key: cord-0967388-03wepr95 authors: Brickhill-Atkinson, Micah; Hauck, Fern R. title: Impact of COVID-19 on Resettled Refugees date: 2020-10-06 journal: Prim Care DOI: 10.1016/j.pop.2020.10.001 sha: ef350ee935477dbc45ab8b15d4f37b375071ac49 doc_id: 967388 cord_uid: 03wepr95 Refugees are among the world’s most vulnerable people, and COVID-19 presents novel threats to their well-being. Suspension of resettlement prolongs persecution for those accepted but not yet relocated to a host country and delays family reunification. For new arrivals, pandemic-related modifications to resettlement services impair smooth transitions. Refugees are additionally more vulnerable to economic hardship, COVID-19 infection, and mental illness exacerbations. Communication barriers make telehealth access uniquely difficult, and children lose the school environment that is essential for their adaptation in a new country. Providers can mitigate pandemic-related harms by assessing barriers, disseminating information, and advocating for inclusive policies. The novel coronavirus SARS-CoV-2 (COVID-19) has infected nearly 13 million people and has caused over 570,000 deaths globally. 1 As the pandemic creates new challenges for worldwide communities, the refugee crisis remains another of humanity's grave tragedies. Refugees displaced due to war, violence, and oppression number 21.3 million worldwide. 2 As of April 4, 2020, thirty-four countries with substantial refugee resettlement reported local SARS-CoV-2 transmission. 3 Statistical data about the impact of COVID-19 on this population is scarce, 4 but a growing body of literature reveals that bureaucracy, poverty, and discrimination have threatened the well-being of refugees during the pandemic. 2 COVID-19 has additionally highlighted barriers to accessing healthcare for refugees, 5 who stand foremost among the world's most vulnerable people. The United Nations 2030 Agenda for Sustainable Development contains a promise to ensure no one is left behind, 3 and COVID-19 will only be controlled when all populations are included in the response. 5 Current literature highlights six themes of the refugee pandemic experience (Table 1 ) and elucidates techniques for assessing barriers and alleviating harms. Case 1: A.N. is a 30-year-old male from Afghanistan. He arrived in the United States one year ago. Soon after, his marriage to an Afghan woman was finalized, and he was assured that his wife would follow him to the US. Now, he reports significant anxiety after his wife's migration was delayed due to COVID-19. The couple was informed that reunification would be deferred for at least six months. Newly arrived refugees also face reduced volunteer and public services during the pandemic. 7 Volunteers and staff may be quarantined or restricted by government mandates, which disturb provision of resettlement resources. 2 For resettled refugees, the impact of COVID-19 manifests in part through economic hardship. Migrant groups tend to fill difficult, low-paying occupations in their host countries. 4 In a study of eight nations that house more than one third of the world's refugee population, refugees were 60% more likely to lose jobs or income due to COVID-19 than the local population. About 60% worked in the most affected occupations, such as food services and retail, compared to 37% of the host population. 11 Low income households have less ability to work remotely, which creates increased susceptibility to job loss amidst the pandemic. 12 Refugees often carry the additional burden of sending money to family in their country of origin, so pandemic-related economic hardship reaches even further than those immediately affected by job loss. 6 Refugees also face barriers in accessing public services and safety nets. The Kovler Center Child Trauma Case 2: M.K. is a 35-year-old single mother of four. She and her daughters arrived in the US two years ago, and she began working as a hotel housekeeper. She lost her job during COVID-19 and has not found new employment. Her landlord comes to the apartment for rent, evoking tremendous anxiety. The family fears eviction as funds become scarce. Program (KCCTP), which serves refugee families in Chicago, recently noted that families frequently experienced job loss and struggled to access unemployment benefits. 13 COVID-19's disease burden is higher in low income settings such as resettled refugee populations due to living conditions, comorbidities, high risk jobs, and delayed care and public health measures. The London School of Hygiene and Tropical Medicine reports that large and multigenerational households are a major reason for the disproportionate impact. 12 Overcrowded housing confers an increased risk of contracting disease, 7 and refugees often live in conditions that make hygiene and distancing impossible. 5 Management of chronic illnesses, such as diabetes mellitus and HIV, is especially challenging among refugee populations during the pandemic. 14 Patients may be afraid to leave the house and may not be able to access prescriptions or appointments. Endale et al. propose that refugees are disproportionately affected by COVID-19 due to the frequency of high risk jobs. 13 For example, a high proportion of African refugees in the US fill nursing home caretaker roles, which places them in one of the most vulnerable settings. 15 Low income families are disincentivized from infection control measures, such as staying home from work, because their livelihoods are stretched too far. 12 Refugees are vulnerable to stigma about disease transmission, which may make them fearful to disclose symptoms. 15 They may also delay seeking care due to fears of contagion or loss of legal protection. 10 Additionally, widespread testing and contact tracing are less feasible in low income settings; therefore, the current extent of disease is likely underestimated. 12 Case 3: N.D., her husband, and five children are refugees living in an apartment with one bathroom. Even pre-pandemic, sharing a bathroom caused problems such as constipation in one of the children due to withholding bowel movements. COVID-19 measures seem nearly impossible to the family in light of their crowded home. Mental health is a chief concern among refugees during both pre-and post-pandemic circumstances. Systematic reviews estimate prevalences of up to 44% for anxiety, 44% for depression, and 36% for post-traumatic stress disorder. 2 Migrants are more vulnerable to mental health risks in pandemics than the host population. 13 A 2020 literature review of international journals examined factors that worsen refugee mental health and found substantial commonality with risk factors for COVID-19. 2 Overlapping themes included overcrowding; disrupted sewage disposal; lower standards of hygiene; poor nutrition; reduced sanitation; and lack of shelter, healthcare, public services, and safety. 2 Boredom, isolation, inadequate supplies, lack of information, financial concerns, and disease-related stigma exacerbate the psychosocial effects of pandemics and quarantine. 13 Isolation and lack of control, prominent conditions in the COVID-19 setting, are known to exacerbate PTSD. Memories of forced hiding may be evoked by lockdowns and empty streets, and the pandemic may be reminiscent of Ebola and cholera for African migrants. 15 Host countries face overloaded mental health care at baseline, making them ill-equipped to adequately care for the pandemic-induced exacerbations among refugees. 2 Communitybased mental health resources have moved to remote operations, making access even more difficult. 13 Baseline shortages combined with the exacerbating factors of a pandemic set up an environment for crisis among refugee mental health patients. Case 4: S.A. is a 25-year-old female refugee with depression, anxiety, and post-traumatic stress disorder (PTSD) who presents to clinic with a chief concern of "stomach pain." During the interview, she becomes tearful as she describes increased nightmares and feeling hopeless when she thinks of her family members still in her country of exit. She fears leaving her apartment and contracting COVID-19, which evokes memories of forced hiding in her childhood. Communication is a particular challenge for refugee patients in the pandemic setting. noted that patients were sometimes unwilling to share trauma or torture histories over phone or video. 15 While the host population may rely on virtual information-sharing, refugees face added barriers in accessing these alterative communication modalities. Pediatric refugees' daily functioning has suffered during COVID-19, attributable to boredom, isolation, and loss of daily structure. 13 International Rescue Committee (IRC) Medical Case Manager Erica Uhlmann in Charlottesville, Virginia, notes a pattern of refugee parents Case 5: D.N. is a 30-year-old female refugee from Afghanistan who recently arrived to the US. She has a history of domestic abuse and fled her husband's family with her three children. In the few months since her arrival, she presented to clinic four times with vague somatic concerns, anxiety, and depressed mood. She was offered telephone therapy, as the clinic had paused in-person counseling sessions due to the health system's COVID-19 precautions. However, she is reluctant to share her traumatic experiences over the phone and reports little benefit from these sessions. She asks if she can instead participate in inperson therapy, where she would feel more comfortable discussing her trauma history. Case 6: C.K. and M.K. are 7 year old twins who arrived to the US one year ago. In clinic, it is noted that they speak and understand little English. Their mother relates that they cannot read in any language. They do not speak English at home, and they did not attend school the past four months due to closings. School closings detrimentally affect refugee children. A systematic review of factors influencing pediatric refugee mental health found that schooling is essential for their adaptation and positive mental health. A sense of belonging at school is associated with lower PTSD and higher self-esteem, while lack of school attendance correlates with externalizing behavior. Poor connectedness with a school increases risk of depression, anxiety, and somatic stress. 16 Schools also provide a vital role in language acquisition for recently resettled children. Refugee students of all ages learn academic English in four to seven years under ideal circumstances, but the interval increases to ten years with interruptions to formal education. Schools maintain an indispensable role for educating migrant students and reducing achievement disparities. 17 While distance learning may be accessible for some students, limited technological proficiency among refugee families poses a barrier to remote schooling. 13 The isolating conditions created by COVID-19 may have devastating impacts on pediatric refugee health and development. 18 The full assessment is available in Table 2 . J o u r n a l P r e -p r o o f The KCCTP offered the following resources to migrant families: exercise videos; guided relaxation and meditation; educational activities; caregiver guides; peer group video calls; virtual storybook readings; and cognitive behavioral therapy. The organization also initiated a response termed "Psychological First Aid." The approach started with information dissemination, dedicating attention to language accessibility. Next, providers turned their focus to active outreach, extensive case management, and telemedicine services. 13 The University of Virginia International Family Medicine Clinic similarly prioritized information dissemination and mailed handouts from the Centers for Disease Control and Prevention (CDC) to families in their first languages (Fern R. Hauck, MD, personal communication, July 21, 2020). Multilingual print resources from the CDC can be found at the following web address: https://wwwn.cdc.gov/pubs/other-languages. The UNHCR found that digital communication techniques are also useful for sharing information with refugees. 2 Fawad et al. discuss the unique challenges of refugee chronic disease management in a pandemic. The 2009 H1N1 influenza outbreak demonstrated the need for contingency planning in chronic disease management; deaths from stroke, myocardial infarction, and acute heart failure increased in this epidemic setting. Providers may consider extended medication supplies, especially for heart disease, HIV, tuberculosis, and contraception. 10 Policy-level mitigation can also help alleviate harms for refugees during COVID-19. For example, public health leaders in the United Kingdom call for temporary citizenship rights for all migrant groups. 4 The UNHCR recommends full healthcare service access for refugees, reminding leaders that protecting all members ultimately shields the community at-large. 10 The Center for Global Development advocates for fast-track credentialing of refugees who could J o u r n a l P r e -p r o o f contribute to the nation's health response or assist with PPE manufacturing, contact tracing, and delivery services. Allocating COVID-19 relief money to local non-governmental organizations is another strategy to meet refugee needs. Currently, only 0.07% of US COVID-19 relief funds reach these non-profit agencies that have a record of effective local community service. 11 Local and national leaders, providers, and neighbors can also mitigate harm by maintaining a posture of openness and trust. Lessons from Ebola and SARS offer reminders that engaging communities and building trust contribute to the achievement of public health measures, while stigmatization opposes success. Transparency, trust, and community partnership are essential for disease control. 10 The novel coronavirus SARS-CoV-2 poses singular challenges to the world's resettled refugee population. Suspension of resettlement prolongs suffering for refugees accepted but not yet relocated and delays family reunification, and modified resettlement agency operations create challenges for new arrivals. Refugees are particularly vulnerable to both economic hardship and severe disease in the wake of the pandemic. Mental illnesses, prevalent among this population at baseline, are exacerbated by isolative and uncertain conditions. Communication challenges make the virtual world less accessible to resettled refugees, and children suffer the consequences of boredom and loss of school resources. Refugee providers can mitigate harms by comprehensively assessing barriers faced by their patients, providing accessible information, and advocating for policies that include vulnerable populations and promote trust. • Implement questions from the Society for Refugee Healthcare Providers Guide to assess refugee patients' needs during the pandemic. • Watch for PTSD re-emergence and other mental illness exacerbations. • Offer linguistically-appropriate information about COVID-19 and preventive measures. Coronavirus disease (COVID-19) Situation Report -176 A crisis within the crisis: The mental health situation of refugees in the world during the 2019 coronavirus (2019-nCoV) outbreak COVID-19 will not leave behind refugees and migrants COVID-19: Immense necessity and challenges in meeting the needs of minorities, especially asylum seekers and undocumented migrants Global call to action for inclusion of migrants and refugees in the COVID-19 response Lost in transition Refugee and migrant health in the COVID-19 response Joint Statement: UN refugee chief Grandi and IOM's Vitorino announce resumption of resettlement travel for refugees Refugee Assistance During a Global Pandemic. Sustaining Sustainability COVID-19 in humanitarian settings and lessons learned from past epidemics Locked Down and Left Behind: The Impact of COVID-19 on Refugees' Economic Inclusion. Center for Global Development, Refugees International, and International Rescue Committee COVID-19 control in low-income settings and displaced populations: what can realistically be done? London School of Hygiene and Tropical Medicine website COVID-19 and refugee and immigrant youth: A communitybased mental health perspective Simple ideas to mitigate the impacts of the COVID-19 epidemic on refugees with chronic diseases COVID-19 and U.S.-based refugee populations Mental health of displaced and refugee children resettled in high-income countries: risk and protective factors How Schools Can Promote Healthy Development for Newly Arrived Immigrant and Refugee Adolescents: Research Priorities Guide to Assessing Barriers to Following COVID-19 Prevention Guidance Among Resettled Refugees Special thanks to Erica Uhlmann, International Rescue Committee Charlottesville Chapter case manager.