good communication skills. Her clinic has bilingual/bicultural staff, including Ukrainian born nurses, professional interpreters, and the ability to call the clinic directly and leave messages in Ukrainian. She understood that taking the time to explain the U.S. health care training process (high school, college, medical school, residency) would be well worth the few minutes of explanation to Ukrainian patients dubious about the quality of public vs private medical care.

Keeping up with the literature

Ukrainians have been coming to the U.S. in significant numbers since the 1880s, reaching over one million arrivals as of 2020 (U.S. Census Bureau: More Than One Million Americans Report Ukrainian Ancestry). Some came after the Holodomor (a man-made famine in 1932 and 1933), with another surge after the collapse of the former Soviet Union in 1989. Many of these earlier arrivals were Jewish and settled in New York, Pennsylvania, and elsewhere. Wilson knew that the newest Ukrainian arrivals were potentially different from these previous waves of immigrants, and decided to do a quick literature search for medical issues of note. She discovered several things of interest:

“It looks like Ukrainians have a high prevalence of chronic disease including hypertension and diabetes. And of course, mental health issues including anxiety and depression.” What was a bit surprising was the lower level of completion of routine vaccinations compared with other countries in the European region (WHO: Immunization Coverage data) and significant vaccine hesitancy. “All the more reason to listen empathetically and engender trust,” she thought. In addition, she learned about:

For many Ukrainians, the U.S. approach to both acute and preventive health visits may require explanation. Many Ukrainians visit pharmacies and speak with pharmacy staff for acute illnesses. In cities, local well-known hotlines, similar to 911, are used to request home visits to assess acute symptoms. Pediatricians and well child checks are not generally available in Ukraine, and vaccines are given at school or dedicated vaccine clinics. Providers should spend time explaining to patients an overview of the U.S. health care system, including urgent care, use of 911 (which can be a very foreign concept), and preventive health care for children and adults.

What you can do & resources

Dr. Wilson’s internet search revealed a wealth of information and connection to local refugee health experts and resettlement agencies. Rochester, NY has a rich history with Ukrainian immigration, and  many local agencies ready to help ease the transition for the newest arrivals (Deeply Rooted: Rochester’s Ukrainian Community, Part One). As is often the case, she learned their immigrant status was quite complex, including both humanitarian parolees and asylees, which impacts health benefits. She was grateful for the vital support provided by the clinic social worker.

Learn more about Ukrainian new arrivals

  • UNHCR Data Portal: Ukrainian Refugee Situation
    Over 9 million Ukrainian nationals have fled their country, primarily to neighboring countries, for safety reasons. The situation is changing rapidly.
  • CORE: Ukrainian Backgrounder (PDF)
    The Cultural Orientation Resource Exchange (CORE) has an excellent backgrounder which contains historical, political, and cultural information intended to cultivate a general understanding of refugees from Ukraine who are resettling in the United States.

Review resources specific to Ukrainian new arrival health issues

Review the approach to the refugee new arrival screening exam

Connect to colleagues

Connect to other national resources

The appointment

When the Karpenko family arrived, a pre-scheduled Ukrainian interpreter was there for the entire appointment. Dr. Wilson spent the first half of the visit asking Mrs. Karpenko to share the story of her journey to the U.S., her fears for her husband’s safety, and trouble sleeping. She prescribed medicines for Galyna’s hypertension and referred her to the clinic’s Russian-speaking psychologist. Hesitant at first, when Dr. Wilson did a soft hand off, inviting her colleague to briefly say hello and welcome Galyna to his practice, she seemed relieved to meet him and agreed to follow up. Dr. Wilson then asked about Liliya and Anton’s medical and vaccination history. She learned that Galyna deeply mistrusted the safety of vaccines in general and the ability of Ukraine’s health care system to safely administer vaccines. The children were behind on routine vaccines, and Galyna was very reluctant to start vaccinations at this clinic visit. Dr. Wilson explained the requirements for childhood vaccines for school in general and recommended a follow-up visit for the family next week to review lab results and continue the conversation about vaccinations. Galyna left the clinic feeling as though she had been listened to and genuinely cared about and decided to come back the next week for follow up.

Caring for Afghan newcomers

Houston, Texas

February 2023

The scenario

Physician assistant Roberto Castillo has a busy schedule in his primary care clinic in Houston, Texas. He has been seeing immigrants for years, but in late 2021 started to see an influx of Afghans. “This is a patient population I don’t know anything about,” he thought to himself. On his schedule today was a family: father Saboor, wife Salma, and their five children, ranging in age from 3 months to 12 years old (those who viewed the November 2022 ECHO Newcomer Health: Afghan Health Considerations webinar will recognize this family was discussed in detail).

Mr. Castillo felt simultaneously interested in seeing someone from a country about which he had no knowledge and anxious about how to best care for the family. He had kept up on the humanitarian crises following the U.S. withdrawal from Afghanistan. Other than that, he knew many Afghans were coming to Texas and wondered about where he could find more information about their health issues.

Salma and Saboor were also anxious about the upcoming appointment: “How will we all get there? Will the provider be kind? Will they know anything about us and why we came to America? And why do we have to have more health checks, when we have been through so many already? We are actually more worried about finding a job for Saboor and school for our children.”

The challenge

Time constraints

PA Castillo was accustomed to seeing large immigrant families, and his clinic had a good relationship with the state refugee health program and resettlement agencies. His entire morning was blocked out to see the family. A ride had been arranged and a Pashto interpreter pre-scheduled. This greatly helped with time management, and he had a few minutes to read about Afghan new arrivals while the family was being roomed.

Lack of knowledge about health issues specific to Afghans

Even though Roberto had seen refugees before, as he quickly realized from reading the rapidity of the Afghan exodus meant the usual overseas screening protocols had not been able to be followed. Many arrived at military bases in the U.S. and Europe without medical pre-screening and vaccinations. A herculean effort to house and feed over 120,000 was rapidly put together via Operation Allies Welcome. Several localized outbreaks of chickenpox, measles, and SARS-CoV-2 occurred on the bases. Vaccination programs were rapidly instituted, and tuberculosis screening began. Evacuees began leaving Afghanistan in August 2021, and the last U.S. bases housing Afghan arrivals completed their work sending Afghans on to resettlement states in October 2021.

He learned quickly that Afghanistan had poor childhood vaccine coverage, estimated by the WHO to be 60%. He also learned he should be aware of diseases including leishmaniasis, malaria (particularly Plasmodium vivax), and tuberculosis.

What you can do & resources

PA Castillo’s quick internet search revealed a wealth of information and connection to local refugee health experts and resettlement agencies. He learned that Texas was the top receiving state for newly arriving Afghans in FY2021-2022, followed by California and Virginia, and that their immigrant status was quite complex, including both parolees and special immigrant visa (SIV) holders; parolees could also become asylum seekers. He knew this would impact health benefits, and knew he would have to involve the clinic social worker for assistance.

Learn more about Afghan history and cultures

Review resources specific to Afghan new arrival health issues

Review the approach to the refugee new arrival screening exam

Connect to colleagues

  • Many state health departments have a refugee health program, and searching for specific information on state health department websites may be helpful, particularly if you would like to receive copies of overseas examinations that occurred as well as domestic medical examinations of refugees. Visit Office of Refugee Resettlement: Key State Contacts.
  • There is a thriving network of clinicians, nurses, social service staff, and national experts who connect through their professional society. This includes a very useful listserv where a helpful Q&A occurs: Society of Refugee Healthcare Providers.
  • Alternating between Canada and the United States annually is the premier academic event for refugee and immigrant health professionals: North American Refugee Health Conference.
  • The American Academy of Pediatrics has a Council on Immigrant Child and Family Health and an active listserv. You must join the AAP to be able to access this Council’s listserv.

Connect to other national resources

Lastly, for more in-depth learning, Global Medicine at the University of Minnesota offers a free seven-hour introductory course on refugee and immigrant health care: UMN Medical School: Introduction to Immigrant and Refugee Health Course.

The appointment

Saboor, Salam, and the children were able to attend the appointment with a ride arranged by their refugee resettlement agency. The clinic had arranged an in-person female Pashto interpreter, who was very welcoming. Saboor had been an interpreter for the U.S. Army and did not understand why an interpreter was needed. PA Castillo explained that the clinic has a policy that all adults are seen with a professional interpreter, and this was accepted. The clinic staff seemed kind and caring, asking about their journey to America, taking time to establish rapport, and explaining the concept of having a primary care provider and clinic for the family. Greatly appreciated at the end of the visit was time spent with the clinic social worker, who helped review housing and educational opportunities in the neighborhood. The family left the clinic feeling as though they had made a connection with a health care team in America and were on to their next challenge.

Caring for Congolese newcomers

Rural Ohio

November 2022

The scenario

Dr. Olivia Russo looked at her schedule, and knew she was in for a busy day. After rounding at the local 20 bed hospital this morning, her afternoon was fully booked. Running her own private practice in rural Ohio, this was not unusual, often seeing 30 or more adults, children, and families in a day.

Today’s schedule, however, held something different. The name Banzalina Ilunga was unfamiliar. When she asked the nursing staff, the reply came, “That is a newly arriving refugee family – a mother and her five children.” Dr. Olivia felt simultaneously interested in seeing someone she had never met before and anxious about how to best care for Banzalina and her family. Realistically, she also had very little time to research the Democratic Republic of the Congo, it’s history and culture, and what kinds of health challenges such patients might face. She decided to do a quick internet search for “Refugees in Ohio” to learn more.

Banzalina was also anxious about the upcoming appointment: How will we all get there? Will the provider be kind? Will they know anything about me and my history, my culture, my journey to America? And what about all the vaccinations and taking so much blood? We have been through so many health checks already; why do we need more when we feel well?

The challenge

Time constraints

Many providers may view a patient with limited English proficiency as a burden in their day, perhaps requiring more time with a professional interpreter, or facing the reality of no professional interpreter being available.

A state-wide group of experts in refugee and immigrant health in Minnesota surveyed providers to ask “How long would you take to answer a clinical question which may impact your health care decisions about an immigrant patient you are seeing during a busy day of scheduled patients?” The sobering answer for the majority of clinicians: “I am able to take no more than three to five minutes.”

Lack of knowledge about refugee and immigrant health issues

“Where were you born?" and "Where have you traveled?” are critical questions to ask of many patients, yet the question often is not asked, in part because the provider may not know what to do with the answer.

Lack of knowledge about available resources

Many clinicians, particularly those with few immigrants in their clinical practice, are not aware of the growing and robust body of knowledge which encompasses refugee and immigrant health. They also may not know that resources are available to guide the screening of newly arriving immigrants, as well as ongoing primary care issues more specific to immigrant groups. Such lack of knowledge may contribute to health disparities and should not be considered acceptable given the abundance of readily available resources which can be found within that three-to-five-minute reality of time available to search for answers.

What you can do & resources

Dr. Russo’s quick internet search revealed a wealth of information and connection to local refugee health experts and resettlement agencies. She learned that Ohio was one of the top 10 states receiving newly arriving refugees in FY2020 and was interested to learn more.

Learn more about refugee history and cultures

Review the approach to the refugee new arrival screening exam

Connect to colleagues

  • Many state health departments have a refugee health program, and searching for specific information on state health department websites may be helpful, particularly if you would like to receive copies of overseas examinations that occurred as well as domestic medical examinations of refugees.
  • There is a thriving network of clinicians, nurses, social service staff, and national experts who connect through their professional society. This includes a very useful listserv where a helpful Q&A occurs: Society of Refugee Healthcare Providers.
  • Alternating between Canada and the United States annually is the premier academic event for refugee and immigrant health professionals: North American Refugee Health Conference.
  • The American Academy of Pediatrics has a Council on Immigrant Child and Family Health and an active listserv. You must join the AAP to be able to access this Council’s listserv.

Connect to other national resources

Lastly, for more in-depth learning, Global Medicine at the University of Minnesota offers a free seven-hour introductory course on refugee and immigrant health care: UMN Medical School: Introduction to Immigrant and Refugee Health Course.

The appointment

Banzalina and her family were able to attend the appointment with a ride arranged by her refugee resettlement agency. The clinic had arranged an in-person Lingala interpreter, whom Banzalina had met previously, greatly reassuring her. Dr. Russo and the clinic staff seemed kind and caring, asking about her journey to America, taking time to establish rapport. Dr. Russo even spoke to Banzalina about the stress of resettlement and hopes for the future of her children. She acknowledged that this was only the first of several future visits in which they could address further concerns. Not everything must be done or addressed at the first appointment! The shots and blood tests were hard, but Banzalina and the children were strong and left the clinic feeling as though they had made a connection with a health care team in America.

Preventing COVID-19 and caring for newcomers with COVID-19

Rural Minnesota

August 2022

The scenario

Mohamed Abdi came home from work tired, as was often the case after putting in a long day as a line worker at a turkey factory in rural Minnesota. “I am worried about what is happening at work,” he told his wife. “Many people seem to be getting sick with COVID.” She was also worried about the vaccine and it’s potential side effects, including infertility.

Mr. Abdi hadn’t decided yet whether to get the COVID-19 vaccine that many people seemed to be discussing. “I am worried about how quickly the vaccine was developed, and whether or not they worked and were safe,” he said. “Plus, I wondered about severe or long-term side effects of the vaccine, and whether I would miss more wok because of them.”

After outreach by the Health Department years earlier, he had learned that autism was not caused by the MMR vaccine but was still wary of how a COVID-19 vaccine might affect his children. “I don’t really know if our kids will qualify for the vaccine or if they should take it.”

A few weeks later, he developed symptoms, and was found to have COVID-19. Isolation and quarantine were unrealistic because of living with his large extended family, despite having a three-bedroom home. He wasn’t sure if there were treatments available to him, and he worried about the loss of income related to being away from work. He wasn’t sure where to turn with his many questions for his own health, and the health of his family.

The challenge

Mr. Abdi’s experiences, while fictional, speak to many issues facing immigrant workers. Many first-generation immigrants work in essential jobs where they are in close contact with coworkers and the general public. This includes work in factories, farming, and long-term care facilities. Fields of employment, limited access to COVID-19 vaccines and healthcare more generally, health co-morbidities and other factors may have played roles in the early disproportionate toll of COVID-19 on communities of color. Many refugee and immigrant communities don’t have access to printed information and video messages in their primary language.

Of note, in the first months of the pandemic, Black people in the United States were significantly more likely to die from COVID-19 compared to white, Asian, and Latino people.1

The remarkable good news is that the uptake of vaccines in communities of color has improved dramatically, thanks to intensive, local outreach by multiple partners. Refugee, immigrant and migrant communities brought many strengths to the work, including trusted messengers such as religious leaders, as well as local refugee organizations. The ability to ask questions in their native language was one key to acceptance.

As a recent report in MMWR2 noted:

“Asian and non-Hispanic White adults had the highest COVID-19 vaccination coverage by the end of April 2021. By the end of November 2021, disparities in vaccination coverage for some racial and ethnic groups narrowed, and coverage was similar for non-Hispanic Black (78.2%), Hispanic (81.3%), Native Hawaiian and other Pacific Islander (75.7%), and non-Hispanic White (78.7%) adult.”

According to recent CDC data, within the last year, the death rate for white people is 14% higher than for Black people, and 72% higher than for Latino people.3 This is a notable public health turn around.

Ultimately, Mr. Abdi fully recovered from COVID, and after encouragement from his Imam, and discussions with his primary care provider, his family has been vaccinated and boosted.

What you can do & resources

Don’t forget the basic tenets of effective immigrant health work4

Help patients access health insurance; use professionally trained medical interpreters, hire providers with expertise in refugee and immigrant health; hire staff who reflect the communities they serve; provide multidisciplinary care that includes community health workers/care navigators; and establish clinics in close proximity to immigrant communities.

Connect to the community

Provide intensive outreach efforts by partnering with local community organizations, including schools and religious organizations; bring Mobile Clinics for vaccination and health outreach to areas where immigrants live and hire culturally and language- matched care navigators or other community health workers to staff these mobile clinics. Provide barrier free testing and vaccination.

National Resource Center for Refugees, Immigrants, and Migrants (NRC-RIM):

Utilize COVID-19 resources that are available in multiple language

This includes translated materials and recorded messages for those immigrants who are pre-literate:

Assure universal phone system access for non-English speaking immigrant patients

This may include, as one example, prerecorded messages in multiple languages for patients who call in to access care.

Connect to refugee and immigrant health experts

References
  1. Covid and Race. David Leonhardt. New York Times June 9, 2022.
  2. COVID-19 Vaccination Coverage by Race and Ethnicity – National Immunization Survey Adult COVID Module, United States, December 2020-November 2021, MMWR, June 10, 2022 / 71(23);757–763.
  3. CDC: Coronavirus Disease 2019 (COVID-19)
  4. Action Steps to Improve the Health of New Americans, P. Ohmans, in Immigrant Medicine, Editors Walker, PF and Barnett, ED, Elsevier Publishing, 2007, pp.27-35.

Acknowledgements

Immigrant Health Matters is written by Patricia F Walker, MD, DTM&H, FASTMH, and is a publication of the Centers for Disease Control and Prevention’s Center for Excellence in Newcomer Health.

Stories from Minnesota refugees

In honor of World Refugee Day, join us in celebrating and amplifying the voices of Minnesota’s refugees.

Bugondo (Blaise) Ntibonera

Bugondo (Blaise) Ntibonera

Congolese refugee, Refugee Resettlement Supervisor at Lutheran Social Services

Why Minnesota?

As all refugees who got resettled in the USA, at the USCIS interview in the refugee country, the immigration agents ask all refugees if they know someone in the USA - these people are called “USTie” - so they can resettle them close to that person so that person can help the refugee to adjust to their new life once they come to USA. That is how I came to Minnesota too because my brother’s lady knew someone who lives here in Minnesota when we were still in Africa.

What makes Minnesota a healthy home for you?

From my home county to Minnesota has been a long journey. I lived in Uganda as a refugee for six years in a bad situation. Refugees didn’t have access to the health system, education, healthy living environment. Therefore, me being in Minnesota makes Minnesota my home because I now have full access to the health system and also, I live in a clean environment which is also safe. For me health is a state in life when I am physically and mentally feeling well. This state enables me to perform my jobs and play a big role in my life otherwise I wouldn’t be able to help other refugees who are coming after me.

Does your identity as a refugee or immigrant affect your definition?

My identity as a refugee doesn’t affect me. I am able to perform my duties while working with other people from different countries or even from here in America. We are all treated the same as others with love, respect and care.

How do you contribute to the health of your community?

Personally, I am a leader of a small group of singers. I try to encourage others to stay healthy at home and to make sure the food they eat is healthy. Because we heard that most of the health problem here in the USA are due to nutrition or diet.

How does art (including music, poetry, storytelling) affect your or your community’s wellbeing?

To stay emotionally health, many people from Congo who are Christian trust and believe in God. They believe that there is powerful message in the music and in reading the bible. Also, by listening to poems and stories while in distress or depression.

How do you see Minnesota as a home for immigrants and refugees in the future? Where do see yourself and your family in the future?

Minnesotans love refugees and always stand on their side, that will make me think Minnesota can be called a “home of refugees”. Many refugee kids are studying in Minnesota which shows that in future many youth refugees will contribute more to Minnesota’s economy than our today’s contribution. I have one brother and seven nephews and nieces who are studying today in Minnesota with plans to be doctors, engineers, law enforcement agents, and case workers. It means the future of my family and I is being built here. I see myself in the future as a father of a heathy family and a great advocator for refugees. I am working hard to make this happen by staying positive in everything I do and always stick to the plan.

Iryna Petrus

Iryna Petrus

Ukrainian refugee, Outreach Manager at the Ukrainian American Community Center (UACC)

What does health mean to you?

Number 1 life priority. My best life investments are in my health! Therefore it's very important and meaningful for me to maintain a healthy lifestyle.

What makes Minnesota a healthy home for you?

Safety, community, perfect environment, support, and medical programs.

How does your community contribute to your health?

UACC creates opportunities, connections, and support. And also, our organization tries to treat people like they would be treated at home. A loving and caring environment is essential for mental and physical well-being.

How do you contribute to the health of your community?

Daily job, volunteering, and support.

What are you looking forward to in the future? Or what are your hopes for the future?

A safe life, no wars, human kindness, respect, and a loving society.

To hear more about Iryna's story, watch Sharing Gratitude (YouTube).

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Last Updated: 09/26/2023