Cultural Health Practices, Political and Historical Backgrounds
“Special Immigrant Visas, Afghan Parolees, and Medical Care” (January 2022) Benjamin Cardenas, MS4
The Special Immigrant Visa (SIV) program provides a path for foreign nationals who work with
the U.S. government abroad to legally immigrate and acquire permanent residence. Special
Immigrant status is similar to refugee and asylee status in that holders leave their countries of
origin to escape persecution and threats of danger and in that they receive resettlement
assistance and many public benefits once they arrive to the U.S. The recent crisis in Afghanistan
surrounding the U.S. withdrawal of troops has complicated the special immigrant program and
created an influx of thousands of Parolees across the U.S. After processing on military bases,
Parolees receive the same public benefits and resettlement assistance as Special Immigrants.
Caring for Special Immigrants and Parolees requires an understanding of their cultures and
unique risk factors for diseases. Learning how to care for them effectively will become
increasingly important for U.S. medical providers as Parolees are transitioned from military bases
and more Afghan nationals apply for humanitarian parole going forward.
“The Biden Immigration Policy” (November 2021) Liz Harvey, MS4
When Joseph R. Biden was inaugurated, the immigration system posed one of the central challenges to his administration. Biden proposed legislation to provide a path to citizenship for the millions of undocumented immigrants who currently reside in the United States. However, migrants entering the United States continued to be turned away under laws from Biden’s predecessor, Donald Trump. Critics of Biden’s administration state he has failed to strike the balance between a humane immigration policy and controlling the influx of migrants. Biden came under fire after the withdrawal of U.S. troops from Afghanistan led to the frenzied evacuation of 123,000 Afghan refugees. This strained an immigration system already weakened by Trump-era policies, leading to challenges with resettling these new arrivals in the United States, now called parolees. The arrival of the Afghan parolees influenced the situation at the Southern border, with the Biden administration limiting the number of migrants allowed into the United States. Haitian migrants who had crossed the border into Texas were expelled from the country in September 2021, drawing sharp rebuke from immigration activists. Overall the Biden administration struggled to manage the unprecedented influx of migrants with an immigration system in dire need of reform and a legislative deadlock in Congress making it extremely difficult to enact lasting change.
“Challenges for LGBTQ Asylum Seekers” (2021) Aviva Friedman, MD
“Caring for the Afghan LGBTI+ Refugee Patient” (February 2021) Beck Jacobsen
Lesbian, gay, bisexual, transgender, and intersex (LGBTI+) individuals face varying degrees of acceptance, safety, and legal protection worldwide. In Afghanistan, same-sex relationships are criminalized, and the punishments can range from imprisonment to death. It is difficult to estimate the number of LGBTI refugees worldwide. Afghan refugees may be hesitant to disclose their LGBTI identity with their healthcare providers based on lack of acceptance of these
identities in Afghanistan; they also may not even be aware of their own identity. Regardless, gently broaching the topic of sexual orientation and gender identity (SO/GI) is still recommended with Afghan refugee patients, as this is recommended for all patients by the National Academy of Medicine and the Joint Commission. Providers are encouraged to seek out specific training to gain comfort in asking SO/GI questions, partly so they can explain why this
information is important to ask if a patient expresses concern or offense. Providers are also encouraged to reflect on how accessible and affirming their practice is for queer patients, and what steps they can take to continue to improve.
Keywords: LGBTI+, Queer Patients, Afghan Refugees, Sexual Orientation, Gender Identity
“Consanguinity: Understanding the Health Risks and Guidance for Providers” (January 2021) Alexa Tabackman
Consanguineous relationships continue to be an integral part of life in many communities across the world to this day. While no longer widely practiced in North America, and in fact expressly prohibited in many states, providers that serve refugee and other immigrant communities may continue to see patients in consanguineous relationships15. For the children of these marriages, there is an increased risk of inheritance of rare autosomal recessive conditions and other congenital malformations. It is important for primary care providers to be able to understand what may be the potential health implications for the children of their patients and be able to provide proper counseling and refer to the proper subspecialty services, such as a genetic counselor, going forward. Patients may differ widely in their knowledge and understanding about potential health risks and their perceptions of genetic counseling, so it remains key that providers tailor their approach to help when guiding patients through this delicate process and consistently engage in collaborative decision making with patients and their families for the best outcomes.
Keywords: Consanguinity, Genetic Counseling, Refugee and Immigrant Communities
“A Healthcare Provider’s Guide to the Asylum Seeker in the US” (September 2019) Emily Aladnani
Asylum seekers are those who have fled their home country and apply for protection in the United States after arriving in the United States. This is what distinguishes asylum seekers from refugees, who seek protection from the United States prior to arrival. Asylum seekers face many unique challenges when they enter the United States, including a lack of government or structural support and a pervasive fear of deportation or detainment. This is in addition to the mental and physical health effects of detainment if the asylee has been detained, as well as the mental and physical health effects of the situation that caused the asylee to leave their home country in the first place. This paper will attempt to outline these challenges in greater detail so that healthcare providers are attuned to the specific needs of this population. It will also attempt to provide several ways in which healthcare providers can better serve this unique group.
Keywords: Asylum Seekers, Mental Health, Asylees, Healthcare Providers
“Challenges in the Provision of End-of-Life and Palliative Care to Ethnic Nepali Refugees” (July 2019) Salim Najjar
After over a decade of resettlement of ethnic Nepali refugees in the United States, there is a significant elderly refugee population that will require end-of-life care. The specific needs of ethnic Nepali refugees in the US were assessed in the 5 domains of (1) social and health inequities; (2) communication; (3) disclosure and decision-making locus; (4) spiritual and religious practice; (5) advance care planning and hospice. Social and health inequities in this population have created a specific burden of chronic respiratory disease. Multidisciplinary care and individualized care plans are the cornerstones of effective respiratory palliative care. The use of trained interpreters and cultural interpretation techniques can help overcome communication challenges in cross-cultural care. The Nepali population is heterogenous in desire for illness disclosure and tend to favor family-centered decision making. Advance directives for disclosure can be considered to clarify the wishes of individual families. A respectful spiritual history and accommodation of end-of-life rituals is important to the end-of-life care of diverse populations. Nepali refugees are likely to be open to hospice and advance care planning if it is framed as supporting their ability to care for ill family members at home.
Keywords: Refugees, Nepali, End-of-life Care, Palliative Care
“Ramadan: An Overview for Primary Care Providers” (May 2019) Brittany Heck
Ramadan, one of the five Pillars of Islam, is a time for prayer, charity, and fasting. For patients with certain medical conditions, fasting may increase the risk of serious health complications. While the Quran grants certain exemptions for fasting, many Muslim patients will still choose to fast despite their acute or chronic illnesses. Because of this, it is exceedingly important for healthcare providers to understand how fasting can impact patients’ health and behaviors and to learn how to empower and educate their patients on ways to fast safely. This paper aims to equip primary care providers with knowledge about Ramadan so that they can provide the best culturally competent support to their Muslim patients who choose to fast.
Keywords: Refugees, Muslim, Ramadan, Fasting, Primary Care
“South Sudan Refugee Crisis” (November 2018) Franck Azobou Tonleu
South Sudan is currently undergoing the 3rd largest refugee crisis in the world, with over 2.5 million South Sudanese refugees, and over 1.9 million internally displaced. Many of the refugees have made their way to Uganda, Sudan, Ethiopia, Kenya, among others and are crowded into refugee camps that are not adequate enough for the high volume of people. In those camps, there is shortage of food, water, and shelters. Furthermore, overcrowding has led to high rates of communicable diseases. In South Sudan itself, food shortage has become an emergent problem as well as many disease outbreaks. It is estimated that over 7 million people are in need of humanitarian assistance. This paper will provide an overview of the history of the conflicts in Sudan leading to the current crisis, a description of the largest refugee camp, as well as the current situation in South Sudan.
Keywords: Refugees, South Sudan, Sudanese, Africa, Refugee Camps
“Attitudes Towards and Use of Contraception in the Muslim Refugee Population” (September 2018) Claire Scrivani
Contraception is an important aspect of primary care for all women. In the United States there are a variety of contraceptive options that a woman can choose from based on her individual preference. Some of the factors involved in this decision are effectiveness, side effects, religious opinions, and cultural attitudes. In the International Family Medicine Clinic, there are many Muslim refugees who use a variety of forms of contraception. This paper aims to explore the Muslim teachings concerning family planning, the use of contraception in both Muslim and refugee populations, and the potential barriers of care that affect the clinic’s Muslim refugee women.
Keywords: Muslim, Refugees, Contraception, Birth Control, Family Planning, Barriers to Care
“An Overview of Infertility in the Muslim Refugee: Psychosocial Implications and Barriers to Care” (May 2018) Simone Reaves
Infertility, defined as the inability to conceive after at least one year of regular unprotected sexual intercourse, affects approximately 70-80 million couples worldwide. Infertile couples face a variety of psychological and social consequences, and for refugee populations the distress of infertility may be exacerbated by stressful life circumstances, the cultural importance of childbearing, and multiple barriers to treatment. For Muslim refugees in particular, infertility carries significant social stigma, and religious doctrines limit the options available for treatment. This paper examines the psychosocial impact of infertility among Muslim refugees and explores barriers to care for this population.
Keywords: Muslim, Refugees, Infertility, Barriers to Care
“Preference for Female Obstetrical Providers: Approaching Muslim patients’ desire for female providers during childbirth” (March 2018) Sylvia Kauffman
This paper aims to explore the religious basis for Muslim patients preferring female providers, the perspectives of immigrant Muslim women who seek obstetric care with a female provider, the perspectives of obstetrical providers who care for immigrant Muslim women, and potential approaches to dealing with Muslim patients who prefer female obstetrical providers at the University of Virginia.
Keywords: Muslim, Refugees, Obstetric Care
“Obstetric Care in Afghanistan and How to Provide Obstetric Care for Afghan Refugee Patients in the U.S.” (June 2017) Lisa Li
Afghanistan is known to be one of the countries with the highest maternal mortality rates in the world. It is important for health care providers to understand some of the factors that contributed to poor or lack of obstetric care in Afghanistan and other factors that may continue to impede obstetric care for Afghan refugee in the U.S. A questionnaire can be given to patients at their initial visit to better understand their obstetric history, psychosocial status, and experiences and expectations of obstetric care. Insight and awareness of the Afghan culture is the first step to delivering quality care tailored to this population. Community engagement plays an important role to bridge the gap between Afghan communities and primary care and reproductive care services in the U.S. Lastly, caring for Afghan women’s emotional wellbeing is also a fundamental part of their obstetric care.
Keywords: Afghan, Obstetric Care, Afghan Refugees, Maternal Health
“Caring for Refugees: Chronic Pain and Employment” (May 2017) Charlotte Heppner
A frequent presentation to primary care doctors from any patient population is chronic pain. This can be debilitating, and in the case of the refugee, can add to job insecurity. At the same time, chronic pain can have unclear etiologies, presenting difficulty in treatment. This project aims to provide information to help providers best serve refugees with chronic pain and employment concerns.
Keywords: Refugees, Management Strategies, Chronic Pain, Employment, Low Back Pain, Knee Pain, Health Education, Social Services
“Female Circumcision: The History, the Current Prevalence and the Approach to a Patient” (April 2017) Jewel Llamas
Female circumcision, also known as female genital mutilation (FGM) or female genital cutting (FGC), is practiced in many countries spanning parts of Africa, the Middle East and Southeast Asia. Over 100 million women and young girls living today have experienced some form of FGM with millions more being affected annually. With the world becoming a smaller and smaller place via media, travel and international migration, widespread awareness (beyond the regions of its practice) of the history and beliefs that perpetuate this tradition is essential. This paper offers a guide to help practitioners understand the terminology, classifications, origin, proposed purposes, current distribution and prevalence of FGM, closing with recommendations for obtaining a history from and conducting a pelvic exam on this patient population.
Keywords: Female Genital Mutilation (FGM), Female Genital Cutting (FGC), Female Circumcision, Africa, Middle East, Southeast Asia
“The World’s Refugee Crisis: An Overview of Conflicts, Life in Camps, and Future Perspectives” (February 2017) Helena Frischtak
There are more refugees today than any other moment in time since the Second World War – an estimated 65 million. About 80% of these are women or children. Not only are refugees confined to camps for longer and longer, but there are ever growing numbers of refugees facing the prospect of life in a camp. The number of displaced people has more than tripled in the last ten years. Many fascinating and essential aspects of life in a refugee camp remain poorly understood in the developed world. In large part, this is due to a paucity of information surrounding camp infrastructure and healthcare. This essay will focus on three refugee populations. The Syrian refugee crisis has overwhelmed the world’s media, and due to the high quality information and reporting already available, is an important population to consider. In contrast, Bhutanese do not represent the largest refugee population in the world, and have significant less media attention, but have re-settled in the U.S. en masse. Finally, the Congolese, while less numerous than other African refugee populations such as the Somalis, are a strong presence at our clinic in Charlottesville.
Keywords: Refugee Camps, Syrian, Bhutanese, Congolese
“Iraqi and Bhutanese Refugees: A Brief History” (September 2014) Walid El-Nahal
This paper is an overview of the conflicts that led to the displacement of Iraqi and Bhutanese refugees, two of the main refugee groups resettled in central Virginia. Over a century ago in Bhutan, immigration of Nepali populations was welcomed to expand agricultural efforts in the country’s southern region, but the growing population eventually led to concern among Bhutan government officials, who enacted efforts to enforce Bhutanese traditions, language, and clothing among the Nepali groups. Reactionary protests led to violence in the 1990s, and by 1996, over 100,000 people had fled the country for refugee camps in southeast Nepal, living in camps for many years and ultimately resettling in countries including the United States. The number of refugees fleeing Iraq has increased since the 1980s due to multiple conflicts in the region. The Gulf War, which followed Iraq’s invasion of Kuwait, displaced up to 3 million refugees, mostly Northern Iraq Kurds and Southern Iraq Shi’ites. A later invasion and occupation of Iraq led by the United States in response to threats of nuclear power resulted in the instatement of a Shi’ite government, leading to subsequent violence from resistance groups and a flow of refugees again leaving Iraq to seek safety in neighboring countries as well as the United States.
Keywords: Iraqi, Bhutanese, Nepali, Gulf War, History, Displacement
“Learning Refugee Diets to Improve Patient Understanding of Nutrition” (July 2014) Shetal Patel
This paper explores the common diets of several refugee groups, including nutritional characteristics specific to Afghani, Burmese, Congolese, and Bhutanese diets. Descriptions of constitutive elements of each diet are coupled with cultural dimensions such as religious dietary guidelines. Government support and grocery restrictions such as SNAP, WIC, and TANF are explained. The paper also describes “a few general lexicons that may easily provide flexibility to doctors wishing to recast their nutritional guidance in familiar terms.” These linguistic suggestions for nutritional prescriptions include describing foods by hot-cold balance, relating nutrition to food colors, and using the USDA food plate visual aid. Additional resources include: Appendix I: Diet Changes and Supplementation Reference Sheets for Afghani, Bhutanese, Burmese, Congolese; Appendix II: Multilingual Nutrition Outreach Toolkits, which contains a link to nutritional information in many different languages.
Keywords: Refugee Diets, Afghani, Burmese, Congolese, Bhutanese, Nutrition, Dietary Guidelines, SNAP, WIC, TANF
“Caring for an Iraqi Refugee Population” (April 2014) Sashka Luque
Understanding Iraq’s customs and recent history are important in caring for the Iraqi refugee population, and this paper explains some of the conflict, warfare, and recent changes in governing regime that have led many refugees to flee the country. Some flee due to religious persecution, targeting based on professional status, or violence toward women and children. Others are viewed as traitors for their work with United States forces, and may receive a Special Immigrant Visa (SIV) in this situation. Many come to the US hoping for freedom, a future for their families, a stable justice system, and better medical services, but are often met with challenges including inability to establish employment qualifications equivalent to those in their home country, continuing mistrust of fellow Iraqis, and worries about their treatment as Muslims in the U.S. The paper further explores changes in Iraq’s health care system over the last several war-torn decades, physician emigration from the country, and differences between the Iraqi and US medical systems. These differences include easy and direct access to medical specialists, common use of antibiotics which do not require a prescription, and lack of preventive care. Educational opportunities, illiteracy rates, and family customs are additionally illustrated, emphasizing the need to ensure patient understanding and be sensitive to family dynamics in medical encounters. Suggestions for initial visits are provided, including labs, tests, and mental health screening that may be helpful in evaluating for common diseases.
Keywords: Iraqi, Special Immigrant Visa, SIV, Muslim, Iraqi Medical System, Family, Initial Visit, Mental Health
“Traditional Medicine Use Among Refugees in Charlottesville” (August 2011) Genevieve Ochs, Samir Panvelker
Abstract: “Objective: This study aimed to determine the extent of traditional medicine use among refugees who moved to Charlottesville and now receive care at UVa’s International Family Medicine Clinic (IFMC). The patient populations chosen for this study were Iraqi and Afghan refugees. Methods: Subjects were interviewed using a semi-structured protocol covering topics including patient demographics, the extent of their therapy and product use and their thoughts on healthcare. Results: 10 Iraqi and 9 Afghan refugees were interviewed. Some patients said they only used health treatments recommended by their providers at UVa, while others mentioned using personal remedies at home. Most common was the use of teas, often purchased from a local Afghan grocery store. Discussion: While some patients mentioned using their own remedies when mildly ill, most seemed comfortable turning to the IFMC for treatment of their health problems. Analysis is still in progress, so themes in their answers may yet remain to be discovered.”
Keywords: Traditional Medicine, Iraqi, Afghan, Home Remedies
“Smokeless Tobacco and Betel Quid Use in Southeast Asia” (June 2011) Mark Troyer
This paper presents a case report of a patient using a product called “khaini” with no awareness of its tobacco content, and further explores smokeless tobacco and betel quid practices across Southeast Asia. The discussion focuses on the home countries or interim countries of refugee populations from Bhutan, Burma, Nepal and Thailand. In these countries, smokeless tobacco products and mixtures vary in preparation and ingredients, and have many different names such as “mishri,” “naswar,” “gudhaku,” and “zarda.” Betel quid ingredients and varieties are similarly explained. The estimated prevalence of smokeless tobacco and betel quid use in several countries is shown in table and figure format. Risks and harms of smokeless tobacco and betel quid are outlined, although these are often not well-understood by users, sometimes as a result of false advertising in foreign countries. The paper emphasizes the importance of providers using open-ended questions to ask recent immigrants from Southeast Asia about use of smokeless tobacco and betel quid preparations, then to educate users of the harmful effects of their use.
Keywords: Smokeless Tobacco, Betel Quid, Southeast Asia, Bhutan, Burma, Nepal, Thailand
“Traditional Medicine of Karen, Nepali, and Iraqi Refugees” (March 2011) Joseph Huang
An examination of the background, culture, and traditional medicine practices of Karen, Nepali, and Iraqi groups, three of the significant refugee populations in Central Virginia. Challenges for providing care related to each specific population are explored. The Karen ethnic minority group from Burma often looks to Indian Ayurvedic or Chinese medicine, and believes in omnipresent spirits. There is a great emphasis on diet and herbal remedies. Nepali refugees are mostly from Bhutan and about 60% are of the Hindu religion. Health and disease are related to balance of passions and the influences of spirits, and also have much to do with karma and a person’s relation with the universe. Diet and the environment can also affect a person’s health. Distinct gender roles and lack of preventive medicine habits may present challenges in caring for the Nepali population. The Iraqi refugee population are generally well-educated, experienced in the professional workforce, and have been forced to resettle for political or religious persecution. Home remedies for a variety of ailments are common.
Keywords: Karen, Nepali, Iraqi, Traditional Medicine, Karma, Diet, Herbal Remedies, Home Remedies
“Chronic Disease Care Experiences of Meshketian Turkish Refugees” (August 2007) Svetlana Y. Lantsman
Abstract: “After many decades of displacement, violence, and discrimination the Meshketian Turks gained refugee status and were allowed to resettle in the United States. About twenty to twenty five families were placed in Charlottesville, Virginia. Many of the adult refugees suffering from hypertension, hyperlipidemia, and type 2 diabetes received treatment from the International Family Medicine Clinic (IFMC) at the University of Virginia. A number of health care providers reported that some refugees were not complying with the recommendations of their doctors (medication regiments, follow up appointments, and lifestyle modifications). In order to ascertain patients’ understanding of their medical conditions and to improve their care, twelve individual scripted interviews were conducted by a Russian speaking medical student. It was found that Meshketian Turks do not understand the concept of a chronic condition, thus explaining why so many have a difficult time complying with their doctor’s recommendations. Furthermore, it was discovered that immigration as well as other stressors significantly impact the health of Meshketian Turks.” The scripted interview questions are attached here.
Keywords: Meshketian Turks, Compliance, Chronic Disease Care, Immigration
“Pregnancy and Infant Care Experiences of Meshketian Turkish Refugees” (August 2006) Eleanor R. Grimm
Abstract: “Many of the Meshketian Turkish refugees are receiving pregnancy and infant care at the University of Virginia Health System’s International Family Medicine Clinic. As new refugees from a different culture and with previous experiences in a different health care system, they are challenged to care for their infants and themselves, and physicians are challenged to care for them in a culturally sensitive manner. This study utilized two focus groups to investigate the experiences and views of these women on pregnancy and childcare in order to improve the care that they receive at UVA. The focus group on pregnancy had two women, and the focus group on infant care had four women. A Russian interpreter was used. Common themes in both discussions were: 1) the importance of family, 2) familiarity with Western medicine, 3) approval of how medicine is practiced in the United States versus Russia, and 4) inadequate communication between UVA and refugee patients.”
Keywords: Meshketian Turkish Refugees, Pregnancy, Infant Care, Cultural Sensitivity, Family, Communication