Asylum seekers and refugees encounter numerous challenges when it comes to health care, such as access to essential mental health and neurologic services. Health literacy, language, culture, and travel expenses are barriers that can limit access to health care for this population if unaddressed.1
In 2022, a record high of 108.4 million people were forcibly displaced from their home countries due to persecution, conflict, and violence.2 The United States has long served as a host country for asylum seekers and refugees for more than 75 years and has welcomed more than 3 million refugees since.3,4 The current US administration plans to increase the cap on refugees and has created the Welcome Corps program, which allows citizens to sponsor and help refugees through the support of nonprofit organizations.3
With the increasing number of asylum seekers and refugees in the US and internationally, it has become increasingly important to shed light on the health care obstacles experienced by this vulnerable population.5 Neurologists and other clinicians play a unique role in treating and helping asylum seekers and refugees.
This patient population can experience trauma and post-traumatic stress disorder (PTSD) in the process of being displaced from their home country, which impacts their mental and neurologic health. According to previous research, refugees in low- and middle-income countries have increased mental, neurologic, and substance use problems.6
“
Mental health is a global issue, but it’s even more drastic in the refugee population because they have experienced a lot of psychological trauma and many have not even started to unpack it.
For insight into caring for refugees in the US, we spoke with Denise Sebasigari, DO, academic neurologist and refugee advocate. Dr Sebasigari came to the US as a refugee and currently serves as a board member at the Sebas Foundation, a nonprofit organization that provides services for relocated refugees in Houston, Texas.
For perspective on treating refugees overseas, we spoke with Ari Zeldin MD, FAAP FAAN, pediatric neurologist at the Naval Medical Center San Diego. Dr Zeldin completed a mission in Bangladesh with Médecins Sans Frontières (MSF), also known as Doctors Without Borders, to provide aid to the Rohingya refugee population.
Drs Sebasigari and Zeldin share their experiences in providing health care to asylum seekers and refugees and the future of mitigating treatment barriers for this patient population.
How can clinicians help asylum seekers and refugees access and navigate the US health care system?
Dr Sebasigari: The first thing is to find out how long they’ve been in the US and then figure out the level of education of not only the patient but also the family. The level of family involvement in patient care is also important to figure out, especially for a child or an older adult.
This background will help determine how well they know how to navigate the health care system. You may be required to educate them more about how to obtain certain services, including social services.
You can ask them what agency is helping them resettle and you may be able to reach out to the agency to find out if they can offer additional resources for this certain individual. Sometimes those agencies can give them more resources that the patient may not be aware of.
What are the major barriers to accessing and providing the necessary care for asylum seekers and refugees overseas?
Dr Zeldin: Regardless of who you are or what your financial means are, health care is completely free through MSF for asylum seekers and refugees.
The medical mission sees the host population as well, so we provided care for the Bangladeshi families along with the Rohingyas. There’s some difference in terms of the ability to follow up with the host population compared with the refugee population.
For example, it was more logistically challenging for the Rohingyas to get permission to leave the camps and get transportation from the camps to come to the hospital.
As a neurologist, the biggest barrier to providing care was the lack of resources. Neurology in general is a fairly high-tech, tech-dependent specialty. I’m used to having electroencephalograms (EEGs), magnetic resonance imaging (MRI) scans, genetic testing, and labs. I had very little technology in Bangladesh, so I was a lot more reliant on physical exams and clinical history and sometimes, just common sense.
There were certainly instances where I would have loved to have been able to run diagnostic tests and at times, I just couldn’t come up with a diagnosis.
How do you gather patient history when taking into consideration their cultural and language barriers?
Dr Sebasigari: A language interpreter is necessary for the care of asylum seekers and refugees who do not speak the language of the country of resettlement.
Aside from translating, the interpreter can help them connect and apply to local services and resources. The interpreter tends to spend more time with the patient and understands the family dynamic, which helps us better serve them.
If you can incorporate multidisciplinary care in treating refugees, it’s the best way to provide care for these patients, and it also encourages a successful patient-physician relationship.
Dr Zeldin: The way it worked for me in Bangladesh was I would work to support the local medical population in trying to strengthen their capacity. So, I was working with Bangladeshi doctors and trying to teach them neurology at a higher level.
However, a lot of the Bangladeshi doctors didn’t speak the Rohingya dialect, so it was challenging. MSF would use Rohingya translators and cultural mediators.
Regarding collecting patient history, you just had to be patient because sometimes you’re going through multiple layers. The cultural mediators are important because there are cultural differences in terms of pure reception of disease processes. It was very helpful for us to understand how the family was perceiving the disease and how we could communicate back to the family in a way that made sense to them.
What are some cultural differences in helping asylum seekers and refugees overseas compared with those who resettled in the US?
Dr Zeldin: Some cultural barriers kept some patients from following up or continuing treatment.
For instance, some women needed permission from a husband, father, or village elder before seeking medical attention, which was challenging for me from a Western perspective.
One of the other things I found challenging was that we would be treating patients and if the family felt it was taking too long, there would be pressure from the community. Sometimes we would have to discharge patients when they weren’t ready to be discharged.
There is a lot of pressure, not just medical pressure, that goes into the decision-making for them. It’s not just based on medical decision-making; it’s also based on societal and cultural pressures.
It was challenging for me to have babies go home with meningitis that probably should have stayed in the hospital for another week.
How is patient trauma addressed when providing care for asylum seekers and refugees?
Dr Sebasigari: Mental health is a global issue, but it’s even more drastic in the refugee population because they have experienced a lot of psychological trauma and many have not even started to unpack it.
Mental health services help improve the delivery of health care and help us better understand the chronic conditions they face. If your clinic has counseling or mental health services, that will help.
Some people have comorbid psychiatric conditions of anxiety, depression, and PTSD and sometimes they also need psychiatric care for medication management for those conditions.
Dr Zeldin: We had a couple of psychiatrists and a psychologist there who were expats. Trauma and mental health are huge components of caring for patients, especially in the Bangladeshi mission. The Rohingya refugees have been through a lot of trauma, so having people there to help with some of these issues is a very important piece of what gets done there.
Is there any reform you feel would help mitigate treatment barriers to patients who are seeking asylum?
Dr Sebasigari: More local and state support is necessary, especially in the first year of resettlement. States have different programs that support people who are resettling but many do not offer services beyond 3 months — I know that in Texas, after 3 months, you’re on your own.
An extended period of support is necessary to help the needs of this population. During this time of resettlement, the main priority for these individuals is to get a job to provide for their families, but as a result, a lot of refugees and older individuals do not continue their English lessons.
There continues to be an English language barrier because they didn’t have the time to learn the language. If they had a longer period of support from an agency and social programs, that transition could then be made smoother.
Funding for housing is also helpful so that they will not feel an immediate rush to get a job. However, a greater emphasis placed on learning the language and the culture in the first 6 months to a year would be very helpful.
Dr Zeldin: Ultimately in a lot of these instances, it’s honestly a political issue that needs to get resolved.
We can try to provide all the care we can, but ultimately, we need to have a more definitive solution. For example, the Rohingyas have a million people stuck in refugee camps. Bangladesh should be commended for welcoming them, but Bangladesh has its challenges.
We can keep doing medical missions and do the best we can but that’s not the ultimate solution. It is a political decision for all sorts of refugee issues, and it needs to be decided as a global community.
How has your experience treating asylum seekers and refugees changed your perspective?
Dr Zeldin: Overall it was challenging, and it was very eye-opening for me. I think you realize how much we have and how lucky we are just in terms of resources. The thing that I took away from it more than anything was just that it was rewarding for me.
When you go to the MSF website, there’s a misperception that you must commit for a year or so, however, for some of the specialties like neurology, you can do shorter missions.
I think that people should be open to it and think about doing it and understand that they can do it for a shorter timeframe, and it doesn’t necessarily disrupt your permanent job in the US.
Editor’s note: This Q&A was edited for clarity and length.
