Afghan refugees face medical, other challenges as they settle into new home in America
Host Amber Smith: Upstate Medical University and Syracuse, New York invites you to be The Informed Patient with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. The United States accepted more than 65,000 people from Afghanistan after the U.S. and allied troops left the country, and less than a month later, Upstate's refugee health team was caring for the first families of Afghan refugees. That work continues. And today I'm talking with Dr. Andrea Shaw. She's a doctor who specializes in internal medicine and pediatrics, and she leads the refugee health team. Thank you for making time for this interview, Dr. Shaw.
Andrea Shaw, MD: Thank you so much, Amber. Happy to be here.
Host Amber Smith: Syracuse is a "sanctuary city," which means we support the arrival of immigrants and refugees. And part of that is making sure these people who are new to our community have health care. How are the refugees connected with your team at Upstate and who pays for their healthcare?
Andrea Shaw, MD: This was a big topic of discussion that was decided very quickly, as things turned very quickly in August. So mid August, when that, when the U S troops pulled out of Afghanistan and they evacuated this massive number of people, they had to figure out a safe pathway to move them along. The United States and Syracuse was not specifically built or organized for humanitarian relief effort, which is what many countries that typically shelter refugees are set up for. We don't have refugee camps. We don't have humanitarian medicine missions. We don't have a UN (United Nations) foothold that helps to support and keep people safe and support basic health needs. So the only system that we had in place, set across the United States, was a long history of resettling refugees. So the United States used that same pathway to move these 65,000 refugees.
Andrea Shaw, MD: Along the pathway that a hundred thousand refugees were already set to come on this year, which is along national organizations that have local branches like Catholic Charities and Interfaith Works, who then partner to assign families and support their resettlement needs. So among those resettlement needs is healthcare, and the federal government allows newly resettled refugees to be supported by Medicaid insurance. Each state has a different plan for Medicaid insurance. We're fortunate to live in New York State where we do have Medicaid expansion that covers most of these refugees for many years after arrival, until they're able to surpass the poverty level and provide for themselves, or be in jobs that provide them alternative insurance. So they are supported by Medicaid health insurance, and that's how we're able to provide service to them in our institutions.
Host Amber Smith: What are the first visits like? Do you, do you typically see an entire family together, or are they separately scheduled appointments?
Andrea Shaw, MD: So I've been very fortunate to have supportive staff at Upstate that have helped me to think outside of the box because most medical systems won't allow you to schedule more than two people from a family at one time, because they don't want to lose a whole clinic day, if the family can't make it. So. I said there's really no other way that makes sense for me to serve these families. They've been through a highly traumatized process. Syracuse was not the place they thought they would land months after their whole lives turned over in Afghanistan. And they come from all different backgrounds. We're getting everyone from translators who worked with the US Army, people who worked as Afghan nationals with the Army for years, people who were just medical students who jumped on the plane to get to a safer life, to people who lived very rurally in Afghanistan, who may not have been offered education or health care where they came from. So we see patients who are across this entire spread, and for them to come to Syracuse and be introduced to Western medicine, a new language, a new culture, not to mention snow, has been a big transition. So I feel like the more we can do to center our own resources, and really basically get everybody to rally together. It really takes the whole clinic to make this happen. If you don't have everybody on board, these patients aren't going to feel supported. Whether it's from the point where they first meet somebody, where you set up a live interpreter and our interpreter services helps us to get the right dialect so that we have the Pashto interpreter or Dari speaking interpreter ready when that family comes, that takes a lot of community clinic partnership to coordinate that.
Andrea Shaw, MD: So the community has to be there to help them with transportation. Our side of clinic has to be there ready to receive them. That first visit we'd like to have a live interpreter present because even though we have great interpreter services through the phone or through video, it's really hard for them to understand what's happening in the setting, when you have two parents and seven children, and you're trying to get them all through a basic health screening, a basic physical and triage any medical complaints. So the nursing staff basically it takes everybody to just step out of a standard encounter and really be there to just serve the family where they're at.
Andrea Shaw, MD: No one family that comes through is the same. No one family has the same needs. And so whether it's the dialect that we're focused on, whether it's certain medical problems that we have to triage or whether it's their social needs, even people in the clinic who get together with donations and make sure that the kids have a stuffed animal that's age appropriate to hold, or a bag full of things that their Medicaid or their food stamps doesn't cover. When you have eight children and they all need boots, how do you make that happen? So our clinic works closely with the community to coordinate around these services, and it's everything from the little things to the bigger things like making sure the Medicaid insurance is working and making sure they can get to the pharmacy, making sure they can get medicines available, working with the health department and making sure we've done public health screenings for tuberculosis and gotten people treated appropriately for parasitic diseases, all of it as part of the process.
Andrea Shaw, MD: And over the last three months, we've found a system that has gotten smoother and smoother each week. And we hope to provide Afghan families a safe place where they can come to get their medical needs met and to keep them healthy in their transition to Syracuse or whatever the step is after that.
Host Amber Smith: So, as the physician, what is your goal of this first primary care visit? It sounds like you have a lot of ground to cover.
Andrea Shaw, MD: I always tell the community it's going to take me all morning, whether you send me a family of three, or you send me a family of 11. We're just, we've got the morning, and that's what it's going to take. Because the amount of education and the amount of building bridges of trust and creating a safe space where people have never really been introduced to a system like this, where they have a primary doctor where they have a primary care medical home. They're coming from a system where they're used to only waiting until the wheels fall off or a serious problem is there, and they're going to go pay for somebody to fix something. But that model only works in America in the emergency room. And that's not the best place for these families to really get non-emergent problems dealt with.
Host Amber Smith: This is Upstate's The Informed Patient podcast. I'm your host, Amber Smith, talking with Dr. Andrea Shaw. She leads the refugee health team at Upstate. And we've been talking about settling refugees from Afghanistan into the Syracuse area.
Host Amber Smith: I wanted to ask you how often you see mental health conditions that were either caused by or exacerbated by the traumatic experience of leaving Afghanistan so abruptly.
Andrea Shaw, MD: So I should say, there's no way to predict how trauma is going to affect an individual until you're working with that individual in front of you. Because we know by definition, any refugee, no matter where you are in the world, has fled persecution. So everybody has a baseline level of some degree of trauma, but human beings are incredibly resilient, and everybody processes that trauma into the fabric of their being very differently. And it's impacted by everything in their social environment as to how they're going to cope with that. So their genetics and their environment is going to predict how they respond to that baseline of trauma. So when I teach about refugee health, we think about it like iceberg.
Andrea Shaw, MD: So the very tip of the iceberg is what we deal with when CDC and the state put forward guidelines that suggest we need to screen for these infectious diseases, because we're seeing cases of measles, we're seeing cases of hepatitis A, we are at risk of polio concern, given the fact that Afghanistan is one of the last places on earth, where wild-type polio is thought to exist. These are public health, infectious disease concerns that are at the tip of our pyramid and amongst the things that we screen for and address right away.
Andrea Shaw, MD: The middle of the pyramid or the middle of the iceberg there is really the bulk of what people who have had a lifetime of trauma and poor connectivity to regular mental health and preventive health care. They're going to identify chronic diseases. So, whether it's a lifetime of stress that puts you at higher risk for diabetes, hypertension, or heart disease, or whether it's just a lifetime of chronic stress that's changed your metabolism and puts children at higher risk of obesity once they find themselves in a food secure place, all of these are chronic diseases that we deal with in refugees. And then what sits underneath the iceberg, that's in the water, is that underlying history of trauma. And so that history of trauma and how it plays out to that individual may come forward as something that appears like a diagnosable mental health condition.
Andrea Shaw, MD: It may come forward as an impaired function that the individual has. But every individual is going to take a different path to how they're going to get through that and what's going to help them heal, or what's going to help them stay healthy or functional here in the United States. And so it certainly takes a creative team to be able to respond to the individuals of that individual's need, because there's no one... One of the residents asked me, "well, don't you just refer everybody to psychiatry when they first come into the country?"
Andrea Shaw, MD: And there's a lot of challenge taking a global population, or even a population focused from Afghanistan, and simply referring everybody to a psychiatrist when they first come in. You have challenges of language, you have challenges of culture, and you have challenges of accepting discussion about mental health and what that means to that individual and the cultural perception about mental health. And that's influenced by a lot of things -- the individual, their social environment, their religious context. So, mental health is very important to the work that we do, but it's very much tailored to the individual's need, and thankfully we have a lot of collaborative partners, both through social work and through school counselors and through a lot of people who recognize this underlying trauma and take a trauma-informed approach to how we provide care to people.
Host Amber Smith: How long do you see a refugee family as a patient? Do you become their primary care provider, or do you help them find long-term physicians that will follow them throughout their time in Syracuse?
Andrea Shaw, MD: We are one of four sites that accept new refugees to Syracuse. So Compassionate Family Medicine, Syracuse Community Health Center, and St. Joe's, and Upstate are the four sites that new refugees will come to. So we will take new refugees who have Medicaid insurance. And certainly after people move out of Syracuse or move to the suburbs or simply change their primary care doctor they will transition in whatever way works best for their family. But those who decide to stay or receive services that fit them well will stay within our group, and we just look to how we can expand that. As we move to the new ambulatory building and the Nappi Wellness Center we'll have a separate center for international health, where the providers who right now provide various levels of part-time support for this group will be able to come under one umbrella that Upstate will support in the center for international health, moving forward.
Host Amber Smith: Do you know how health care in America differs from health care in Afghanistan?
Andrea Shaw, MD: I've not been there myself, so I can't speak directly. But for the most part, many of our patients give two different answers. Those who were connected to the American forces on the ground, who either worked as translators or as engineers or consultants with the U.S. Army, said they were able to access care at U.S. Army bases. And they said that was very timely, and they liked it because they didn't have to deal with Medicaid insurance and the frustrations that they're struggling with me now on a referral process that seems to be taking longer than they wanted it to take. But then there's many others who are part of the Afghan national army or who were Afghan nationals themselves, and they said insurance was very hard to come by because any sort of national or social supported plan covered very few things. So most things you had to pay for out of pocket. And people typically just went to the doctor when they were really sick with something.
Host Amber Smith: So preventive care really wasn't a thing for some people, at least, there?
Andrea Shaw, MD: Not commonly.
Host Amber Smith: Do you have a feel for how welcomed the refugees feel in the Syracuse area? How are they settling in?
Andrea Shaw, MD: I think it's a tough transition when their lives, when they didn't expect this. I think some of them mentally had gone through the motion of, this could potentially be something someday. The fact that some of them already worked with the U.S. Army suggested an openness to that. But I think for many others, especially who were, who had lived in Afghanistan their whole lives, they did not expect their whole life to turn upside down in August. And they were not ready for their families to be split apart. So I think that's been the most jarring thing for those who are here, without a clear path forward as to how they're going to reunite their families. When you have one parent here with young children and another parent there, or another parent of missing and children that remain in Afghanistan, I think that's the hardest thing for people.
Andrea Shaw, MD: We don't have an immigration path put forward that really gives them any hope of reuniting. So even though they could take their Afghan IDs and save up and get on a plane and go back home, there is no way to bring their family to safety, and they left an unsafe environment. They just don't have a way to reunite the rest of their family. So I think that's the most unsettling thing. So no matter how friendly or how many nice faces or many of our services that open up to them, at the end of the day, as long as they're family members back home in Afghanistan are in the unsafe situation that they're in, I think it's going to be hard for them to really settle in to life here But they're doing the best they can. And I can say with certainty that they are very resilient and the children are already engaged in school, and they fully recognize... I've had families tell me, "Doc, we've spent the last 20, 30 years of our life in war. We never thought we would leave war. So to be in a place where we're not at war is an incredibly settling moment, even though we don't know what the future will bring for sure, and we don't know how to get the rest of our family to safety, we're certainly safe now."
Host Amber Smith: If anyone who's listening to this would like to help out in some way, what would you advise? Are there organizations they can connect with?
Andrea Shaw, MD: There's three organizations in town, Catholic charities, Interfaith Works and Rise, the Refugee Immigrant Self Empowerment Group are all local, community-based organizations who have been long supporting refugees who come to this area and really took up the call when the government said we have 65,000 Afghan nationals who need homes. They stepped forward, and they said, "we will stretch our staff, expand our services, do everything we can to provide them a safe new home." And so that's access to social services. That's access to safe living conditions. And a network of people that are here to really see that their transitions and safe assimilation happens. It takes a lot to do all of that and to really support people in the setting that would normally be supported in a humanitarian camp. In any other country where people fled across the border, there's humanitarian emergency relief set up and our country, even though we weren't originally set up to do this, I'd say everybody stepped forward and heard the call. Just human to human, people are all doing their best right now.
Host Amber Smith: I thank you for making time to talk about your work. My guest has been Dr. Andrea Shaw. She specializes in internal medicine and pediatrics, and she leads the refugee health team at Upstate. The Informed Patient is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York. I'm your host, Amber Smith, thanking you for listening.