“Refugees are mothers, fathers, sisters, brothers, children, with the same hopes and ambitions as us—except that a twist of fate has bound their lives to a global refugee crisis on an unprecedented scale.” – Khaled Hosseini

The global refugee crisis represents a critical public health concern that requires comprehensive attention to the healthcare needs of this vulnerable population. In the world today, over 37 million people are recognized as refugees under the mandate of the United Nations High Commissioner for Refugees (UNHCR, 2024). Unlike other immigrants, a refugee is someone who has been forced to flee their country because of persecution, war, or violence. A refugee has a well-founded fear of persecution for reasons of race, religion, nationality, political opinion, or membership in a particular social group (UNHCR, 2024). This perpetual fear not only drives displacement but also creates profound psychological and physical stress that can present as a weakened immune system, exacerbated pre-existing health conditions, a multitude of mental health disorders, and more (RHTAC, 2022). As such, this population comes with a vulnerability to health issues stemming from a complex interplay of multidimensional factors.

As many as 125,000 refugees have been allowed to resettle in the United States annually during the past three years and the responsibility of addressing their healthcare needs falls on our medical professionals (Ward & Batalova, 2023). However, without adequate training in effectively working with people of different cultures and languages and without background knowledge about the refugee experience, many healthcare providers may inadvertently subject their refugee patients to insufficient care, hindering these patients from achieving optimal health. This gap in care is not a reflection of the physicians’ expertise, but rather an indicator of the layers of challenges that impact refugee healthcare. As a refugee healthcare intern at World Relief, a refugee resettlement agency, I gained a firsthand perspective on the challenges and gaps within the healthcare system serving refugees. The importance of addressing these challenges became evident as I recognized how language barriers, cultural differences, and the toll of displacement complicate the delivery of effective health care, underscoring the multidimensional health vulnerabilities of refugees. Building on these insights, this paper will examine the multifaceted factors of the refugee experience and highlight the crucial need to address these issues to ensure that refugees receive the equitable care they deserve.

Exploring the origins of refugee displacement is crucial, as the reasons why most refugees flee often shape the specific health challenges they face. Over the past 3 years, most refugees coming to the US were originally fleeing from Myanmar, Afghanistan, Ukraine, and the Democratic Republic of Congo, driven primarily due to wars and pervasive violence in these countries (Ward & Batalova, 2023). The circumstances in these regions have left refugees with a considerable lack of resources, ranging from food and medical supplies to basic human rights and education, that forced them to flee. Consequently, many “refugees have experienced imprisonment, torture, loss of property, malnutrition, physical assault, extreme fear, rape and loss of livelihood”, resulting in significant trauma both physically and mentally before they have even begun the journey to leave for another country (RHTAC, 2022).

The journey in getting to their final host country is equally challenging, evidenced by over 28,000 recorded deaths in the Mediterranean Sea and over 15,000 across transit routes on the African continent in the last 10 years (Migration Data Portal, 2024). These figures, stemming from starvation, violence, and diseases that go untreated due to lack of resources, likely underrepresent the true scale of the crisis. Those who survive and reach refugee camps or their final host country carry with them the physical and mental pains of the refugee experience which may have lasted anywhere between a few days to several years. Further, refugees with pre-existing conditions, such as cardiovascular disease and diabetes, face exacerbated challenges due to disrupted treatment and management during this arduous journey.

Upon reaching their host country, the trauma of displacement and the “misanthropic actions of others” continues to impact refugees’ lives, having “significant implications for health and for their ability to develop trusting interpersonal relationships”, which are critical to resettlement and healing (Yeo et al., 2024). This can pose a serious challenge when refugees arrive in the US, as hesitancy to trust outsiders, especially those from a different cultural background and primary language, may hinder the formation of effective relationships with healthcare providers (Vella, White & Livingston, 2022). Consequently, this mistrust can become a detrimental barrier to obtaining effective treatment for the “communicable diseases and chronic and mental health conditions” that refugees have accumulated throughout their journey (Yeo et al., 2024).

To overcome these barriers, professionals working with refugees should implement culturally sensitive training programs, designed to educate them about the cultural norms, values, and traditions of the common diverse populations they serve. Such training equips providers to better understand the cultural stigmas surrounding certain illnesses, such as mental health disorders, which are often misunderstood or ignored in some refugee communities. Although these programs are relatively new and require further research to assess long-term impacts on patient outcomes, a meta-analysis of existing cultural competence training programs found “improvements in patient perceptions of health providers' cultural competence”, highlighting the training’s potential (Vella, White & Livingston, 2022). Additionally, by practicing patient engagement strategies to build trust, and by recognizing that it may take multiple visits for refugees to feel comfortable opening up, physicians have the opportunity to improve the health outcomes of their refugee patients.

Cultural differences profoundly influence how refugees often engage with and perceive healthcare, eliciting significant variations in how they receive and respond to medical care within the Western healthcare system. Many refugees arriving in the U.S. have “limited awareness of preventive healthcare” and face a “high prevalence and suboptimal management of chronic conditions” (Yeo et al., 2024). This is primarily due to the “lack of established healthcare systems for regular screenings of chronic diseases and conditions” in their home country (Yeo et al., 2024). While these challenges are not universal and can vary widely depending on factors including whether the refugees come from urban or rural areas, healthcare providers and resettlement agencies have observed that many refugees are unaccustomed to the Western health delivery model “characterized by preventive care, referrals to outside specialists, and multiple follow-up appointments”, simply because they weren’t exposed to it (Yeo et al., 2024). Thus, a large majority of refugees are approaching healthcare with different expectations and a different understanding of what the process entails compared to that of the providers treating them. For instance, a common challenge faced by physicians is helping refugee patients understand that feeling well does not necessarily mean they are healthy. This can become problematic in the management of chronic conditions like hypertension or diabetes, where refugee patients may not see “any reason why they should continue to take their medication” if they no longer experience symptoms (Yeo et al., 2024).

Understanding these cultural differences is essential for healthcare providers to build trust and effectively communicate with and teach their refugee patients. The traditions and norms of the Rohingya and Afghan communities, for instance, illustrate how unique cultural factors influence their health outcomes and interactions with medical professionals. Both communities predominantly follow Islam, and religious practices such as fasting during Ramadan, where Muslims abstain from food and drink from sunrise to sunset, can impact medication regimens and treatment for food intake-related diseases like diabetes (Attum et al., 2023). Additionally, cultural norms surrounding modesty and gender roles lead to the need for patients, especially females, to be matched with providers and interpreters of the same gender to ensure comfort and respect (ADHS, 2015).

Privacy is another significant cultural value in both Rohingya and Afghan communities, with refugees from these backgrounds potentially feeling reluctant to share personal information about their families with providers and interpreters. This can hinder effective communication and care if doctors are not aware of pertinent family history information. Additionally, there is a strong emphasis on family-centered decision-making when it comes to healthcare decisions in both Rohingya and Afghan communities, which contrasts with the US healthcare system’s focus on patient autonomy (ADHS, 2015). To prevent this difference from causing delays in care or conflict, healthcare providers should be aware that refugees may prioritize family input over individual medical advice.

Mental health is an additional area where cultural differences play a significant role in access to care. In both the Rohingya and Afghan cultures, seeking help for mental health issues “is very stigmatized and is often considered a last resort”, with the Rohingya language lacking even a specific term for mental health (Tay et al., 2019). This stigma is particularly concerning given that “the prevalence of depression may be as high as 73% for Afghan women and 59% for Afghan men” (ADHS, 2015). For a population with such heavy trauma, untreated mental health issues can have serious implications for their physical health. Therefore, more healthcare providers should be trained in trauma-informed care to better address these complex needs. Further, traditional beliefs in both cultures may lead to preferences for prayer-based treatments or “home remedies made from boiling herbs and plants over Western medicine”, driven by skepticism and unfamiliarity with our healthcare system (ADHS, 2015). This preference can affect patients’ willingness to accept certain treatments or adhere to medical advice, ultimately impacting their overall health outcomes.

Upon arrival in the United States, refugees often face a healthcare system that, despite its resources, struggles to meet their complex needs due to gaps in cultural competence and systemic barriers. Many refugees come from areas with a broken healthcare system leaving them without access to functioning primary care and preventive healthcare services (Yeo et al., 2024). As a result, “refugees may be confused when their doctor recommends screenings, labs, or other preventive care options they are not accustomed to”, often leading to a lack of follow-up, as back home, “scheduling medical appointments was unnecessary because hospitals served as central locations to see patients, obtain laboratory tests, and acquire prescribed medications (Yeo et al., 2024). However, in the US, refugees must find a primary care provider, schedule appointments, pick up medication or undergo laboratory tests from different locations, and handle complicated tasks such as medicine refills, referrals for specialty care, or addressing medical billing errors all on their own. Navigating the complexity of the US healthcare system proves to be a significant challenge for them, leading to delayed care. Furthermore, a study examining insurance coverage among refugees in the US discovered that 49 percent of them lacked insurance, further exacerbating their difficulties in accessing care as there are very few clinics that offer affordable care for uninsured patients (Yeo et al., 2024). For many refugees, particularly those who have spent a significant amount of time in refugee camps, arriving in the US marks the first time in years, if not decades, that they have had access to a quality doctor and received a diagnosis for long-term health conditions they were previously unaware of. This sudden exposure to a formal healthcare system underscores the urgent need for culturally competent care and better support mechanisms to ensure refugees can effectively understand the ins and outs of the process to effectively manage their health in their new environment.

Overall, it is clear that many factors contribute to the healthcare outcomes of refugees. Addressing this increasingly prevalent public health issue requires medical professionals across all disciplines to be trained in cultural competency measures and the basics of the refugee experience, enabling them to better understand and connect with their refugee patients. This training is essential for delivering equitable and compassionate care, ensuring that the unique healthcare needs of refugee populations are met with the sensitivity they deserve. Practical measures, such as those taken by Sinai Antillas Clinic, a refugee-focused clinic that hires staff who speak refugee languages and offers in-person interpretation, or the use of cultural centers like the Rohingya Cultural Center to host health classes in a familiar setting, demonstrate how healthcare accessibility can be improved through community partnerships. Furthermore, during my internship as a refugee healthcare intern at World Relief, a protocol was implemented to remind clients of upcoming appointments via interpreter phone calls rather than standard text reminders, highlighting a simple yet effective strategy that should be adopted broadly to better serve patients who speak English as a second language to increase healthcare follow-up.

While it may seem easier, both financially and logistically, to overlook this issue, we must advocate for the well-being of this vulnerable population within our healthcare system, especially given all the hardships they have endured to reach safety in our country. Moreover, a recent study by the U.S. Department of Health and Human Services has shown that refugees significantly contribute to our economy, with a nearly $124 billion positive fiscal impact in the past 15 years, further reinforcing the value of investing in their care (USHHS, 2024). Refugees, like all of us, have hopes and ambitions; they deserve the same quality and attention of care as anyone else to realize these aspirations, even if it demands additional effort from the community. With ongoing global conflicts and the growing impact of climate change, the number of displaced individuals seeking refuge is likely to only rise, making it even more crucial to address how to effectively care for them. If physicians and other healthcare providers commit themselves to this standard of care, they will not only fulfill their ethical obligations but also strengthen the healthcare system and society as a whole.

Notes

1. Conflicts of interest: The author has no conflicts of interest to disclose.