Yale Psychiatry Grand Rounds: October 1, 2021

October 01, 2021

"Refugee Mental Health: An Overview"

Aniyizhai Annamalai, MD, Associate Professor of Psychiatry, Yale School of Medicine; Director, Yale Adult Refugee Clinic

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00:00Good morning everyone and welcome to
00:02the Yale Department of Psychiatry.
00:03Grand rounds. My name is Bob Rohrbaugh
00:05and I'm deputy chair for education in
00:08the department and it's my distinct
00:10honor to introduce Dr Annie anomaly
00:13to our grand round speaker today.
00:15Doctor normal.
00:16I received her MBBS degree from
00:18the JSS Medical College in Mysore,
00:20India and her Masters in education
00:22from the Rivier College in Nashua NH.
00:26She completed her internship and
00:28residency in both internal medicine.
00:30And in psychiatry at Southern University,
00:34Illinois University in Springfield, IL,
00:37and joined our department after graduation.
00:40Doctor normally is an associate professor
00:42in our department and internal medicine,
00:45and is an associate clinical professor
00:48in the Yale School of Nursing.
00:51With their training in both internal
00:52medicine and psychiatry, Dr.
00:54Namoli was the ideal person to lead
00:57development of the Wellness Center at CMHC.
01:00She's been named the deputy medical
01:02director of medical services at CMHC,
01:04where her dual training also
01:06provided her the expertise,
01:08which enabled her to be the point person to
01:11address issues related to the COVID pandemic.
01:15This dual training has also proved
01:17invaluable for her work as director of
01:19the Yale Adult Refugee Clinic at Yale,
01:21New Haven Hospital,
01:23which she's LED for the last 10 years.
01:26Clinic serves as the gateway for
01:28all health care for refugees coming
01:30to the greater New Haven area and
01:33operates in partnership with Iris,
01:35the local refugee resettlement agency.
01:38The refugee clinic is a central point
01:40for refugee outreach activities,
01:42education programs and research projects.
01:46It's always a pleasure to introduce
01:48someone with deep expertise in an area,
01:50and in this case,
01:52doctor normally has literally
01:53written the book on refugee health.
01:56A textbook entitled Refugee Health
01:58Care and Essential Medical Guide,
02:01which is in its second edition and which
02:03is viewed as the primary reference,
02:06informing health care for refugees.
02:09She's a founding member of the Board
02:11of directors of the Society for Refugee
02:13Health care providers and has served
02:15as the associate editor of the Journal
02:17of Immigrant and Minority Health.
02:21Not surprisingly,
02:22Dr Namala has been recipient
02:24of numerous awards,
02:26including our Clinical Innovations Award
02:28for development of the CMHC Wellness
02:31Center and the Steven Fleck Award is an
02:34exemplary physician and clinical teacher.
02:37She received the Roger Coleman Award from
02:39a Connecticut Psychiatric Association
02:41for her work with refugees and the
02:43Nancy CA Rawski Teaching award from the
02:46American Psychiatric Association for
02:48her work with medical students last year,
02:51Dr Anomaly was awarded to Leonard
02:53to award for Humanism in Medicine
02:56from the Yale School of Medicine
02:58and the Gold Foundation,
03:00one of the highest honors our medical
03:03school bestows on a member of our faculty.
03:06According to the New York Times,
03:07our nation has the opportunity to help
03:10resettle 50,000 Afghan refugees this month,
03:13and so I can't imagine a more timely talk
03:16than the one we're about to hear Doctor.
03:18Normally,
03:18we deeply appreciate you and the
03:21work that you do in this field,
03:22and we look forward to your
03:24presentation on refugee mental health.
03:29Thank you, thank you Bob for
03:31such a glowing introduction.
03:33So let me get right into it.
03:36Uh, I will share my screen.
03:47OK, I think everybody can see this.
03:51Yes perfect. OK alright so I won't
03:53really say anything about myself at
03:56this point because Bob has said it all.
03:59But I think you have gathered that I wear
04:01many hats and the refugee hat is one that
04:04I won't for probably more than 10 years.
04:07Most of my tenure here in in the
04:10department and at Yale I have.
04:13No conflicts to disclose and what I'm going
04:16to do is because this is an audience that.
04:19You know knows a lot about refugees.
04:21From what we learn in the media,
04:23but may not necessarily
04:24have worked with them.
04:25I'm going to talk a little bit about
04:27the background of who refugees are
04:28and how they get here and come to us
04:30and then spend a good amount of time
04:33on the mental health problems that we
04:35know about what we know about them
04:38and what we don't know about them.
04:40And you know the treatments.
04:42And then finally,
04:42what we do here is Bob said this
04:44is very timely and I think many
04:46people have questions about what
04:47they can do and how they can help.
04:49So I'm going to spend a little
04:50bit of time at the end.
04:52About our local program here and
04:54what we do so refugee resettlement.
04:59So.
04:59Maybe not, we all know conceptually
05:01what or who a refugee is, but really,
05:05formally, this has existed.
05:07It's recognized that you know,
05:10refugees are a population that need to be.
05:15Uhm, you know, cared for,
05:17need to be resettled?
05:18Need to be repatriated?
05:20This started after World War Two with
05:23the United Nations convening with many
05:25countries and then at that time it was
05:28meant mostly for European refugees.
05:31But later on in 1967 there was
05:34an amendment to include refugees
05:36originating from any part of the world
05:39coming to any part of the world.
05:42And the actual legal definition as
05:44somebody who basically has good reasons
05:47to believe that they're being persecuted,
05:49and it could be,
05:50it doesn't always have to be
05:52war and conflict, though.
05:54That's the major reason it could be
05:56because they belong to a particular group,
05:58or it could even be because
06:00of their sexual orientation.
06:01For example, we've certainly seen that.
06:04So for whatever reason,
06:05if they feel persecuted and if they
06:07feel their country cannot protect
06:09them and they've fled their country
06:11and crossed international borders,
06:13than you know they're eligible to
06:16potentially to the help that the
06:20United Nations Health Commissioner
06:23for Refugees UNHCR provides.
06:27But even though refugees,
06:30I mean,
06:31we used loosely used the term for
06:33many categories,
06:34but it's a little important to know,
06:35especially right now with the incoming
06:38Afghani refugees to know some other
06:41populations of concern as UNHCR calls them.
06:44So internally displaced persons.
06:46These are people who are essentially
06:49refugees but have not crossed their
06:52countries borders for whatever reason.
06:54Either they cannot or they could not, but.
06:57Unfortunately,
06:58we call them IDP's.
07:00They don't come under the UNHCR mandate,
07:03and the UNHCR resettlement efforts and
07:06unfortunately these are the largest
07:08group of displaced people in the world
07:10right now and these are not the people
07:12most of us are likely to see unless
07:15we do on the ground work in those
07:17countries where conflict is happening.
07:19Asylum seekers also very similar to refugees,
07:22but typically either have entered the
07:25country in some other way, either EU,
07:27S or any other country and are subject
07:30to the same parameters of when
07:33they can obtain resettlement help,
07:35but they did not come through
07:38the formal resettlement program.
07:40You know, they came here,
07:42you know some other means and
07:44then they are seeking refuge.
07:47And there's also a big category of
07:49stateless people. These are people.
07:51Sometimes when former States and
07:54countries have dissolved or one example
07:56is now the Myanmar refugees who live
07:59in Bangladesh who basically have
08:01no identity who have not recognized
08:04either in their country that they
08:07you know temporarily being hosted
08:09or or in their native country.
08:12So there are ethnic groups sometimes
08:14that that have no recognition by.
08:16You know any state and so we call them
08:19stateless people which is complicated.
08:22Sometimes generations of children are born
08:24in these camps without a formal identity.
08:27And then what we call the SVS,
08:30they are the special immigrant visa holders.
08:33That's a special program exclusively for
08:36Iraq and Afghanistan for obvious reasons
08:38because of EU S military presence there.
08:40There's a special program where
08:41they don't have to go through the
08:43whole vetting process of refugees,
08:45but they can be.
08:47I mean,
08:48they're still go through a vetting process,
08:49but they can come directly from their
08:52country to the US and not go through
08:55the formal process of fleeing and
08:58going and registering with UNHCR etc.
09:00And you know we were getting mostly from
09:03Iraq in the early years of the 2000s,
09:06and and now you know,
09:08we're getting more from Afghanistan.
09:10And I'll talk a little bit more
09:12about this later.
09:13So just to put things in perspective,
09:16even though more than 80 million people
09:19are forcibly displaced at this point,
09:21which if you think about it,
09:22is like a fourth of the US population.
09:25You know which if you think about
09:26it that way, it's it's pretty,
09:28it's it's, it's sad.
09:31And unfortunately of them only 20 million
09:34are actually under the UNHCR mandate,
09:36and as I was saying earlier,
09:38the IDP's internally displaced
09:40people are the largest number.
09:43And then there are some
09:44other categories including.
09:46Now we include in the displaced numbers.
09:48The Venezuelans have been forced
09:50to flee for economic reasons.
09:52But basically what the UNHCR estimates.
09:55It's about one and 120 or so.
09:58People are basically forcibly displaced
10:00and I think more than 25 people
10:03every minute are being displaced.
10:06I mean by the time we finish this talk,
10:08there's going to be a few hundred
10:10more that are displaced.
10:11Uhm,
10:12show where do they come from?
10:14I mean now we hear Afghanistan all the time,
10:16but Syria has and actually continues to
10:18be the one that's producing the largest
10:20number of refugees in the last few years.
10:23And again, not necessarily.
10:24Doesn't mean that we see them here in EU
10:27S But you know they're formed the largest
10:30number of displaced people. And then.
10:34Outside and there's like ongoing conflict,
10:36and then, of course,
10:37Afghanistan and me and Mark that
10:39I briefly mentioned, so these are.
10:41These are the top countries
10:43that we see refugees from.
10:44But just to remember that the ones
10:46that we see here are a fraction
10:48of the people who are displaced.
10:51And most of these people are actually
10:53hosted in neighboring countries.
10:55For example,
10:56the Afghanis are mostly in Pakistan
10:58or Iran are you know people
11:01from city are mostly in Lebanon,
11:04Jordan and Turkey.
11:05So those are the countries that
11:07are really hosting the largest
11:09numbers of refugees.
11:11But what happens in the resettlement
11:13program and every country has its
11:15own pathway which is very similar.
11:17So once the UNHCR identifies
11:19somebody as qualifying for refugee
11:21resettlement and always the first.
11:26Attempt is to repatriate if
11:28the conflict in the region is
11:29over and it's safe to go back.
11:31That's always the goal,
11:32but often that's not the case.
11:34So then when they're eligible for
11:36resettlement, then UNHCR refers
11:38them to the relevant country and
11:41that's depends on a lot of factors.
11:44Which country, depending on whether
11:45they have other ties in that country,
11:47whether there's always a good population
11:49from that region in the country.
11:51There's a lot of factors that go
11:53into deciding who goes where,
11:55and obviously the.
11:56The restrictions of each country,
11:58but after that it's a multi step
12:01process where they're cleared
12:02both for security reasons and
12:04then for medical screening.
12:06It's multiple layers of screenings and
12:09this process even for an SIV can be like
12:13two years and it usually is 2 years.
12:15But for refugees who have
12:17fled to camps and are waiting,
12:19sometimes it's years and years
12:21and I've seen people from the
12:23Congo who come to the US 20 years
12:25after their trauma happened.
12:27So it's it's a very prolonged process,
12:29but once they come here then they're
12:32connected to a resettlement agency.
12:34There are about 10 agencies in EU S,
12:37and each works with local affiliates
12:39and they work on the resettlement.
12:42Health is one of them,
12:43but they work on multiple
12:45aspects of resettlement.
12:46So for EU S itself US used to have
12:48the distinction of hosting the largest
12:51number of refugees that changed a
12:53little bit in the last few years.
12:55We'll have to see how the trend is.
12:57Going forward,
12:59historically,
12:59it's averaged about 95,000 a year,
13:02but that's just the ceiling that EU S.
13:04The government decides doesn't mean.
13:06Every year we're able to resettle
13:08that many because there's you need
13:10the personal you need the funding.
13:12Sometimes even if we haven't
13:14crossed the ceiling,
13:15you may not have the resources
13:16to resettle that many.
13:17Which kind of happened last year with Kovid.
13:19The ceiling itself was low this year
13:22because of the prior administration,
13:24both last year and this year,
13:25but we settled even fewer.
13:28And to give you an example like of.
13:32How few we resolved. In Connecticut,
13:37I think we in the last.
13:43Year in the last 12 months we we
13:46only resettled under 150 people
13:49that that's like very very.
13:52Few, and that's in part
13:54because of multiple reasons,
13:55including kovid this year you probably
13:58heard President Biden talk about his
14:01intent to resettle about 95,000 Afghani
14:04refugees in the next several months.
14:06That's not counted towards the
14:08overall cap that was set earlier
14:10before the Afghani crisis,
14:12yet set the cap at 62,000,
14:14so that's that's a separate number.
14:17So even though like I said,
14:19you know we're seeing the influx
14:22from Syria and Afghanistan,
14:23the people coming into the country
14:25are not necessarily them just
14:27because of all the various bans and
14:30restrictions on certain countries.
14:32EU S was seeing more people from
14:34Democratic Republic of Congo,
14:35for example,
14:36and it's very regional like
14:37Connecticut might see something
14:39very different from California,
14:41but these are just.
14:43Just to give you an idea of some other
14:46countries that we see refugees from.
14:48And in terms of the states,
14:51it's often like the bigger states
14:53that tend to resettle more refugees.
14:56The list here is, you know,
14:58the top ten states in terms
15:01of larger numbers.
15:03In Connecticut, like I was saying.
15:06You know from last October to
15:07this August was was very few.
15:09We just we just had quite a bit of a dip,
15:11but these fluctuate a lot back
15:14in 2016 if people remember that's
15:17when there was a lot of like.
15:20We saw a lot of things in the media
15:22about the refugees fleeing Syria
15:23and the Middle East on board,
15:25and many of them capsizing and dying.
15:27And that time there was also some terror
15:32attacks in Europe and many states in EU.
15:34S said.
15:35Like we don't want to take these refugees.
15:38Connecticut was one of the states
15:40where the Governor Malloy made made
15:42it a point to very publicly say
15:44that he wanted a few just to come,
15:46so we actually had more that year.
15:48Typically in Connecticut we have about
15:51500 that year we had almost 1000 refugees.
15:55So so it it fluctuates a lot
15:56depending on not just what
15:58conflict is happening in the world,
15:59but just what's happening internally too.
16:02So with that I'm just going
16:04to move on to what, uh,
16:06we know about their mental health.
16:09So I just like to think of this
16:12other people here probably know
16:14more about sort of how the roots
16:16of resilience and how we we think
16:18about the refugee experience.
16:20And I sort of want to say that we try
16:23not to pathologize what they have
16:25and give them psychiatric diagnosis.
16:27It's really understanding the
16:30refugee experience in totality.
16:33So I like this model,
16:36it's it's the development after
16:39persecution and trauma and adaptation.
16:41And it just talks about how like these
16:44the psychosocial pillars are eroded.
16:47You know your basic sense of safety,
16:49you know,
16:49just going out and being able
16:51to do your day-to-day chores,
16:52your interpersonal bonds, you know.
16:54Friends may have become enemies.
16:55Enemies may have become friends.
16:57You know when there's a lot of
17:00interethnic conflicts and also.
17:01You know, within your family
17:03some of you may have been
17:05able to escape and resettle.
17:07Some have not.
17:08And you know this can clearly fracture
17:11your bonds with your community and
17:13just your basic sense of justice.
17:16You know when when your state
17:18has not been able to help you
17:20and do do you know what what's
17:22needed to protect you and lots of
17:25shifting roles and identities.
17:27This we see a lot.
17:30Within who you were before you came
17:32and then during your path of migration
17:34and after you resettle who you are now.
17:37I mean,
17:37this shifts a lot and you know just
17:40just a basic sense of who we are.
17:45That's not to say it's all bad,
17:47so these are all, even though
17:49we see these things happening.
17:51I mean, there's a significant
17:52amount of resilience.
17:53Also that we see and people
17:56do develop and grow so.
17:59In terms of like what you know or the
18:03potential factors for people you know,
18:06having good outcomes are
18:08developing resilience.
18:09A lot of it is personal qualities
18:11of how adaptable they are,
18:13but also like community support,
18:15and that's where it's important
18:17where they resettle.
18:18And what the community can do for them.
18:21And if there's if they're reselling
18:23to area where there's a significant
18:25amount of discrimination.
18:27And if there's not much support
18:28for them in terms of language
18:30or whatever else it may be,
18:32then that can be a problem.
18:33And I sort of alluded to the labeling.
18:35We try not to pathologize, you know,
18:38we talked at one of our conferences
18:41about when do you actually like label it?
18:43Like when do you?
18:44When do you?
18:45When does that refugees stop being a refugee?
18:47You know,
18:48that's that's a question that you know.
18:50Sometimes we debate,
18:51but the point is generally that.
18:55There are external factors that can.
18:58Promote resilience and promote
19:01refugees succeeding.
19:03And I also just wanted to make a point
19:05that we talked a lot about sort of
19:07trauma and the experience of migration,
19:10but then also what happens
19:12after they come here.
19:13And clearly my view is skewed because
19:15that's the majority of people that I see,
19:17but I see tremendous amount of
19:20challenges and difficulty adjusting
19:23and there's there was, you know,
19:25like some international survey of
19:28like looking at several countries.
19:30Where they looked at youth and
19:31and this was not just refugees,
19:33but migrants too.
19:34And they found that for the most
19:36part youth do integrate well,
19:38which is basically like able to
19:40maintain their own identity but
19:42also able to adapt their value and
19:45relationships with their host society.
19:47And so I,
19:50I think that's definitely important.
19:52Uhm, but in in the context of refugees,
19:56I'll talk a little bit about,
19:57you know some of the refugee
20:00groups that we see.
20:01But one important point I want to make
20:04again here is just the host society.
20:07You know how much support there is and
20:09how much experience with migration does
20:10seem to affect like how well they integrate,
20:13and this is not just anecdotally.
20:14I mean people are actually looked at this.
20:16So when a country has experience with
20:19migration and welcoming migrants,
20:21then you know people have a
20:23better chance of integration.
20:25Uhm, so actually,
20:26notwithstanding,
20:27you know all the things I've
20:30said about not pathologizing,
20:32you know, PTSD and depression.
20:35Having the most studied in
20:37among refugee populations.
20:39Anxiety disorders comes after that.
20:41So in terms of percentages.
20:46Approximately like about 30% of refugees
20:49seem to present with depression and PTSD.
20:52The bar graph on the right is actually
20:54a study from like almost 15 years ago.
20:57At this point when they look
20:59particularly at refugees coming
21:00to Western countries.
21:01So resettle in high income countries.
21:03And if you can see,
21:04it's sort of surprising the PTSD
21:07rates are comparable or just they are
21:10more than the local host populations.
21:13But you know not by that much and the
21:14depression maybe even less than some.
21:16Most populations, so there's a lot of,
21:20UM, you know discussion on
21:22sort of the reasons why it was.
21:26It looked as though,
21:27like the outcomes were good
21:28and the high income countries,
21:29one thing is dumb.
21:33You know the resettlement these
21:34people have been resettled in a place,
21:36and they're safe.
21:38And the the studies showing higher
21:40prevalence of PTSD and depression
21:42are usually like across the board.
21:44People living in the neighboring countries.
21:46People who have, you know,
21:48still near areas of conflict so.
21:52There's there's a.
21:53There's a lot of factors that go into this,
21:56but I also wanted to.
21:57I like looking at it the other way.
21:59Even if you look at the 3035%
22:02prevalence of pathology,
22:04that's still 70% who actually
22:07don't have these two diagnosis,
22:09which are the two most common
22:11diagnosis we study.
22:12But that doesn't mean necessarily.
22:14They're healthy.
22:14We see a lot of somatic symptoms.
22:17We'll see a lot of like partial symptoms.
22:19They may not have a full blown diagnosis,
22:21but they might have some symptoms
22:23that's interfering with her functioning
22:25and stress related behaviors.
22:27We don't see that much substance use
22:31in these populations, but you know,
22:33there could be other personality changes.
22:35Acting out behaviors,
22:36especially among youth.
22:37There are other things that we
22:39could see that that may not be
22:41actually like PTSD or depression.
22:43So just the I.
22:44I just wanted to have,
22:46UM.
22:47Spend one minute on this because
22:49we see this so much so people who
22:51see refugees it's it's a very,
22:53very
22:56frustrating cycle of the
22:58interplay of physical symptoms
23:00and their psychological health.
23:02So the question is, do refugees.
23:06Present with more somatic
23:10symptoms than other populations.
23:13It's kind of hard to know.
23:14It's difficult to compare across
23:17studies because populations are
23:19very heterogeneous and we don't
23:21necessarily have good numbers.
23:23They don't use the same
23:24somatization definitions.
23:25Some of them use the formal
23:27somatic symptom disorders,
23:28some of them will just look at
23:30just the prevalence of somatic.
23:31You know X number of somatic symptoms,
23:33so it's kind of difficult to tell,
23:35but from what we know.
23:36It seems that you know refugees
23:38do present with higher prevalence
23:40of cymatic symptoms,
23:41and the numbers that you see there the
23:45general fight and you can see the range.
23:47I mean how do you?
23:48How do you interpret something that's
23:505 to 63% but that was seen across
23:52the range of studies and then those
23:54refugees seen in primary care and
23:56that were actually seen in psychiatric
23:58practices that seem to be even higher.
24:02And definitely we do.
24:04We don't know this just
24:06intuitively and anecdotally,
24:07but we know based on looking
24:09at the correlating factors,
24:11that it you know,
24:12not only is it correlated
24:14with psychopathology,
24:15but also this seems to affect
24:18their migration, so there's.
24:20Even though I say that migration
24:24is a big stressor and we shouldn't
24:26be just looking at trauma,
24:28definitely the past trauma and past
24:31experience does affect migration
24:32and people who have a stronger
24:34psychopathology to begin with
24:36definitely have more difficulty like
24:38adjusting in their new environment.
24:42Uhm, and then formally,
24:45UM,
24:45there was a study of like almost
24:49100,000 refugees across multiple studies
24:51looking at what are the risk factors.
24:54You know,
24:55that would be.
24:59In favor of or risk factor for,
25:02for mental health.
25:03So in general, older adults.
25:08Have a hard time.
25:10Female, the gender seems to
25:12be skewed up against females,
25:15so generally having poorer outcomes and
25:18also the area where they come from.
25:21So coming from more rural areas
25:23coming to more Western societies
25:24where there's sort of a larger
25:27gap between them and the local
25:29residents seems to be a poor factor.
25:33And then in mostly in any disaster,
25:36people who are more educated and
25:39wealthier actually fare better.
25:41But in this case,
25:42people with higher education and
25:44higher socioeconomic status prior to
25:46displacement actually fare more poorly,
25:49and that's probably because of just a
25:51loss of in addition to everything else,
25:54they've lost.
25:54You know their livelihood.
25:56They've lost their ability to be doctors,
25:58lawyers, bankers, whatever.
25:59They're trained to be.
26:01They're completely starting
26:02fresh in a new place,
26:03and they've come here with almost nothing,
26:06you know, except the clothes and
26:08the bags that they come back.
26:09So it's more of a drop.
26:12For them.
26:14Uhm, in terms of positive factors, UM,
26:16in general children and adolescents.
26:19I mean they definitely have.
26:20I mean,
26:21there's particular problems
26:22with children and adolescents,
26:23but generally they they seem to
26:25bounce back and adapt much better.
26:27And obviously the other things like housing.
26:31There's still a limbo somewhere,
26:33or have you been resettled and
26:35you've got some permanent housing
26:37and economic opportunities?
26:38Are you going to be financially independent?
26:42You know in your new country
26:44and also the longer.
26:47The duration of Displacement,
26:49it seems to be better,
26:51but with a qualifier like if you have
26:53been in limbo and you've been waiting
26:55for asylum and there's been uncertainty,
26:57maybe you know that's
26:59that's that's a problem.
27:01But generally,
27:02people who whose trauma has happened
27:04years ago like I've seen people from
27:07the Congo who literally had their
27:09family butchered in front of them,
27:11come and,
27:12you know,
27:13display a lot of resilience and not
27:15just to say one or two cases make.
27:17Make the majority.
27:20Because definitely the people
27:22from Africa in sort of this
27:25meta analysis definitely show
27:27higher rates of psychopathology,
27:29but generally when you see
27:31people closer to the conflict,
27:34you do see more pathology
27:36as opposed to later on.
27:38Also, people who are resettled,
27:41you know,
27:42fare better than the people who
27:44were repatriated and also people
27:47who you know where near there.
27:49Source of conflict.
27:51Like I said,
27:52or that we're internally displaced,
27:54you know, they they fare less well.
27:58And along those lines,
28:00so sometimes people wonder
28:01what happens to refugees.
28:03Long term,
28:04you know,
28:04for better or worse lot of the studies are
28:08done in people who are recent refugees.
28:10But in some of these systematic
28:12reviews and meta analysis,
28:13they do look at the duration of displacement.
28:17But the most recent one just last
28:20year looked at people less than four
28:22years and displaced more than four years,
28:25but.
28:25It doesn't necessarily look
28:27at like what happens 10
28:29or 20 years later, but there are
28:31smaller studies of like you know,
28:33maybe 100 refugees or 50 refugees
28:35that have looked at this and mostly
28:37from what we know it seems like.
28:40You know the symptoms do
28:41persist in a sizable minority,
28:43but overall it declines overtime and
28:45I would say that's true based on just
28:49what I've seen in our population.
28:51Uhm, so just a word on.
28:56Uhm refugees from Afghanistan and.
29:00I always feel like.
29:03Outsiders should not speak
29:04about the culture of a country.
29:06I mean they are the best
29:07to talk about themselves.
29:08We can't claim to know that you
29:11know what they can tell us,
29:13but just sort of highlights.
29:15You know there's been decades long
29:18instability in the region since
29:20the Soviet invasion decades ago.
29:23You know we've had refugees
29:25leaving Afghanistan.
29:26The current crop that I've seen are mostly
29:30like coming sort of in the post U S.
29:32Presence and some of them are
29:34just in their 20s thirties.
29:36You know they were. They were kids.
29:37When all this started.
29:40But decade a decades long history of
29:45instability and also culturally like,
29:47I was alluding to earlier just.
29:50The fact that many of them come
29:53from rural parts of the country and
29:56have had little exposure to Western
29:59countries and Western way of life.
30:01It's it's more challenging the
30:03transition to life in EU S.
30:06And you know,
30:06we talked about the role of women
30:08in the family.
30:09And again,
30:10I don't want to steal your type
30:12because there's a lot of heterogeneity
30:14within countries within ethnicities.
30:16But in general,
30:19women have a more traditional role,
30:22and you know,
30:22that's for various reasons which
30:24people were hoping we're going to
30:26change in the last two decades.
30:27But in general,
30:29it's the role of women is considered
30:31very family centric and also in general.
30:35Women tend to be especially from the
30:38rural areas tend to be less educated
30:40and like I said, tend to have less.
30:45Have had less contact with anything
30:48Western in the crop of people that
30:50we've seen in the last several years,
30:53which are often SVS.
30:54It's a little bit different demographic.
30:56Often it's a person who.
31:00You know work with the US Army,
31:01so he's somewhat more acclimated,
31:04but we resettled EU S
31:06researchers people as family,
31:07so you often have spouses and children,
31:09and this pulses frequently are
31:11not so acclimated and I've had
31:14definitely Afghani women who come
31:16here and they tend to have larger
31:18families so I've definitely had them
31:20come here and then sort of not.
31:23Haven't had challenges like even
31:24adjusting to how to take care of their
31:26children because they were always
31:28used to living in large families
31:30with multiple generations helping them
31:32and it's sort of a shock for them.
31:33They come here and they have nothing.
31:36And then also some what you
31:38know of a feeling of,
31:40like being isolated from others.
31:42I mean that can be for
31:44any immigrant or refugee
31:45community, and the Afghan is definitely do.
31:48You know, spend time together with the
31:51other Afghani people in the region,
31:54but you know they it.
31:56It's harder for them to engage
31:58and sort of integrated integrated
32:00with the society at large.
32:01And again, like I was saying.
32:03I mean, refugee groups are heterogeneous.
32:05Each group is a little different
32:07and similar in many ways.
32:10But I mean these are some sort
32:12of things we see and last thing
32:15is intergenerational tensions,
32:16often kids come here and.
32:19Adapt much more quickly the land.
32:21Learn the language much faster,
32:23and this creates tension.
32:24Sometimes they're the ones in
32:26the room who know the language,
32:27and they're used as interpreter sometimes,
32:29and that creates problems at multiple
32:31levels and not just in healthcare settings.
32:33I mean, in general,
32:35the children become in that sense
32:38have more power to do this,
32:40so it changes the dynamic within the
32:43family and also child rearing I've.
32:45You know how we treat children?
32:47What we consider this abuse.
32:49They will not necessarily considered abuse,
32:52and I've definitely had refugees
32:53like say like I'm afraid to say
32:55anything because then I'm afraid,
32:57like people will take away my kids.
32:58You know,
32:59the way they discipline their kids
33:01and also just in terms of women too.
33:07I mean people think about
33:09domestic violence and abuse.
33:10I really have not seen that much
33:11in the population we see again,
33:13I'm seeing only a slice of the population,
33:16but.
33:16Also what we consider abuse may
33:18not necessarily what they consider
33:19you know abuse.
33:20We may think that sort of being
33:23controlled and allowing the husband to
33:25make all the decisions is a form of,
33:27you know, limitation restriction,
33:28whatever you want to call it,
33:30but they don't because this is,
33:32you know, this is their way of life.
33:35Uhm, just that the web link below is just a,
33:38you know it has like background
33:42information on many refugee groups.
33:44The one in Afghanistan is very outdated.
33:46It was actually put there in 2002.
33:48But I mean you, you can look at that.
33:52In terms of what we actually know,
33:54like have we actually studied
33:56them separately as refugees?
33:58So there was one review which looked at.
34:00I don't know,
34:01like a handful of 1520 studies and you know,
34:03try to characterize the Afghanis
34:05refugees and their mental health
34:07and it seems that the risk factors
34:08were more or less similar to the
34:10other groups that we see in terms
34:12of you know the losses and the
34:14cultural feeling like a loss of
34:16culture and other losses.
34:18And then you know their
34:21depressive PTSD symptoms.
34:22Symptomatology is comparable to other groups,
34:26and in general there's low uptake of
34:28mental health care even in those who
34:30recognize that they have a problem,
34:32and that's we see across other
34:34refugee groups too.
34:36And people ask about stigma
34:37and other things you know.
34:38In general,
34:39I find that the more the impairment
34:41there more likely they are
34:42to accept that there's,
34:43you know something maybe that needs
34:45to be addressed and to get care.
34:47But oftentimes, many people who
34:50who are sort of in the middle.
34:54Dangers of not being quite healthy,
34:56but not being significantly ill.
34:58Feel like you know they.
35:00They don't really need the mental health
35:02help or they're not like you know, quote,
35:04unquote, crazy so we definitely do see
35:07that just one word on like how we assess.
35:11I mean, we don't necessarily do
35:13this in the clinical setting,
35:14but I thought some people might
35:17have just questions about you.
35:19Know how valid is that?
35:23Our assessments for these?
35:24Populations,
35:25so there's a bunch of scales,
35:26some of them were developed
35:28for refugee populations,
35:29some of them were adapted for them.
35:31They have variable validity and
35:34reliability across these scales.
35:36And most of them are meant for screening.
35:39I mean, they're not meant to replace
35:41a full psychological assessment.
35:43Some of them have some, some of us.
35:45Some of my colleagues in the
35:47refugee will have made it.
35:49I mean, the the the carrier is
35:52studying these screening instruments.
35:54Uhm,
35:54so in terms of treatment uhm?
36:00Most. I think there's a shift within the
36:05refugee academic community that we have
36:07to focus on like Wellness and health
36:10promotion and less on just the trauma.
36:12But most of what we have
36:14so far is what we know.
36:15If you want solid evidence is mostly
36:18based on trauma based treatment.
36:20So the NET stands for narrative exposure
36:22therapy. That's a particular type of.
36:25That'd be which you know.
36:26Basically, the idea is you're
36:29incorporating the traumatic
36:30experiences in a refugee's life as
36:32part of their whole lives narrative,
36:34and that's you know if it
36:37is a sequential trauma.
36:38It's not just one traumatic event, right?
36:40So that seems to have shown good
36:44efficacy in terms of outcomes.
36:49CBT sort of plus minus there's one
36:51group in Massachusetts that have done
36:53several studies but focus mainly on
36:55Southeast Asian refugees because they
36:57started working on them in the 80s and
37:0090s and most of our data is from them
37:02and they talk about culturally sensitive
37:05meaning particular to that group,
37:07and they've published,
37:09you know, positive outcomes,
37:10but it's sort of mixed and across
37:13the board and I've had some
37:15psychologists whereby the EMDR for
37:17the refugees that they work with.
37:20But in terms of actual evidence,
37:21there are like a handful of studies,
37:22and it's been mixed.
37:24Some show positive outcomes and some do not.
37:27In general there was a Cochrane
37:29review actually about the treatment
37:32modalities and basically what they
37:34sort of reiterated what we knew that.
37:38Some like I said that IDP's the
37:42internally displaced to form the
37:44largest numbers are not as well
37:46represented in these studies.
37:47And then most of them are focused on
37:50treatment and not sort of Wellness
37:52and health promotion and also.
37:54Uh, I know there are people in
37:57this audience who you know,
37:59work with kids and who probably
38:00would like to know more about what's
38:02what's most effective for kids.
38:04So just very briefly,
38:06there are school based programs where
38:08they trained teachers and then along
38:10with the teachers they have programs
38:13where you do like creative art or
38:15like you do drama or you do dance and
38:18those and then see if those have outcomes.
38:21In general they've been positive
38:22they've improved the interaction of the
38:25kids with their environment they had.
38:26The kids have to be able to
38:29express themselves better,
38:30but in terms of actual
38:32outcomes on functioning,
38:33the effects are a little mixed and also
38:35it's not clear whether the effects
38:38sustained six months later or a year later.
38:40So it's a little bit mixed,
38:41but some people have done
38:44small studies looking at that.
38:46And then you know my favorite
38:48because it's the most frustrating
38:50is like coping with all the physical
38:52symptoms that you just come with.
38:54There are some small studies which look
38:55at if you treat the psychiatric symptoms,
38:58does it help the pain?
38:59It usually doesn't help
39:00the pain intensity as much,
39:02but it seems to help the coping with pain,
39:05which is sort of one of our goals.
39:07So that's just a natural what
39:09we know about the evidence base
39:12for treatment an and before.
39:18OK, uh, sorry I think somehow I
39:23skipped OK so I just want to say a
39:24word because I thought people might
39:26be wondering what's happening with
39:28COVID and refugees and like have there
39:30been outbreaks so just very briefly
39:33definitely refugees are more vulnerable
39:35because lots of programs were suspended.
39:38Even this Mediterranean rescue operations
39:41were suspended and also they live in
39:44obviously congregate settings in camps.
39:46So that was a potential.
39:48Issue and like anybody else,
39:49loss of financial support.
39:51They often work in low wage jobs
39:53and they're often on, you know,
39:54very limited budgets and then social
39:56isolation like we always try to
39:58help them engage in the community.
40:00But now we're telling them to sort
40:01of isolate soon after they come,
40:03so they did a modeling in the
40:06Cox Bazar in Bangladesh,
40:09where which is the largest
40:10camp for in the world.
40:11Actually, for me and more refugees,
40:13and they predicted that COVID
40:14was going to be very high.
40:16But actually a year later.
40:18That hasn't proven to be true.
40:20We had our annual conference
40:22a couple weeks ago and I mean
40:23some of the theories where that.
40:25Do we have enough data and is this good data?
40:28And also,
40:28are we just not testing them
40:30enough or is it because mostly the
40:33numbers come from camps in general?
40:36People at camps have more UNHCR
40:38aid and assistance compared to
40:40people who might just be living in,
40:42you know, wherever Turkey,
40:44Jordan, wherever it may be,
40:45as part of the Community,
40:46but not having the protections.
40:48Having a camp.
40:49So if you studied them maybe there
40:51would be more COVID so we don't know,
40:53but at this point we haven't had
40:55such sort of major COVID concerns
40:58in refugee populations.
41:00Uhm,
41:01what do we know about mental
41:03health and COVID?
41:04I mean very little in terms
41:06of actual hard evidence,
41:07but there was like one survey of about
41:10500 refugees in Australia and then
41:13WHO had a survey of over 30,000 refugees.
41:16These were all self reports.
41:18But refugees did say that you
41:21know they had you know more
41:24anxiety depression and they said
41:25it seemed like the the predictor
41:28of them having poorer outcomes.
41:30From the effect of Kovid was when
41:32it was a reminder of the past
41:35events that they had experienced,
41:37and then there was also some report
41:39self reports that there were increased
41:41use of drugs and alcohol like I was
41:43talking the stress related behaviors.
41:45And again I haven't seen that
41:46in the people who come here,
41:47but that was reported in this survey.
41:50Uhm?
41:51So,
41:51so that's sort of like a whirlwind
41:56tour of what we know about.
41:59In general,
42:00about refugee populations across the
42:02world and what we know about the
42:05evidence and what we know about treatment.
42:08So I'm going to talk a little bit about
42:10sort of what happens on the ground here.
42:13So in general,
42:15health care delivery for refugees is up.
42:20Multiple ways.
42:20So I was talking about
42:22the resettlement pathways
42:23so once they come here, the resultant
42:25agency is responsible for providing.
42:27Or giving them access to healthcare
42:30and actually the Department of
42:31Health and Human Services mandates
42:33that it has to be within 30 days.
42:35And so they the idea is that they really
42:38want the agencies to make this a priority.
42:40I mean, that's the reason behind that.
42:43And all finished the community health
42:46centers to sort of do health assessment.
42:49But oftentimes, in many regions,
42:51what happens is that the follow up
42:54follow through becomes a little unstable.
42:57What we have here is basically
42:58like a university based clinic in
43:00partnership with the Community agency,
43:02the resettlement agency.
43:04And that's actually not the norm at all.
43:07I mean, there are several of those in the
43:10country but but that's really not the norm.
43:12But I think that.
43:14Having such a model really ensures
43:16that we can establish them in long
43:19term care and not just to sort of
43:22the health assessment upon arrival,
43:24and then in terms of access to services.
43:27So when they come through the
43:29formal resettlement program,
43:30they do have the refugee.
43:33What we call the Refugee medical
43:35assistance that takes the form of Medicaid.
43:38Basically, in many states,
43:42including Connecticut,
43:43and they're obviously also eligible
43:45for the health care marketplace.
43:47So even though they come with a
43:49special visa there eligible for
43:51these benefits when they come,
43:52but the refugee medical assistance
43:54runs out in the first after the
43:56first eight or nine months.
43:58So either you have to be eligible for
44:00Medicaid in that state for other reasons,
44:02or you have to become financially.
44:04Independent enough to have your own health,
44:07employer based insurance or you know
44:09you have to look for insurance in the
44:11marketplace, and that's how it's usually.
44:13And I'll talk in a minute about
44:15sort of the incoming refugees.
44:18In relation to this.
44:20Uhm,
44:20so I was saying earlier that the refugees
44:23are one of the most vetted groups both
44:26for security reasons and health reasons.
44:28I mean,
44:28no other immigrant group is vetted as
44:30much as the refugees are health wise so.
44:34Overseas screening and CDC is basically.
44:38Has published lots and lots and lots
44:41of guidelines about what we look
44:43for overseas and what we look for
44:45after they come here and the idea
44:47in general is to see if there is
44:49anything of public health concern,
44:51mainly any communicable diseases.
44:52I mean,
44:53COVID has sort of taken over in
44:54the last year,
44:55but it used to be more TB measles, you know.
44:58Are there anything that should be of concern?
45:02And then it's shifted more and more
45:04towards like infectious diseases
45:06to just chronic diseases.
45:08Identifying what may have been
45:10untreated so far,
45:11and that includes mental health,
45:12two and justice of interest to note.
45:18For mental health,
45:20if people are considered to be an
45:23immediate danger or unstable acutely
45:25than they cannot be raised at all,
45:28they have to be treated and they have to be
45:31more stable before they can be resettled.
45:33And there are some other categories
45:35among medical conditions too,
45:37which may prohibit somebody from
45:39being resettled right away.
45:40But in general it's not
45:41meant to be restrictive,
45:42it meant it's meant to.
45:46Give them the care,
45:48but also protect the local population from
45:51unexpected outbreaks of whatever it may be.
45:54And you know, there's some predeparture
45:56treatments that they're given,
45:58and then the health information is
46:00actually comes through an electronic
46:02database through the CDC and you
46:03have to actually specially get get
46:06permission and register for that.
46:08So this was all what we were normally doing,
46:11but now.
46:14It's very unclear what's going to
46:16happen to the incoming with the
46:18incoming Afghani refugees,
46:19so there are different categories.
46:21There are there's one category
46:23that's the SIV approved.
46:24They're like all the other CVS.
46:26Then there's a category where their paper
46:28was being processed and they were going.
46:29If I did, but it's not completed.
46:31They're called the S IV pending.
46:34Both these categories are
46:36eligible for Medicaid,
46:37but then the largest group that we are
46:40expecting according to our resettlement
46:42partners is the humanitarian parolees.
46:44Who may not even be a savvy eligible?
46:47Maybe, maybe not.
46:48We don't know,
46:48but they haven't gone through that process
46:51and it's unclear at this point what I mean.
46:54I just had a meeting with the
46:56resettlement folks couple days ago
46:57and they still don't know what shape
46:59the health care assistance will take,
47:01whether it's going to be some
47:02sort of emergency Medicaid,
47:03or will they think that they're going to
47:06be eligible for the marketplace coverage,
47:08but they won't necessarily be
47:09eligible for the routine Medicaid.
47:11They may just have some sort of
47:13emergency care soon after they come,
47:14so it's it's very.
47:15Uncertain at this point.
47:17And also because there's being
47:19evacuated in a hurry up with you
47:22know with a sense of urgency,
47:25they haven't had the same kind of health
47:27vetting that they used to have before,
47:28so we've already seen some people
47:31who are coming through EU.
47:32S military bases and the bases are now
47:37like very quickly trying to do these
47:40health assessments for them and do
47:43the basic sort of infectious disease
47:45screening during the COVID vaccinations.
47:48Testing,
47:48but also starting the vaccination process
47:50so this has started on the basis just
47:52in the last few weeks, but it's still.
47:56The information is not necessarily
47:57getting to us.
47:58We've been talking about,
47:59like, you know,
48:00sort of some of the logistics
48:03of of those issues,
48:04but.
48:07It's it's very new, so it remains
48:09to be seen and it remains to be seen
48:11where we will be with with the mental
48:14health of these Afghani refugees so.
48:19Our Refugee health program.
48:21I mean, the clinic is the basic.
48:23The fulcrum of everything we do.
48:26This is actually in our old location.
48:28These are in the picture you see all
48:32internal medicine refugees with me.
48:34We're talking about a patient,
48:37but also we have a mental health
48:41team and you know my approval,
48:44who many of you know in our department has
48:46been a significant ally of the clinic.
48:50And you know, has been.
48:55You know mentoring a trainees.
48:58We've had residents who elected to work here.
49:00We've actually had a public
49:03psychiatry fellows under, you know,
49:05Doctor Steiner who worked in our
49:07clinic and what we've tried to do is.
49:13Basically like find them mental
49:14health services when it's been
49:15challenging and I'll talk about for.
49:17The challenge is also a little bit more,
49:20but basically as I've been saying
49:22it's a partnership with with Iris.
49:24This is our new location where
49:27the clinics have moved and the.
49:30As I said, Connecticut doesn't get
49:32that many refugees in terms of like
49:34numbers compared to other states,
49:36but most who come to Connecticut
49:38come through IRAS.
49:39That's the local resettlement agency,
49:41so New Haven is the biggest hub.
49:44So right now we're talking about how can we
49:47like work with other clinics in the state.
49:50And you know, have more providers
49:53and clinics see these people?
49:55And the plan is that.
49:58We're going to get like,
50:00or at least the expectations we're going to
50:02get 100 a month starting like this month,
50:05and many of them will be in New Haven.
50:08Some of them will be sending to Hartford,
50:10so there's a lot of discussions about
50:13sort of how to accommodate the the
50:16need needs that they will come with.
50:20What we do when they come.
50:21As you know,
50:22we do a normal sort of physical
50:24and mental health assessment
50:26just like you would with anybody,
50:27but with special attention to what
50:29we know about their mental health.
50:31And you know, as I said,
50:34chronic diseases are becoming
50:37increasingly common and.
50:39We are,
50:40you know,
50:41fortunate that we have actually very,
50:44very motivated trainees who really
50:46want to be part of the system and.
50:52The challenge actually has been uhm, in.
50:57In a. Accessing some of the required
51:02services so the clinic is really
51:04more sort of a medical home for these
51:06patients because they come here and this
51:09becomes becomes their healthcare home.
51:11The challenge has been in
51:13accessing mental health services,
51:14and that's just because of the
51:17structure of the system here and
51:19the fact that it's the care is.
51:23You know, across multiple systems
51:25and we haven't had sort of one
51:29place or one clinic to send them to.
51:32What has happened in the last year
51:34as people may or may not know,
51:37is that now the primary care clinics,
51:39along with the refugee clinics,
51:40have moved to the new location under the
51:43federally qualified health care centers.
51:45So we do have more resources.
51:47In that sense,
51:48we have a whole behavioral health
51:51team for the adults at Cornell.
51:53Scott Hill Health Center and
51:55then we have for kids.
51:57We have the Fair Haven health system.
52:01And as I said,
52:01we haven't had that many refugees
52:03in the last few months to utilize
52:04a lot of their services,
52:06but they're actually going to meet
52:07with them later today just to sort
52:09of talk about how to build capacity.
52:11If we're going to have a lot of people with.
52:14Mental health needs.
52:17So what we used to do while we
52:20were still located as part of
52:22the larger hospital was uhm.
52:25My my opera Boo and you know the
52:27team of residents we had would.
52:29Basically we would hold them for.
52:32The amount of time that they
52:34needed some acute care,
52:35and then we would try to triage
52:37based on the level of need.
52:38And you know CMFC,
52:40which is my primary location,
52:42you know,
52:43has definitely taken a lot of our refugees.
52:47Are you know RCMS leadership has
52:50been very supportive of taking the
52:53care of some of our very complex,
52:55severely ill refugees.
52:56And then we've used other
52:59Community resources.
52:59You know, sometimes private clinics,
53:01sometimes other hospital based clinics,
53:06and we. Have even like utilized dumb.
53:12You know other private agents,
53:14for example, come?
53:17We had a social worker at Iris who
53:19was there for case management,
53:21but she was interested in being
53:23actually providing some therapy,
53:24so we she consulted with us and
53:26we talked about sort of what it
53:28would look like and how we can
53:29actually build a place where she
53:31does some supportive counseling
53:33for them so that we don't refer
53:35everybody or look for specialized
53:38mental health services for everyone.
53:40So we've had to be creative
53:43and sort of look for sources.
53:46And in general,
53:47like with everything else with anybody else,
53:49like employment, school, housing,
53:50you know these are not things that
53:53we have a lot of control over.
53:54But the iris is a great partner
53:56and they have a,
53:57you know very very effective CEO
54:00who who you know,
54:02actually you know,
54:03manages to actually get a lot
54:05of resources and and so we're
54:07actually lucky that they are
54:09our partners. And I was just talking
54:11about sort of the barriers to like.
54:12You know how we can help people
54:14engage and part of the engagement is.
54:16Getting them involved in activities,
54:18either it's employment or
54:20if it's not employment.
54:21You know other activities in the community,
54:23not just within their group,
54:24but and you know some people in the
54:28Community are already doing that,
54:29helping these people integrate.
54:33Uhm, within our program itself,
54:35beyond the clinical work,
54:37we have something called the Yale.
54:41Medical Student Navigator Program,
54:43which has been tremendously helpful.
54:44UM Paul Bordelon, one of her.
54:47He actually in 2015.
54:49He was a Med student at
54:51the time and he basically,
54:53you know,
54:53built this program where a medical
54:55student would work with a refugee
54:57with complex needs and help them
54:59navigate the millions of things
55:01that they need help with from
55:03anywhere from how to get to a
55:05pharmacy and ask for their meds too.
55:07Like knowing how to make a follow up
55:10appointment so they've kind of taken off.
55:12And run with it and you know they we.
55:15We don't even like UM,
55:17consult with them that much they
55:19it's still an active program
55:21and now actually they have.
55:23They have included undergraduates
55:24as part of it.
55:25And then health literacy classes we've had.
55:29Actually,
55:29this has been more from that pediatric team.
55:32They have had gone to arrests and
55:35actually done various interactive
55:37sessions with the refugees about
55:39various health related issues.
55:42And speaking to the low uptake
55:44of mental health care,
55:45we had a mental health session
55:47once run by a student,
55:48actually very capable student, and it was.
55:52It ended up that a lot of people actually.
55:55Didn't even quite know what
55:56the mental health was or what
55:58they should be looking for.
55:59People were actually looking for
56:01a lot of case management needs.
56:03Then,
56:03like learning about sort of mental Wellness.
56:06So that was just educational for
56:09us to know where where people are,
56:11and then we have.
56:13You know we after this whole thing
56:16broke in 2015 and the Syrian conflict
56:19and we had large numbers of refugees.
56:21That's when we actually started
56:24having a yearly.
56:26Uhm,
56:27like sort of 1/2 day session for
56:29providers across the state and
56:30we actually meet twice a year
56:32with these providers.
56:33All the providers who see refugees in
56:36our state and then sometimes there's
56:38just like sudden crisis interventions.
56:40The iris folks may call us because
56:41there's somebody with some mental
56:43health issues who's never engaged.
56:44We've tried to engage them.
56:45They haven't.
56:46They're in crisis and they don't
56:47know what to do.
56:48Sometimes they consult with us and you know.
56:52Very rarely we have any legal.
56:57Activities, except sometimes
56:58later on in their course.
57:00Sometimes we do actually have
57:02asylum seekers that have just
57:04received asylum and they come to us.
57:06This is just I thought,
57:08all end with some you know,
57:10just pictures to give life to what
57:12we do and and you know these are
57:14just last year we we cancelled
57:16our conference because that was
57:18just when COVID was beginning.
57:20But these are just different years.
57:23What we've done with our conference and.
57:26You know we've had actually the one
57:29on the right is actually, UM, Daniel.
57:31Trust he's in.
57:33I think his New York now,
57:34but he came here as a Rwandan
57:37refugee and then he has,
57:39you know,
57:40he's basically like really thriving here.
57:42He was going to come talk to us about Sir.
57:44So local advocacy.
57:45But that was the one that we cancelled.
57:48But we try to.
57:49Sort of have people who experience
57:52that come and talk to us about about,
57:54you know their ex.
57:56Instead of us talking about them,
58:00and this is actually a group of
58:01US students and we actually have
58:03a contingent every year we haven't
58:05in the last two years because
58:07the conference is having virtual,
58:09but we have a contingent help
58:11students every year.
58:12These are all actually medical
58:13school students except the person
58:15in front who actually was a former
58:17refugee who worked as an interpreter
58:18and then worked in some research
58:20projects with our students.
58:23Uhm,
58:24and I also wanted to mention
58:29Sanctuary Kitchen, Donna Golden,
58:31who's very closely affiliated
58:33with our department.
58:34UM,
58:35has actually done a really good job of of,
58:39you know,
58:41building this program for refugees
58:43and you can look at the website,
58:46but it's basically a program,
58:47not just for people to cook and caterer,
58:50and potentially like,
58:51you know, have some income.
58:52But also it's it's.
58:54It's a community activity and this is a
58:56picture where they actually were very kindly,
58:59gave us some food one
59:01clinic night as a thank you.
59:04And I also wanted to.
59:07Mention there are other community programs.
59:10There's one organization
59:12called Ellen's Light,
59:14and I'm just very proud to say
59:15that this is founded by somebody
59:17who came through our clinic when
59:19I was beginning in this clinic.
59:21Who came to us then?
59:22Actually learned English,
59:24became an interpreter for us,
59:26then work with the resettlement
59:28agency on their staff,
59:29and then left to build their
59:31own organizations.
59:31Mainly, she, you know,
59:33wants to help refugee women,
59:35so I think it's just sort of anecdotally,
59:37some of the stories.
59:40Of our refugees.
59:42Uhm, so just so in in closing uhm?
59:47You know I I don't need to say this,
59:48but we know that it doesn't seem
59:51like it's ending migration,
59:52just forced migration just seems to rise.
59:56Uh, we said we were at.
59:58All time high.
59:59A few years ago and their high
01:00:00just seems to be getting higher
01:00:02and and then just to remember
01:00:04that the refugee experiences
01:00:05and experience. It's not necessarily all
01:00:08pathology and there's a lot of resilience
01:00:11and a lot of success stories that come
01:00:14out of these groups and to also just a
01:00:17reminder that not everybody needs treatment,
01:00:19but we really have to focus on Wellness
01:00:22activities and health promotion.
01:00:24And, uhm, you know there's always.
01:00:28You know, like I said,
01:00:29most researches on resettled communities.
01:00:31But you know more research just
01:00:34across communities around the world,
01:00:36but also in general you know
01:00:38compared to some other groups you
01:00:40know we we just we need more.
01:00:42We need to understand more
01:00:44their characteristics of
01:00:45different refugee populations.
01:00:47Uhm, just wanted to acknowledge these people.
01:00:51I mentioned my earlier.
01:00:53I mean,
01:00:54she's been a critical piece piece
01:00:56of her mental health outreach and
01:00:59Tracy Rabin and ask her rastegar
01:01:02or the Office of Global Health.
01:01:05Without them we wouldn't be able to
01:01:07have our annual refugee seminars
01:01:09and I also wanted to mention we
01:01:11are planning a webinar series
01:01:13specifically for the Afghani arrivals
01:01:15and sort of like a basic 101.
01:01:17Uhm of refugee health because we
01:01:19are expecting that more providers
01:01:21who have never seen refugees before
01:01:23will probably start seeing them.
01:01:25So all this is supported by the Office
01:01:27of Global Health and then Camille Brown.
01:01:30She's our pediatrician doing
01:01:31what I do on the adult side.
01:01:34And all the residents and fellows
01:01:36who've been with us over the years.
01:01:39Brian Brown. I put him down at the bottom.
01:01:42Not because I mean he's any less important,
01:01:44but he's he.
01:01:45Unfortunately, for personal reasons,
01:01:47had to leave Yale,
01:01:48so he's not with us any longer,
01:01:49but was integral part of the clinic.
01:01:52And of course, Iris.
01:01:54And we have our partners
01:01:57in the immigration branch.
01:01:59Allison Stratton, Mitchell Joel, you know.
01:02:02Also, you know they.
01:02:04They are very much our partners.
01:02:06So I'll stop there and I just I'm sure you
01:02:09can just find my email address anyway,
01:02:11but I just put the email addresses
01:02:14for myself and Maya if people want
01:02:16to continue any of this conversation,
01:02:18especially in light of what is likely
01:02:21to happen over the next few months.
01:02:23But I'm happy to answer other
01:02:24questions here now.
01:02:28I think you could put your
01:02:29questions either in the chat or
01:02:31or if you wanted to raise your hand or
01:02:34just unmute and and and ask and Trisha
01:02:38will help to moderate. Doctor tech.
01:02:44Wonderful presentation, thank you so much.
01:02:48The better group of people
01:02:50come from the same location.
01:02:53How ready do you think our health system?
01:02:56Uh, to deal with the.
01:03:00Diseases that are endemic to that area,
01:03:02but you know very rarely seen in the US.
01:03:06I'm talking about the medical illnesses,
01:03:08of course, right?
01:03:11Uhm, you know, for the most part we at
01:03:13least in my 10 plus years seeing refugees.
01:03:15I mean very rarely they come with
01:03:18rare diseases or even like things.
01:03:20I mean like for example like Talasi Mia.
01:03:23You see that more in the Middle East,
01:03:24and we definitely see that a little bit more.
01:03:27And then we definitely see a lot
01:03:29of like latent tuberculosis.
01:03:32I didn't even go to the medical
01:03:33issues like the list of what we see
01:03:35we don't see as much latent TB here,
01:03:37but mostly I think.
01:03:39People working in the refugee
01:03:42field know some specific node
01:03:45to look for specific illnesses,
01:03:47and that's part of why we want to do
01:03:49the training to see what to expect
01:03:52in this particular population.
01:03:53But it's a challenge because we
01:03:55need to do the training.
01:03:57We need to have the resources
01:03:58we need to have the ability,
01:03:59and I didn't even.
01:04:00I actually didn't stress on the
01:04:02language services as a clinician like
01:04:04I can't tell you like how important
01:04:06and frustrating it is when you don't
01:04:08have the language services too.
01:04:11To provide necessary care and that
01:04:13could be a whole talk in itself,
01:04:15but but anyway, to answer your question.
01:04:17I mean,
01:04:18it's just basically sort of already
01:04:20available expertise and then like
01:04:22expanding that to the best of our abilities.
01:04:31So we have a question in chat.
01:04:32Could you comment on when you refer
01:04:34patients out for care in the Community to
01:04:37have access to providers in the Community
01:04:39who may have some cultural connection?
01:04:42Or is this is this important or not really?
01:04:46Yeah, uhm. So yeah, So what?
01:04:51So I briefly alluded to it.
01:04:54So especially I'm talking
01:04:55about mental health care.
01:04:57So I had like a sort of triage Ng UM thing.
01:05:01So I would say some people
01:05:03are relatively healthy.
01:05:04They need mostly Wellness services
01:05:06and you know they can mostly,
01:05:09in collaboration with Iris
01:05:10and Community agencies,
01:05:11we can serve their needs.
01:05:13And then there's a group of people that
01:05:15may not have a diagnosable pathology.
01:05:17But we're still in some
01:05:19psychological distress.
01:05:20And mostly we try to train primary care
01:05:23providers and how to take care of them.
01:05:26So that we're not sending them
01:05:28for specialized mental health
01:05:29services because they may not even
01:05:30be ready for it to begin with.
01:05:32And then we really the people that we
01:05:34really try to send for specialized
01:05:36mental health services or people you know,
01:05:38like anybody else that we see
01:05:39in the mental health field.
01:05:40People who have significant you know trauma,
01:05:44pathology or significant depression,
01:05:46or anything else that's impairing
01:05:48their psychological functioning
01:05:49and that they're willing for care.
01:05:52And so that's who we try to refer,
01:05:55and we try to.
01:05:57Uh, at one point we, uh, well are.
01:06:03Dimas Commissioner is no longer.
01:06:04I mean, she's moved on,
01:06:05but we had talked to her a few years ago
01:06:07about the possibility of sort of connecting.
01:06:09You know other clinics in the area,
01:06:11and, as I mentioned,
01:06:13we've definitely brought some people to CMHC.
01:06:15For care and,
01:06:17UM, yeah, so I.
01:06:19I guess it's basically
01:06:20just like anything else,
01:06:21it's severity of illness and
01:06:23having access to providers in the
01:06:25community is definitely a challenge,
01:06:28not because of lack of will,
01:06:29you know,
01:06:29people who want to help people
01:06:31want to do this.
01:06:31It's often like other systemic barriers
01:06:33like we've had a lot of people from
01:06:36the VA say that they want to help.
01:06:38And even when we were part of yearly even
01:06:40hospital like they couldn't just do it.
01:06:42I mean,
01:06:43we we had to go through a process of.
01:06:46That they were, you know,
01:06:47able to practice in that environment.
01:06:49And now we're part of the FQHC's,
01:06:51so it's a different issue.
01:06:52So what we're actually trying to do
01:06:56now is talking to the CVV to we're
01:07:01going to talk to the actually doctor AJ
01:07:05Tak about how we can accommodate this,
01:07:08and not everybody may need
01:07:10specialized mental health services,
01:07:11but are there other non direct clinical
01:07:13activities that they can help us with?
01:07:15And how can we?
01:07:16Accommodate providers,
01:07:17so that's what we are working on.
01:07:22So yeah, it's it's a work in progress.
01:07:28Doctor Golden is asking does it deal
01:07:31refugee clinic provide training to
01:07:33provide his own cultural competency
01:07:35for the cultures presenting for care?
01:07:38And if yes, how did they do this?
01:07:40And do you have refugees
01:07:41who are able to participate?
01:07:44Yeah, so yeah. I mean there are many
01:07:46people in this audience who know
01:07:48a lot about cultural competency,
01:07:50but basically I I decided long time ago
01:07:52that you couldn't really be competent
01:07:54because there were too many groups.
01:07:56There was too much variety and
01:07:58heterogeneity among the population.
01:07:59So mainly, you know,
01:08:00sort of like just having the cultural
01:08:03humility humility in being aware and
01:08:06open to what you might see and not
01:08:09necessarily hoping to be codoncode
01:08:11competent in any particular culture.
01:08:14Now with the influx of people
01:08:17coming from one particular region,
01:08:18it definitely is worth, you know,
01:08:21talking about some of the sort of
01:08:23major highlights of what we could see,
01:08:25and that's part of what we are
01:08:27planning to do in the webinar series.
01:08:29We're hoping to have one sort
01:08:30of later in October,
01:08:31and then how followups in November
01:08:33and December to talk about these,
01:08:35and definitely the cultural
01:08:36piece is going to be a big thing,
01:08:37and like I was saying earlier, I think.
01:08:40Nobody can speak better to the culture
01:08:42of society than the society itself.
01:08:44I mean,
01:08:44I can never know really all the
01:08:46in's and outs of what happens there.
01:08:48Only they have to be able to tell us.
01:08:49So I think having ambassadors
01:08:51within the community to talk is.
01:08:53And I know doctor Golden that
01:08:55you're working on this.
01:08:56Based on our conversation.
01:08:57I know you and my are working on this,
01:09:00so I and I think that's extremely important.
01:09:05Doctor Srihari yes. The clinical
01:09:07business with the need for translation
01:09:10sound time consuming.
01:09:11What kinds of resources do you recommend?
01:09:13Healthcare organizations
01:09:14commit to prepare for refugee
01:09:16needs and clinical settings.
01:09:19Yeah, so again this is not
01:09:21a sustainable way to do it.
01:09:23We have relied heavily on volunteer
01:09:26efforts and this is being a bane of
01:09:30my my refugee work from the beginning.
01:09:33If anybody is especially like
01:09:35I tell students and new,
01:09:37you know trainings like if they're
01:09:38interested in advocacy work
01:09:39and they want to work on this.
01:09:40The first thing they should ask for us.
01:09:43Increase like reimbursement for services
01:09:46that require interpreter services.
01:09:48You know. Like I said,
01:09:49like clinics and providers want to help.
01:09:50They want to do this.
01:09:52It's not that they don't want to,
01:09:53but you know it has to be
01:09:56viable and sustainable.
01:09:57And even though clinics by law are
01:09:59required to provide language services,
01:10:02they are not reimbursed more for that.
01:10:04So it it becomes a problem when you
01:10:08have the same amount of time and
01:10:10you're spending extra on the resource
01:10:12of interpreters and you don't.
01:10:14You know you're not able to do it,
01:10:15So what I have done is the standard
01:10:18of care that you use certified
01:10:21medical entrepreneurs,
01:10:22and there's certainly what we try to do.
01:10:24But sometimes,
01:10:25in an acute situation I will
01:10:28use what I have available.
01:10:30I mean,
01:10:31I will use a spouse when I
01:10:33think it's appropriate.
01:10:35When it's not an issue,
01:10:36I think where it it's going to be a
01:10:39problem an sometimes I'll use like
01:10:41our latest refugee health coordinator at.
01:10:44Health coordinator iris.
01:10:46Actually happens to be a happens
01:10:49to speak a couple languages.
01:10:51Mainly Daddy from that the Afghan
01:10:54is big and sometimes they use her.
01:10:56I mean she's not a certified
01:10:57medical interpreter,
01:10:58and that's not the standard of care.
01:10:59But sometimes you have to do
01:11:02what works best at that moment.
01:11:05So.
01:11:08I,
01:11:08I guess one resources that is
01:11:10part of cultural training,
01:11:12like how to best use an entrepreneur
01:11:13in the limited resource you
01:11:14have and the time you have.
01:11:16And there's a whole like you
01:11:17could do a whole session on how
01:11:18to work with an interpreter.
01:11:20But but otherwise we've relied
01:11:22a lot of on volunteer services.
01:11:26That's what we're probably going to rely on.
01:11:29The acutely in the next few months.
01:11:37Only a few years ago I went to one of your
01:11:40trainings and I was really shocked by
01:11:43the small amount of assistance that
01:11:46the US government provides for housing
01:11:49and other needs for resettlement.
01:11:52And given that your presentation.
01:11:55Noted the that that housing stability
01:11:59was one of the things that was
01:12:01proportionate to better health outcomes.
01:12:03I was wondering if that had changed
01:12:06at all over the past few years.
01:12:10Yeah, uhm. No, I mean it's.
01:12:15I mean, we're still faced.
01:12:19Sort of a lot of the same,
01:12:21UM, challenges. And yes,
01:12:23the actual regulations have not changed,
01:12:27so the assistance for medical care still
01:12:31runs out after eight months of resettlement.
01:12:35We're actually fairly lucky in Connecticut,
01:12:37a lot of people end up being
01:12:39eligible for Medicaid after,
01:12:40and if you have dependent children
01:12:42than like you have more benefits.
01:12:44So fundamentally it hasn't changed,
01:12:47but we just look.
01:12:48Living in a relatively resource
01:12:51registered compared to other
01:12:52States and like I was saying,
01:12:54Iris has a very effective CEO who.
01:13:00Actually lot of you.
01:13:01I mean I know,
01:13:03contribute to Iris and that actually.
01:13:06You know it.
01:13:07It helps find that housing and find
01:13:11those supports for refugees who
01:13:13are not able to become financially
01:13:15independent in that time period.
01:13:16I mean, that's just sort of the US.
01:13:19Message come here and you know,
01:13:22succeed,
01:13:22that's kind of how that's the message and.
01:13:26You know most people do eventually succeed,
01:13:29but but yeah, uhm.
01:13:31None of the supports have have
01:13:34changed or really increased.
01:13:40And I see some chats about
01:13:42the interpreter services.
01:13:46Yeah, I mean like I said,
01:13:48the whole interpreter thing
01:13:49is a whole talk in itself.
01:13:51But definitely I always
01:13:53prefer somebody in person.
01:13:54There's a lot of body language
01:13:56and things that you know you
01:13:59miss in a phone interaction.
01:14:00But sometimes people will want
01:14:02the phone as my eyes saying,
01:14:03because it might be somebody
01:14:05in their community that that's
01:14:06happened more than once that they
01:14:08don't want to be in the room with
01:14:10that person because the person has
01:14:11seen them in some social setting.
01:14:13You know, it's not such a large community,
01:14:14so then they don't want to
01:14:16be in the same room.
01:14:17They want to be on the phone.
01:14:19And we try to respect that,
01:14:21but for the most part we like in person.
01:14:24Services and we're actually trying
01:14:25to lobby for that now because after
01:14:27we moved to the aafcs we haven't had.
01:14:31Face to face interpreter services
01:14:33and we're trying to see if the
01:14:36hospital can actually like fund
01:14:37that just just as a special
01:14:39need for newer refugee arrivals.
01:14:41So hopefully we can make that happen.
01:14:47I think we've come to the
01:14:48end of our time with you.
01:14:50We really appreciate your your
01:14:51work and your willingness to share
01:14:53your expertise with us today.
01:14:54Thank you so much.