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For Refugees, American Dream Starts With Better Mental-Health Screenings

In 2010, when Wasfi Rabaa, an Iraqi native, arrived in Seattle as a humanitarian refugee, he felt “hopeless” and drained. Six years earlier, he had been tortured and maimed by kidnappers who threatened to rape his wife. He escaped to Syria, then a safe haven, where his then 11-year-old son worked in a restaurant to support the family. There, fellow exiles predicted that in America, his children would “end up as drug addicts.”
Thanks to an innovative Seattle program called Pathways to Wellness, which identifies refugees with mental health problems, Rabaa was quickly diagnosed with post-traumatic stress disorder (PTSD) and received medication and counseling. He answered a specially designed questionnaire, which takes most refugees less than 10 minutes to complete, and then was referred to a mental health center with bilingual staff. Speaking through an interpreter, Rabaa says that the intervention “brought smiles back to my family.” His son, now 20, is studying to be an engineer at a college in Washington State.
Since 1975, the United States has accepted more than 3 million refugees, and more than 58,000 in 2012 alone, according to the Office of Refugee Resettlement (ORR), a subdivision of the U.S. Department of Health and Human Services. According to a meta-analysis in the Journal of the American Medical Association, roughly 30 percent of refugees surveyed suffer from PTSD and about 30 percent battle clinical depression.
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Pathways to Wellness, a public-private partnership, is part of a grassroots trend in the last five years to address refugees’ mental health. A keystone for providers is the Domestic Medical Examination that newly arrived refugees can receive under the Federal Refugee Act of 1980. (Refugees also undergo a mandatory physical exam before they arrive in this country.) “It’s the first chance you get to explain what mental health is in the United States,” says Beth Farmer, program director of International Counseling and Community Services at Lutheran Community Services Northwest, which helped develop Pathways. “It’s the first time you get to reduce stigma.”
Funded by groups that include the Robert Wood Johnson Foundation and the Bill & Melinda Gates Foundation, Pathways to Wellness is one tool that refugee settlement organizations can use to help those who’ve fled to the U.S. for a better life. “We wanted to find refugees in distress, get them to care, and have care that works,” says Farmer, who speaks about the initiative with the palpable pride of an adoring parent.  Perhaps that’s because she spent considerable time defending her program from naysayers during its design in 2008 and 2009. “People said, ‘it’ll never work. We’ve tried it before. There are too many different languages. The stigma is too high,’” she recalls. But Pathways has proved effective and popular; more than 50 refugee aid organizations across the country and as far away as Australia have signed utilization agreements to replicate the program.
But such initiatives remain the exception rather than the rule, despite plenty of evidence that mental health screenings benefit newly arrived refugees. Many resettlement experts worry that the nationwide procedures for screening refugees for mental illness are scattershot and inadequate. Lisa Raffonelli, a spokesperson for the ORR, said it recently revised guidance to states, calling for “a head-to-toe review of all systems, including a mental health screening to assess for acute psychiatric emergencies.” The agency also plans to add one staff position devoted to the “emotional wellness” of refugees. But the federal government gives states wide latitude to design initial health exams, which were historically used to detect communicable diseases such as tuberculosis rather than PTSD or depression.
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“Some states have developed highly sophisticated programs with excellent screening,” says Ann O’Fallon, former executive secretary to the Association of Refugee Health Coordinators. “Other states, with smaller numbers of arrivals or smaller budgets, have struggled to develop a quality program.”
A 2012 survey of 44 state refugee health coordinators published in the Journal of Immigrant & Refugee Studies found that 19 states failed to screen refugees for symptoms of mental illness. Of the 25 surveyed states with screening programs, most relied on informal conversations with patients rather than screening tools tailored to assess refugees. The findings “dismayed” the study’s co-author, Patricia Shannon, an assistant professor in the School of Social Work at the University of Minnesota. She believes that proactive questioning of refugees about their trauma is common sense. “People who are in need of mental health services, like torture survivors, are not going to raise their hand and say, ‘I’m the one you are looking for over here.’”
The format of the initial medical exam varies considerably, observes Paul Stein, national president of the State Coordinators of Refugee Resettlement and state refugee coordinator in Colorado. The spectrum ranges from “bare bones minimum — no mental health included, just a health screening that’s done in one visit” to multiple visits and a comprehensive emotional health checkup, Stein says. His state recently entered into a public-private partnership to open the Colorado Refugee Wellness Center in Aurora, something of a one-stop health shop where refugees can receive a range of services, including mental health screenings and treatment. “When you come in for one service, you can access other services at the same time in the same location,” Stein says. This helps avoid the care disconnects that can occur “when you are referred across town for a follow-up appointment.”
Exactly when to schedule mental health screenings spurs debate. Some newly arrived refugees may feel like they have just won the lottery, says Greg Vinson, senior research and evaluation manager at the Center for Victims of Torture in St. Paul, Minn. He pointed out that Somalis in the Dadaab refugee camps in Kenya often refer to acceptance into the U.S. refugee program as the “Golden Ticket.” Once freed from immediate danger, many refugees experience “a honeymoon period . . . but then the issues re-emerge,” he says.
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Eh Taw Dwe, an ethnic Karen from Myanmar, knows that firsthand. As the “head man” of his village, Dwe found himself as a buffer between government soldiers and Karen rebels fighting a long and brutal conflict.
In 2002, government soldiers forced Dwe to watch four of his villagers executed. “They didn’t use a gun. They used a knife,” Dwe recalls. The soldiers imprisoned him at a military base for three days. There, an officer played Russian roulette with Dwe. “He put a gun right to my forehead. He counted ‘one, two, three’ and pulled the trigger. They laughed….” After Dwe’s family paid a ransom to his kidnappers,  he was able to escape, and marched with his pregnant wife and two young children through thick jungle to Thailand. Toward the end of the harrowing 13-day journey — he had packed only enough food for 10 days — Dwe’s infant daughter became seriously ill. “She was dying,” he says, his voice breaking. “She had diarrhea. She could not breathe. I hold my wife’s hand, and I prayed.”
His family survived, arriving in Minnesota in 2004. Dwe underwent a health exam, but it did not include a mental health screening. Within two months, Dwe got a job as an interpreter with St. Paul-Ramsey County Public Health. At first, he felt euphoric, “because I don’t have to worry that people were going to kill me.”
Then the flashbacks started, imprisoning Dwe again in his cell on the military base in Myanmar. “The words that they say are still in my ears,” says Dwe, who started having angry outbursts. He was eventually referred to the Center for Victims of Torture, one of 30 federally financed programs across the country that rehabilitate torture survivors and advocate on their behalf.
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The center, founded in 1985, treats survivors at their headquarters in St. Paul. If he had not received therapy and medication, Dwe, who now runs his own translation business, imagines that life would be very different: “Maybe I would be in jail,” he says.
Ann O’Fallon, the former head of state refugee coordinators, praises states like Minnesota and Colorado — “a really beautiful model,” she says — for devoting more resources to refugees, but she faults the federal government for collecting insufficient data on mental health screenings. “It needs to be beefed up,” she says. “What percentage of refugees get screened? Is there a requirement that states report in?”
Paul Stein of Colorado understands the human and financial toll caused by not taking action. The longer that barriers to employment, such as mental illness, are not addressed, he says, “the longer it takes for somebody to start building income and paying taxes.”
Several mental health providers concur that not acting to detect and treat mental illness in new refugees amounts to neglect; some untreated refugees likely suffer from psychosomatic illnesses and as a result overutilize emergency rooms. Patricia Shannon, of the University of Minnesota, concludes that, in general, “the high cost for repeat medical visits that are based on mental health distress is something that isn’t quantified.” Instead, she offers anecdotal evidence. When a wave of Somali refugees settled in the Minneapolis area starting in 2004, many newcomers with mysterious illnesses turned up in emergency rooms. But doctors “wouldn’t find anything wrong with them,” Shannon says. “On some of the charts, I had residents tell me that they would write ‘Sick Somali Syndrome.’”
Data showing a connection between chronic stress, PTSD and depression and long-term poor health is “overwhelming,” says Dr. Michael Hollifield, a psychiatrist who primarily designed the Pathways to Wellness questionnaire.
Hollifield does not consider improved mental health screenings a cure-all for the many challenges faced by refugees, but he is certain that it is the sensible place to start. When contemplating the issue, he says he often thinks about a classic television commercial for Fram oil filters, in which a mechanic rolls out from under a broken-down wreck with a gunked-up engine and delivers the company’s catchphrase: “The choice is yours. You can pay me now or you can pay me later.”
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