Alfred T. Kisubi, Ph.D.
International Editor, Human Services Today
University of Wisconsin Oshkosh
Oshkosh, Wisconsin, USA
Who’re Immigrants and Refugees?
In this International Editorial I wish to highlight the mental, physical, and social health issues among refugees and call upon all human service and healthcare workers to pay attention to the refugees’ problems and try to solve the mental health needs of the new arrivals in their community. As the healthcare bill snakes toward final legislation, there are those who point out that it should not cater to “illegal immigrants.” That has been happening in this country for some time.
Immigrants have long been on the fringes of medical care. But, in the last decade, and especially since the terrorist attacks of Sept. 11, 2001, steps to include them have faltered in a political climate increasingly hostile to those who face barriers of language, cost and fear of penalties like deportation, say immigrant health experts, providers and patients. More and more immigrants are delaying care or retreating into a parallel universe of bootleg remedies and unlicensed practitioners.
Here ‘refugees’ and ‘new immigrants’ mean people who have legally just come here to stay as permanent residents and naturalized citizens or just for a little while as students, visitors to new immigrants. ‘Refugees” are the core of our discussion. These are people, who the United Nations High Commission for Refugees (UHHCR) has relocated to the U.S. as a third country as mandated by international Convention and Protocol Relating to the Status of Refugees (UNHCR, 1951 Convention, and 1967 Protocol), which the U.S. ratified. Usually the refugees include people that fled from their country to avoid the chaos caused by wars that the U.S. and allies do frequently sponsor or wage directly such as in Vietnam, Afghanistan, Iraq, or by proxy, such as Somalia, Sudan, Congo, Uganda, Ruanda, Angola, and Bosnia.
When the refugees arrive in the U.S. they are received by some U.S. settlement agency, such as Catholic Charities who sponsored the lost boys and their families from South Sudan to Oshkosh, or Shelter Now that sponsored the Kurds also in Oshkosh, Wisconsin. Therefore, the refugees are not ‘illegals’. They are the aftermath of America’s international (foreign) policy coming home, where their welfare, particularly healthcare, ought to be part of the healthcare debate at national, state and local community levels.
Milwaukee Self-help Response
In Milwaukee the Pan-African Community Association, Inc in response to the mental, physical and social issues, organizes free medical screening for diabetes, and high blood pressure. They disseminate culturally sensitive healthcare information for ethnic minorities, including refugees and immigrants, in Metro Milwaukee. Also they promote modern and traditional best practices such as learning about health care challenges and opportunities faced by ethnic minorities, including refugees and immigrants, in Metro Milwaukee. Alternative healthcare strategies for ethnic minorities, including refugees and immigrants, are encouraged and the role of culture and spirituality in healing are recognized and promoted.
The Pan-African Community Association (PACA) liaisons with all various African national groups with the purpose of providing on-going workshops on mental health, AODA, domestic conflict relation, sexual assault and harassment literacy. It sponsors events for children under 12 year old, youth, young adults, and initiates an energetic outreach effort to mobilize mature and elder adults from Africa. PACA also addresses issues of loneliness, relocation, enculturation, mature/elderly dating, safe domestic conflict resolution, and responsible sexual relations and other pressures upon marriages that are caused by relocation. This includes polygamy laws and effects on families. PACA addresses psychological factors that promote school success, emotional adjustment at school, gang resistance, drug abuse choices, and healthy emotional living among clients from 10 different African nations and puts on educational workshops about this group. The Islamic Family and Social Services (IFSS) provide a venue on women, the young, middle aged and elderly among the Somali Bantu. IFSS hosts at least 2 such sessions per month for 12 months.
Response to the Problem by the Sebastian Family Psychology Practice, LLC
Also in response to refugee mental health needs, Sebastian Family Psychology Practice, LLC (A New Immigrant Psychologist-owned business) is well poised for refugee mental health issues. The proprietor, having experienced the throws of leaving ones country and living in another, decided to focus a great deal of his practice on the needs of the new immigrants in his community. Accordingly, a special refugee project was set up under the CY 2005 grant activities, continuing into CY 2006. In 2005, over 300 clients received services. This caseload included Americans and refugee clients, who consumed services in direct mental health services programs. 85% of the clients had a dual diagnosis of major mental disorders, such as depression, mood disorders, anxiety, and agoraphobia in addition to AODA issues. Only 15% were in the pure AODA category. Of the major mental health disorders found, at least 40% of the refugee clients had major disorders, such as post-traumatic stress disorder, adjustment disorder, affective disorders, and domestic abuse. A total of 172 cases received services in CY 2006. Of these, there were about 20 torture cases, primarily from Sudan, Liberia, Ivory Coast and the Congo. There were 10 referrals to resources, which included severe psychiatric hospitalizations, alternative medicine referrals, as well traditional healers, providing a needed recourse. Table 1 shows the number of refugees targeted and served in FFY 2005 and FFY 2006.
# And Ethnicity Of Refugees Served In 2005 And 2006
|Refugee Group||FFY 05 Target||# Served in 05||FFY 06 Target||% to be served in 06|
In order to ensure active involvement by all parts of the community in the resettlement and orientation of the refugees, the Sebastian Family Psychology Practice, LLC runs a Community Education Service with the following activities: 1) Outreach, 2) Group education workshops on issues affecting refugees to sensitize the community and workplaces to understand refugee problems that might impact performance and adjustment, 3) Group orientation for elementary, middle and high school refugee children. They also study the problems that afflict refugee pupils in school and educate teachers and other school authorities about the needs of their refugee pupils.
The task of reaching out to the refugees is about a third of the entire clinical and case management activities of the office per year. Generally, the office has experience in serving a diverse group of clients, including children, youths and families experiencing emotional distress, psychological traumas and negative effects of extreme poverty, as well as AODA effects of alcohol and other drugs. Here is why.
The Refugee Issues
Demographics and Issues:
Between 2001 and 2005, 1564 refugees arrived in the Milwaukee area.  An estimated 603 more refugees settled in the area between October 1, 2005 and September 30, 2006.  Of those who settled in the area between 2004 and July 2005, 650 refugees were Hmong, 231 refugees were African and 57 refugees belonged to the category “other,” forming a total of 1245 refugees.  Wisconsin saw a 31% increase in the number of foreign-born residents between 2000 and 2004. They arrived from Central America, Asia, Europe, as well as Russia and Africa. The entire nation has seen a 10.1% increase in the number of the foreign-born over the same period (Milwaukee Journal Sentinel, February 22, 2005)  .
Milwaukee County, which boasts of a long immigrant history, has become “home” to a new wave of additional Hmong new arrivals, making the Southeast Asian refugee community the largest of the recent arrivals, followed by refugees from Ukraine, Bosnia, Croatia, Serbia, Russia, and various African countries, such as Somalia, Sudan, Congo, Liberia, Ivory Coast, Uganda, and Eritrea (The Milwaukee Catholic Herald, November 21, 2002). 
Fennely and the Minnesota Health Taskforce (February 2004) in their study of the health needs of African immigrants and refugees found the following general needs: Housing 71%, health 67%, jobs/poverty 64%, education 55%, language 51% and transportation 14% (Refugee Health Taskforce, 2/04). H. Gerson Jones in his special to the Voice and Viewpoint article entitled “Health Needs and Language barriers Facing African Immigrants Now Documented” outlines the findings of the Summit Institute for Research and Education in their report Giving Voices to the Voiceless. The report concludes that recent African immigrants face formidable barriers to health care access due to limited English skills, lack of resources, and the absence of healthcare insurance and lack of awareness of how to get through the healthcare system.
Mental Health and Orientation Issues
Newly arriving refugees come with anticipation of their new lives. They come burdened with the traumas of war, torture, persecution and conflicts that have torn the fabrics of their lives. They also have difficult adjustments with the resettlement experience. Some arrive having experienced severe trauma related to their flight.  The phenomenon of mental illness among recent refugees has been highlighted by recent publicized events. The shooting spree during the 2004 hunting season, implicated a Hmong male with alleged mental health issues. In Milwaukee, police shot a Hmong male under circumstances involving mental illness and cross-cultural misperceptions.
Current observations by the Sebastian Family Psychology Practice, LLC office and shared information with the Milwaukee Area Refuge Resettlement Agencies (MARC) reveal increasing numbers of complex symptoms among various African, Hmong, other S.E. Asians refugees, and those in the Bosnian/Croatian/Serbian, African and Burmese refugee (B/C/S) communities. These problems include physical health problems, sleep and appetite pattern disruptions, work and ESL related stressors as well as marriage and family relationship pressures. Children and youths present with a variety of emotional and mental health problems that include personal disorientation, homesickness, fear, anxiety and depression. Adjustment pressures for some of the Somali Bantu and Hmong children have led to conflicts within their host school settings. Often the urban neighborhoods and schools they are resettled into have additional environmental pressures that overwhelm their psychological security.
Like mainstream U.S. popular views, refugee communities struggle with misperceptions of mental health challenges and attitudes. Therefore, there is a need to educate both the general public and the refugees about the mental health issues among the refugee and immigrant communities of Wisconsin as a whole, and Milwaukee County in particular.
The Minnesota study concluded that healthcare needs for the African immigrants and refugees included: Health insurance, information about services and eligibility, mental health care and treatment, dental and eye care, and preventive services. Factors impacting how immigrants relate to and use or not use the U.S health care and welfare systems were reported to be: culturally based belief systems, values, traditions and practices culturally defined needs and attitudes toward seeking help. The Summit Institute for Research and Education reported in 2005 that the American lifestyle works against protective elements within the various cultures that promote health status. Barriers to health care mentioned in most studies are: lack of awareness about preventive medicine, language, translation/interpretation needs and communication problems, limited or no insurance, and dissatisfaction with the care received (Ibrahim, 2005). Other barriers unique to health care include frustration with long waits for doctors and interpreters in hospitals or clinics, concerns about inadequate or incorrect translation and mistakes made in diagnoses and treatment, and fear that confidentiality would be violated by interpreters. (Qamar Ibrahim, 2005).
Language barriers were significant. The Summit Institute for Research and Education, (2005) reports that language barriers have a huge impact on the entire range of social function especially education, employment, housing, politics and law. Immigrants and refugees had a hard time finding a job because of language barriers. Therefore, this leads to isolation. Adults who don’t speak English remain in the home. African immigrants and refugees with limited English skills are generally unable to assist children with educational efforts. Those who had a trade could not afford re-certification costs. According to the Summit Institute for Research and Education (2005), African immigrant health care workers lack the opportunities to obtain additional training and credentialing to utilize their skills in the United States. The stress and complexity of every-day life in a foreign country engulfed with discrimination and lack of economic opportunities for adequate income manifest themselves in mental illness and depression (Summit Institute for Research and Education, 2005). Most studies found mental issues to be significant in the African immigrant and refugee population. Mental health afflictions included: depression, post-traumatic stress disorder and domestic violence. Anita Wadhwani (2005) concluded that the language gap hurts mentally ill immigrants and attributed it to cultural conflicts and mistranslations due to the poor training of the translators.
Education for Immigrant/refugee and for Health workers
Education or the lack of it is a significant barrier to refugees and immigrants. Some didn’t finish school in their home country. Therefore, they cannot sign forms and get what they need from the System. So, learning English will open opportunity to work or socialization outside the house. Education programs must also target American health workers to educate them about the health needs of the African immigrants and refugees. The Summit Institute for Research and Education, (2005) reported that there are very few health care providers in the United States who understand the various African cultures and how to communicate and interact with these patients.
Of course the process and task of resettling persons who have fled persecution from their countries of origin, is hard and complex, but someone ought to do it. That is what Sebastian Family Psychology Practice, LLC is bent to do in collaboration with several community agencies that know and appreciate the need for an integrated approach to assist the refugees rebuild their lives in honor. They see it as appropriate that the State of Wisconsin Department of Workforce Development has regarded mental health services as an integral part of refugee resettlement.
Response to the Problem process
Bilingual professional staffing patterns:
The Sebastian Family Psychology Practice, LLC, agency has a diverse multilingual and multiethnic pool of mental health and AODA providers. These providers possess long clinical experience, each in their category of expertise. All clinical staff is hired on contract and thus are not agency employees but they are dedicated to the mission of serving the diverse clientele of this office. Presently, the agency has 13 bilingual staff where 2 males and 1 female Hmong, 1 male and 2 female are bilingual Caucasians, 3 males and 4 females are African immigrants with African multilingual skills. The other mainstream American born clinical staff is improving cultural competence so that they can serve the diverse target clients.
Ethnic community counselors:
Also, the agency in 2007 recruited and trained a cadre of crisis community counselors for each of the targeted ethnic groups. This approach was based on the rationale that, in addition to trained clinicians, the lay crisis community counselors would greatly fit their ethnic communities. They received fundamental coursework in youth counseling training via the U.W. Milwaukee youth worker program. The 6-10 week program targeted a total of 10 such lay crisis counselors. These individuals were drawn from the Hmong, Bosnian/Croatian/Serbian, African and Burmese refugee communities.
It is understood that all contracted bilingual/bicultural clinicians who have their credentials have vested professional interest in remaining in this community and with this agency. The fact is that all current agency contracted clinicians are also actively involved at civic levels within their sub ethnic communities. Thus, it is safe to assume that they are here in the community to stay. Each of the credentialed staff is already enrolled in some of the mainstream reimbursement systems that fund mental health and AODA services. For example, all current clinicians, parent assistants and case aides are also enrolled in Wraparound Milwaukee, the Bureau of Child Welfare, the Wiser Choice Programs, and other funding sources. Some of the refugee clients may qualify for these services, thus their care would then be shifted to the appropriate payer entity.
Other community partners such as Access Mental Health, Islamic Social and Community Services, and the MARC agencies, have a mechanism of enrolling their clinical staff into the funding channels mentioned above. This agency has all credentialed staff enrolled in at least all the local HMOs of the Milwaukee Metropolitan area. The agency energetically seeks funding through the local, Federal, private and collaborative means, to secure adequate funding of the program year after year.
Outreach Process: Mental Health and AODA Services:
Currently, outreach efforts include regular communication with the resettlement agency directors and their case managers. All MARC and case managers’ monthly meetings are attended by agency staff. Other outreach efforts include: contact with school officials, religious leaders, ESL programs, primary care providers as well as ethnic community leaders among Hmong, African, and Bosnian/Croatian/Serbian and Burmese communities.
Other proposed outreach efforts include:
1. Hmong American Women Association, Hmong American Friendship Association, Lao Family and Burmese community leaders;
2. Engagement of Hmong radio stations that targets the youth, young adults, and the elderly;
3. African national groups via their grassroots organizations with the help of Pan –American Community Association;
4. Identification of work sites that employ significant (i.e. 10) workers from the designated populations;
5. Continued engagement of mainstream media (print, radio, T.V, Website sites to educate on issues effecting refugees; and
6. Engagement of the professional training programs of medical and mental health providers including the Medical College of Wisconsin nurse training programs as well as education and human service worker training programs.
It is anticipated that the increased awareness of refugee issues will increase understanding, and later, service delivery.
Referral and Termination Process:
The referral process involves:
1. Self or relative referral to agency ;
2. MARC agency case managers;
3. Referral form is filled by the referring person/agency that serves the elderly;
4. Clinic director reviews all referrals and assigns appropriate providers within 24 hours;
5. If the case is approved, treatment plan guides the level and frequency of care.
The length of interventions is contingent upon need and HMO authorization. Those without insurance are covered by the refugee grant funds. Cases are closed or transferred according to the acceptable standards of care for Mental Health and AODA services.
Transfer of clients to another agency is done according need or at end of the grant period. The agency is a mandated outpatient mental health and AODA clinic and as such, it is bound by State laws to ensure patient care continuity in the event of service disruption. This could be due to an end of funding and/or contract termination for the agency.
In anticipation of the grant termination the agency assesses its capability to continue care. They check the payment patterns, problems and solutions for each of the HMOs and T-19. They also check grant revenues from funded proposals. They have careful resource allocations to each case on a monthly basis. Thus, each clinician or case aide receives “Authorized Units” per month, per case. Thus subsequent utilization is based on case needs. After 3 months of continuous services, cases will be evaluated for discharge.
Transfer of cases to competent providers is facilitated with the consent of the client or guardian. Since the agency is staffed by independent clinicians who are free to move on with their clients who so choose, the case transfer can be seemless. The agency follows a similar model presently used by Wraparound Milwaukee and Bureau of Child Welfare in Milwaukee County.
A Humanist Proposal
We (new immigrants) should work with native-born Americans in recognizing the existence of immigrant groups, whose specific vulnerabilities are the outcome of both individual behavior and of high risk social and economic situations. It means stressing the importance of such co-factors of vulnerability to infection as poverty, exclusion, obstacles to information and prevention, lack of access to care and to drugs, and lack of facilities for care and support.
Human Services workers should recognize that each refugee or immigrant has unique problems to present. Africans from various nations and background are not to be seen as the same. In addition to the differences between ethnic groups, each person is a unique individual, whose beliefs idiosyncrasies and values mix with cultural background and personal experiences to influence their health care needs and wants.
In order for the health care providers to provide culturally sensitive care, they must be given culturally sensitive training/education in all health care training institutions. Efforts must be made to improve communication between immigrants/refugees and their health providers.
A wide, culturally sensitive, and appropriate education program about the importance of preventive health care practices and screening for all African immigrants and refugees must be designed and implemented in every community hosting new immigrant.
In order to treat cultural practices with empathy, health providers must be knowledgeable about each and every practice and treat it as normal to the client, instead of reacting with shock or ethnocentric disapproval they should give their new immigrant patients ‘Hull House’ treatment.
Delivery Strategies: Health in Our Communities
Community human service organizations should make a public commitment to the following seven resolutions to combat disease and promote health for individuals, families and the community:
1. Support a greater involvement of people living with any disease at all levels.
2. Promote community collaboration for research on common diseases among us.
3. Strengthen community collaboration for physical, mental, social, political, economic and spiritual health and safety.
4. Encourage a community care initiative.
5. Mobilize community, state and federal organizations at all levels for a movement for the our children.
6. Support initiatives to reduce the vulnerability of women.
7. Strengthen the community mechanisms concerning human rights and biomedical ethics with reference to diseases common among us.
We should implement these noble resolutions in our advocacy, education, research, and service. This effort necessitates our empowering everyone concerned in this effort.
Fennely, K. and the Minnesota Health Taskforce. (February 2004). Listening to experts: Provider Recommendation on the health Needs of Immigrant and refugees. Hubert Humphrey Institute of Public Affairs, University of Minnesota.
Jones, H.G. (2005). Health Needs and Language Barriers Facing African Immigrants Now Documented. The Voice and Viewpoint. California Black Health Network: A consortium of Community Based Agencies Promoting Improved Health Status of Black Americans.
Ibrahim, Q. (2005). Health Perceptions and Knowledge of Preventive Health Care of East African Women. LEAD: Helping African Immigrants and Refugees to Become Leaders in America.
State of Wisconsin Department of Workforce Development, (September 19, 2005). Volag Refugee Arrival Projection FFY 2006.
State of Wisconsin Department of Workforce Development, (September 19, 2005). Attachment 1 – Wisconsin Refugee Chart.
State of Wisconsin Department of Workforce Development, Bureau of Migrant, Refugee and Labor Services. (October 18, 2005) Attachment 2 – Estimated Total Eligible Refugee Population by County/Workforce Development Area.
Summit Institute for Research and Education (2005). Giving Voices to the Voiceless.
The Milwaukee Catholic Herald (November 21, 2002), Pan-African Association welcoming African refugees, immigrants.
UNHCR, (August 2007). Text of the 1951 Convention Relating to the Status of Refugees. Resolution 2198 (XXI) adopted by the United nations General Assembly. Geneva Switzerland: UNHCR. Retrieved on November 19, 2009 at http://www.unhcr.org/3b66c2aa10.html
UNHCR, (August 2007). Text of the 1967 Protocol Relating to the Status of Refugees. Resolution 2198 (XXI) adopted by the United Nations General Assembly. Geneva: Switzerland: UNHCR. Retrieved on November 19, 2009 at http://www.unhcr.org/3b66c2aa10.html
U.S. Department of Health and Human Services (2001), Annual Report to Congress, p.3.
Wadhwani, A. (Thursday, 2003). “Language gap hurts mentally ill immigrants.” The Tennessean. A Gannet Co. Inc. newspaper.
 State of Wisconsin Department of Workforce Development, Bureau of Migrant, Refugee and Labor Services. (October 18, 2005) Attachment 2 – Estimated Total Eligible Refugee Population by County/Workforce Development Area.
 State of Wisconsin Department of Workforce Development, (September 19, 2005). Volag Refugee Arrival Projection FFY 2006.
 State of Wisconsin Department of Workforce Development, (September 19, 2005). Attachment 1 – Wisconsin Refugee Chart.
 Milwaukee Journal Sentinel, February 22, 2005.
 The Milwaukee Catholic Herald (November 21, 2002), Pan-African Association welcoming African refugees, immigrants.
 U.S. Department of Health and Human Services (2001), Annual Report to Congress, p.3.