Migrant and refugee health

Migration is the temporary or permanent movement of an individual from their usual place of residence to another. The reasons for migration are diverse, ranging from voluntary migration (e.g., for professional relocation, marriage, tourism) to reluctant migration (e.g., to escape poverty) to forced migration (e.g., due to war, political or religious persecution, natural disasters). Depending on the circumstances of their migration, individuals may face particular health risks, with individuals migrating reluctantly or forcibly generally having the greatest risk and disease burden due to poor health care in their previous place of residence and the physical as well as psychological stress experienced at home as well as during migration (e.g. due to war, travel via unofficial channels of transport, long and potentially perilous journeys). Migrants often face barriers to health care and discrimination in their new place of residence regardless of their socioeconomic and immigration status. The barriers are especially high for undocumented immigrants, who generally do not have access to the state health care system and must rely on volunteer work or illegal providers to meet their health care needs. Within 90 days of arrival, all immigrants to the US, including refugees, asylum seekers, and displaced persons, must undergo the Domestic medical screening program, a comprehensive medical examination aimed at identifying acute and chronic diseases, establish vaccination status, and introduce individuals to the US health care system. Just and equitable health care for migrants regardless of their status and motivation for migration benefits society by ensuring standards of public health and wellbeing that reduce the disease burden for the population as a whole.

Migration is the temporary or permanent movement of an individual from one place of residence to another for any reason. Depending on the motivation for and circumstances surrounding the relocation, migration can be categorized as voluntary, reluctant, and forced with subcategories.

• Migration/migrant: Migration is the temporary or permanent movement of an individual from one place of residence to another for any reason. Migrant is the umbrella term for any individual emigrating from their usual place of residence to another for any reason, either temporarily or permanently. Often understood to imply temporary residence in the country of immigration (e.g., for seasonal work).
• Voluntary migration: any movement from the usual place of residence, permanent or temporary, undertaken out of free will and personal initiative
  • Traveler/tourist: any individual temporarily moving their usual place of residence to another for purposes of business or pleasure
  • Immigrant: any individual moving from one country to another with the intention of longer-term or permanent residence; reasons for immigration include changes in one's course of life (e.g., marriage, professional relocation), politics (e.g., movement to a state or country that recognizes gay marriage), and personality (e.g., move to a warmer or colder climate, desire to improve an adequate standard living).
• Reluctant migration: any movement from the usual place of residence, permanent or temporary, undertaken out of free will and personal initiative but under pressure from an unfavorable situation at home
  • Economic migrant: any individual moving from a place of residence with a low standard of living seeking a better standard of living elsewhere
  • Other reasons for reluctant migration include an unfavorable political situation that does not (yet) amount to persecution (e.g., a regime change that makes persecution likely) or an environmental situation that does not amount to disaster (e.g., rising sea levels)
• Forced migration (forced displacement): the longer-term or permanent movement from one's usual place of residence to another for reasons of conflict, persecution, natural disaster, or other events that have seriously impacted the public order
  • Refugee: any individual moving from their usual place of residence to escape the circumstance that forced their migration and who is unable or unwilling to return to their home
  • Asylum seeker: a refugee seeking protection from persecution in their usual place of residence who has officially applied for asylum status
• Undocumented immigrant: any immigrant who has entered their new country of residence without the proper records and identification for admission. The motivations for entering a country without the proper documentation are diverse, and migration may, accordingly, be voluntary (e.g., to avoid the law), reluctant (e.g., economic migration without having received a working permit), or forced (e.g., due to human trafficking).

Awareness of social determinants of health, cultural differences, and the barriers to health care that migrants face can help health care workers appropriately address the needs of migrants. Just and equitable health care benefits society as a whole by ensuring public health standards that reduce the disease burden for the entire population. ^[1]

• Barriers to health care
  • Language and literacy challenges
  • Social exclusion and discrimination
  • Difficulty obtaining prescriptions and specialist care without full documentation or health insurance
  • Poor continuity of care prior to gaining a permanent place of residence
  • Poor or delayed engagement with preventative medicine strategies (e.g., vaccination and screening programs)
  • Potential for social stigma associated with diagnoses
  • For more information, see “Social aspects of health care.”
• Cultural considerations ^[2]
  • An individual's cultural background may influence their views on health and health care and affect their preferences and decisions regarding treatment.
  • To avoid misdiagnosis and provide the best possible care, health care workers should be aware of the individual's cultural background.
  • Health care workers should make an effort to recognize their own implicit biases and be respectful of their patients' cultures.
  • For more information, see “Culture in the health care setting.”

Migrants face barriers in all of the 5 As of access to health care: availability, adequacy, (physical) accessibility, affordability, and appropriateness.

The CDC has developed the domestic medical screening program as a comprehensive medical examination for individuals entering the US. This screening is carried out by designated civil surgeons. All individuals applying for an immigrant visa, including those with refugee or asylum seeker status, should receive domestic medical screening within 90 days of arrival in the United States. ^[3]

• Goals
  • Identify acute or chronic health conditions
  • Establish vaccination status and arrange for catch-up doses where necessary
  • Promote wellbeing
  • Connect individuals with routine and specialty care
  • Familiarize individuals with the US health care system
• Funding
  • Clinics are reimbursed through various programs, overseen by the Office of Refugee Resettlement (ORR).
  • To qualify for reimbursement, screening should occur within 90 days of arrival.
• Program elements
  • Screen for communicable diseases, e.g., HIV, TB, viral hepatitis, malaria, intestinal parasites
  • STI screening and contraception counseling
  • Screen for female genital mutilation (FGM) and associated medical complications (e.g., chronic pain, recurrent UTIs, obstetric complications)
  • Mental health screening
  • Pediatric nutritional status and growth assessment

When taking a patient's medical history and discussing a shared management plan, it is particularly important that the patient feels at ease. Check if they would prefer a trusted individual to be present and, where possible, find a private environment. Note that this information may already have been documented during the individual's initial domestic medical screening, and the patient's chart should be carefully reviewed prior to subsequent consultations.

• Determine whether an individual prefers to speak to a health care professional of their own gender.
• Discuss consent, confidentiality, and limits of confidentiality at the first opportunity.
• If there is a language barrier between the patient and yourself, you are required to organize an interpreter, either via phone, video, or in person.
• Provide orientation regarding the US health care system
  • The importance of routine and preventive care
  • The concept of a patient-centered medical home
  • How and when to access primary care, after-hours care, and emergency services
• Discuss preventative measures regarding wellbeing and safety
  • Access to healthy foods and local resources to tackle food insecurity
  • Use of seatbelts, helmets, and child car seats (according to state law)
  • Use of protective measures where there is a risk of temperature extremes (e.g., frostbite prevention, sunscreen use)
• Educate parents from countries where FGM is practiced that this is considered child abuse and that it is illegal in the United States.

Consider using visual aids or resources written in the individual's language, if available (see “Tips and Links” below).

In addition to a thorough general medical history, the following information should be obtained to ensure that optimal care can be delivered:

• Country of origin and route taken to current location
• Dates of travel
• Mode of travel
• Immunization history: Initiate or continue catch-up vaccination doses, if necessary (for more information, see “ACIP immunization schedule” and “Domestic medical screening program”).
• Medication history: including adherence to any treatment initiated during the domestic medical screening program
• Accommodation in initial reception facilities, shared accommodations (incl. duration/location of stays in migrant/refugee camps en route)
• High-risk incidents (e.g., insect or dog bites, open wounds, unprotected sex, and sexual violence)
• Ingestion of food or water that was potentially contaminated
• History of medical care received en route

Any consultation with a migrant offers the opportunity to continue the health promotion efforts initiated by the domestic medical screening program (see also, “Secondary prevention”). The health inequalities and barriers to health care faced by migrants at home and en route to their destination increase the risk of certain noncommunicable and communicable diseases as well as psychiatric disorders. These may include rare and nonendemic diseases that providers may not be familiar with or equipped to diagnose and treat accordingly. Where necessary, patients should be referred or transferred to a specialist for further consultation (see “Tips and Links” below for relevant resources).

Noncommunicable diseases

Noncommunicable diseases currently represent the greatest source of preventable illness, disability, and mortality among migrants and refugees. ^[4]

• Specific health consequences of migration ^[1]
  • Poor general physical health
  • Perinatal disorders: inadequate and/or late access to antenatal care increase the risk for adverse maternal; (e.g., increased rates of maternal mental health conditions and maternal mortality) and fetal outcomes (e.g., increased rates of preterm birth and congenital anomalies)
  • Cancer diagnosis and timely management: migrants are less likely than the general US population to participate in screening for cervical, breast, and colorectal cancers, increasing the risk of delayed diagnosis.

• Some conditions that merit special attention in the migrant population:
  • Cardiovascular disease (e.g., hypercholesterolemia, hypertension, ischemic heart disease, stroke)
  • Dental disorders (e.g., caries)
  • Undernutrition
  • Diabetes mellitus
  • Visual disorders (e.g., cataracts, impaired visual acuity, glaucoma)
  • Iron deficiency anemia (especially in women and children)

Communicable diseases

Communicable diseases may be acquired by a migrant or refugee either in their country of origin, en route, or in their destination country. While the increase in worldwide travel also increases the risk of pandemics, risk of communicable diseases being transmitted from the migrant population to the host population is generally low. ^[1]

• Specific risk factors: social and political factors make migrants and refugees more susceptible to contracting communicable diseases
  • Health care system inequalities: lack of access to preventative medicine, vaccination programs, prophylactic medicine
  • Unstable social situation: including access to adequate accommodation, nutrition, and exercise
  • Unstable political situation, e.g., war
• Some conditions that merit special attention in the migrant population:
  • Diseases associated with close human contact (e.g., in initial reception facilities)
    • Lice infestation and louse-borne diseases
    • Keratoconjunctivitis epidemica
    • Flea-borne diseases
    • Scabies
    • Traveler's diarrhea
  • Diseases associated with a lack of vaccination protection (e.g., influenza, meningitis, diphtheria, measles, and chickenpox)
  • Diseases endemic to countries of origin/transit
    • Tuberculosis: reactivation of latent tuberculosis, tuberculous meningitis (especially in children)
    • Parasitosis: malaria, helminth infections (e.g., schistosomiasis, hookworms, taeniasis, ascariasis)
    • Viral diseases: viral hepatitis, HIV

Rapidly arrange a blood smear in any individual arriving with a fever from a malaria-endemic region.

Mental health

It is important to determine if an individual is at risk of certain mental health problems by assessing their mood and affect (although a full mental status examination is rarely required). Traumatic experiences in an individual's past, along with uncertainty about their future, can combine to have a detrimental impact on mental health.

• General approach
  • Use empathic interview techniques with a trauma-informed approach.
  • Be aware of the impact cultural differences can have on health care (see “Culture in the health care setting” for more information).
  • Ask the patient how their experiences or physical symptoms may be affecting their mood.
• Specific risk factors: ^[1]
  • Trauma: physical or psychological
  • Abuse: physical, sexual, or psychological
  • Bereavement or loss of contact to family and friends
  • Social isolation
  • Cultural displacement (for more information, see “Cultural concepts of distress”)
• Some conditions that merit special attention in the migrant population:
  • Acute stress disorder
  • Post-traumatic stress disorder (PTSD)
  • Adjustment disorder
  • Anxiety disorders
  • Major depressive disorder
  • Survivor's guilt
  • Cultural syndromes

Refugees are more likely than the general population to experience mental health problems, with unaccompanied minors being the group most at risk of depression and PTSD.