By Stuart M Butler, Nehath Sheriff
Over 130,000 people were evacuated from Afghanistan as United States and allied troops left the country at the end of August, with more individuals and families expected to leave Afghanistan in the next few months. Many will eventually be settled in this country, though that will be a complex processing challenge and will require the coordination of multiple support programs.
A particularly pressing concern is that many of these arrivals have immediate or long-term physical and mental health conditions caused or exacerbated by their traumatic experiences. How can we best address these health needs?
Humanitarian aid groups across the country have been addressing the Afghan arrivals’ immediate needs. These groups have mobilized resources and volunteers to help ensure that individuals forced from their homes receive essential items upon arriving here—including shoes, culturally appropriate clothing, baby formula, diapers, and toiletries. Since the end of July, one such organization, Lutheran Social Services in Virginia, has reported having resettled over 665 people and expects to settle at least 10 more families each week. Meanwhile, as of October 6, more than 50,000 Afghan evacuees are at eight safe-haven military bases across the country.
Beyond immediate settlement needs, however, Afghan evacuees will require a long period of assistance and many services—from basic housing and food assistance to education and employment. Addressing health care needs will be especially important. Fortunately, there are good examples around the country of approaches to providing health care for refugees—and addressing the social determinants that impact health—that can guide efforts to assist the new arrivals from Afghanistan.
Refugee Status and Access to Health care
Many of the Afghans who assisted the U.S. war effort as translators and other roles arrive with either completed (or pending) special immigrant visas (SIV), which will allow them to become green card holders, or permanent residents. All individuals with SIV status are eligible for federal public benefits to the same extent as refugees and without any waiting period, including the Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Medicaid (or refugee medical assistance in some cases) and other Refugee Resettlement Program benefits.
Due to the emergency nature of their evacuation, however, most newly arrived Afghans—including those with pending SIV applications and those who lack immigration petitions—were authorized to enter the United States through a temporary mechanism known as humanitarian parole. This status is available to individuals affected by a compelling emergency or urgent humanitarian situation. Thanks to changes included in the congressional Continuing Resolution adopted in late September, humanitarian parolees are now eligible temporarily for the same benefits and services as refugees, including Medicaid, food assistance, and placement support. While this designation allows individuals to live and work temporarily in the United States, it does not provide a direct pathway to permanent residency—humanitarian parolees must still apply for asylum or another status.
Even with legal access to health programs, however, actually getting connected to health care services is not simple and is often a long process for newly arrived refugees. Most Afghan evacuees arriving in the U.S. have undergone basic health screenings and vaccinations, including COVID-19 vaccines. However, underlying physical and mental health needs are often not detected or addressed at these basic screenings, which focus primarily on identifying infectious diseases. Moreover, very few studies have examined how the utilization of basic health care services affects the post-resettlement health of refugees. Increased understanding of health needs and potential barriers to accessing health care of resettled refugees is thus critical for planning the allocation of health care funds for these newcomers and for improving post-resettlement health.
The need for culturally relevant health care services
Making health services available is not the only challenge. For these services to be fully effective for Afghans settling in the United States, they must be provided in a way that is sensitive to differences in culture, language, and community dynamics—with interpreters an immediate need. An appreciation of cultural difference should characterize health services to all populations, of course, but it is particularly important for new arrivals with no knowledge of the U.S. health system and U.S. approaches to health care. In a previous Brookings report, we drew attention to the importance of building trust in the health care system and being culturally competent in order to achieve good health outcomes. There are at least a few studies that attempt to identify key factors characterizing the health of Afghan immigrants in the United States—and these have influenced guidance issued by the Centers for Disease Control. Some studies do examine Afghan women’s understanding of their health, which is critically important in achieving good results. Other studies have looked at the health profiles of earlier groups of Afghan special immigrant visa holders, and will help clinics and other health organizations to focus on common health problems among the Afghan refugees. Such research generally finds that Afghans show low health literacy and a relatively high level of psychological disorders, and that they also experience high rates of discrimination when they reach the United States—all of which exacerbate the health impacts of stressors during refugee immigration.
Some promising approaches
During periods of immigration following violent unrest in other countries, certain communities and organizations in the U.S. have been quick to step up and provide culturally responsive care to individuals and families resettling here. Indeed, some well-established health clinics, such as SeaMar Community Health Centers in Seattle, WA and La Clinica del Pueblo in Washington, D.C. were launched many years ago specifically to address the health needs of arriving families with or without legal status—many of whom had been displaced by civil wars in Central America. Similarly, the Colorado Refugee Medical Center in Aurora, Colorado was established to address the unique mental and physical health needs of the Southeast Asian refugee community. For these groups, accessing health care services in the United States has historically been very challenging because of cultural, linguistic, and economic barriers; Afghan evacuees will likely face the same obstacles.
Many states are trying to reduce barriers by encouraging social and health services to collaborate and ensure a full spectrum of services is available for incoming Afghan evacuees. In Washington State, for example, the Department of Health has enabled an Afghan Evacuee Support Initiative to bring together a coalition of local and national organizations such as the Afghan Health Initiative, Muslim Community Resource Center , Refugee Women’s Alliance, and the International Rescue Committee. Each organization is uniquely positioned to address various social determinants of health, and their understanding of the cultural context of displacement has been instrumental in their success.
In Virginia, Neighborhood Health, a nonprofit Federally Qualified Health Center (FQHC), has partnered with Virginia’s three primary refugee resettlement agencies—Catholic Charities Migration and Refugee Services, Ethiopian Community Development Council, Inc., and Lutheran Immigration Social Services—to facilitate the entry of Afghan arrivals into ongoing health care and establish a primary care medical home. During its first Afghan-evacuee clinic session in September, Neighborhood Health provided school physicals and vaccines for children, adult medical exams, women’s health care including prenatal care and family planning, COVID-19 vaccines, labs, medications, and dental care. The FQHC also helped with Medicaid applications for those eligible. Neighborhood Health plans to continue to hold these clinics as humanitarian parolees begin to integrate into the community.
A Particular Challenge: Mental Health
The mental health of Afghan evacuees is a particular concern. Several studies have shown that post-migration stress threatens the mental health of refugees and impedes their assimilation and success. Studies of Vietnamese refugees who resettled in the United States after the Vietnam War, for example, found that pre- and post-migration stress related to acculturation and lack of social support manifested itself in various forms of distress in both children and adults. The impact of these experiences is very important to understand in the case of arrivals from Afghanistan, and underscores the need during the resettlement period to provide culturally sensitive mental and emotional support.
A particularly effective way of providing mental health services to refugees who may be skeptical of or resistant to these services is to provide them within other services and in a range of settings.
- Addressing mental health in schools. Schools are often the first institutions that refugee children and youth encounter, and engaging with young refugees and their families at school, rather than at home, can be a particularly successful way to provide mental health services. This is not just because existing school clinics are a convenient place to provide a range of health services, but also because parents of immigrant children—who often perceive a strong cultural stigma associated with mental health—tend to be more receptive to their children receiving these services in a trusted and familiar school clinic. The Caring Across Communities program is an example of this approach, enhancing the mental health of school-aged refugee children by fostering innovative partnerships among schools, mental health service providers, and immigrant and refugee community organizations. Another example being implemented across school districts in the U.S. and Canada is STRONG for Schools, a program aimed at building resilience among refugee students transitioning to new communities.
For approaches like the above to be effective, it is critically important for teachers, school counselors, psychologists, and administrators to be trained to support these students in their mental well-being.
Mary’s Center, an FQHC in the Washington, D.C. area is an example of a community health clinic developing a partnership with a network of schools to provide behavioral and mental health services to children. The clinic underscores the importance of appreciating a family’s cultural background in delivering care, including the importance of recognizing that parents are often disinclined to discuss the needs of their children out of a desire not to relive the trauma of the refugee experience. Once families begin to trust that the school is a safe place, however, parents typically become more open and supportive. Some school districts have taken the lead in similar approaches. In Burlington, Vermont, for instance, the Burlington School District has launched Multicultural Support Services as part of their initiative to welcome refugees into the school community. The service center includes several support programs, including Multicultural Libraries and a Parent University, to help break down stigmas and misconceptions about refugees and to promote an inclusive school culture for parents as well as students.
- Combining mental health with primary care and telehealth. Primary care plays an important role in refugee mental health care since access to mental health services generally begins with referrals from a primary care provider. To be effective, providers need to be culturally sensitive when providing mental health care or resources. So, health care providers need to become more aware of their own assumptions and preconceptions when working with refugee children, youth, and families. That often requires training and awareness programs for staff in primary care clinics that see refugee patients. In addition, some clinics, for instance Siloam Health in Nashville, have sought to become more aware of the cultural factors in serving refugees and other immigrants by assembling special teams working with community “ambassadors” to improve acceptance of their services within immigrant communities.
There are also indications that telehealth services could be promising ways to address mental health issues for refugees, although familiarity with the technology and other limitations remain obstacles. COVID-19 greatly expanded the use and sophistication of various forms of telehealth, and this will help make this tool more available for providing mental health services to new Afghan arrivals. The use of “facilitated” telehealth—in which trusted medical assistants or family members are with the patient—allows therapists to work with patients who can remain in a familiar and “safe” setting, which is particularly important for anxious evacuees.
Resettling so many arrivals over a short period will be logistically very difficult, and providing these new immigrants with culturally appropriate and effective health care will be among the more challenging tasks. The United States does not have a good track record in addressing cultural and racial differences in the delivery of health care, and this will make it harder to address the health care needs of thousands of evacuees. But fortunately for these new arrivals, the country is rich with organizations that have long focused on the special needs of immigrants and honed techniques that reflect these needs. That experience needs to guide our approach for Afghan newcomers.
 Nehath Sheriff is an unpaid volunteer and Clinic Director of the community health clinic operated by the Muslim Community Resource Center
 Discussion with Marisa Parrella and Leah Shoval, Mary’s Center. Stuart Butler is an unpaid board member of Mary’s Center.