Yale doctors ready to care for new arrivals

Injuries, disease, trauma all need attention

NEW HAVEN — As Greater New Haven gets ready to welcome a large number of Afghan refugees, the Yale Refugee Health Program will be one of the first stops on their way to resettling in America.

The medical professionals, including mental health caregivers and hospitalists, treat the usual ailments, but refugees may bring issues of trauma and psychological distress, as well as untreated diseases or injuries.

Working with Integrated Refugee & Immigrant Services, the Yale School of Medicine program offers more comprehensive services than a medical exam would, including connecting people to housing and helping children get immunized and settled in school.

“The situation is very uncertain and it’s hard to predict how many new people from Afghanistan we will get in the next weeks or months,” said Dr. Aniyizhai Annamalai, who directs adult care at the program, which is housed in the primary care center at 150 Sargent Drive.

“What we’ve been doing is basically trying to increase our capacity,” Annamalai said.

The program, begun in 2010, sees 250 or more refugees per year, depending on the number allowed by the U.S. government.

“One year we went all the way up to 800,” Annamalai said.

“We have physicians who are outside of our system who really want to help,” she said. “I’ve been working on having the right pathway in terms of credentialing and privileging.”

Medical resident trainees and students “also want to come on board,” she said.

The program also includes medical student navigators, who make appointments, pick up prescriptions and take on other tasks to help the families.

From Oct. 1, 2014, through July 31, Connecticut resettled 2,165 refugees, according to the Refugee Processing Center. In addition to IRIS, the Connecticut Institute for Refugees and Immigrants in Bridgeport resettles refugees in the state. The record was in fiscal 2016, when 819 arrived, largely from Syria and the Democratic Republic of Congo.

Other countries refugees arrive from include Eritrea, Burma, Sudan, Iraq and Somalia, according to the center. The number does not include those with special immigrant visas, Afghans who assisted the U.S. military as interpreters, drivers and in other tasks that have put them at risk from the Taliban.

Ann O’Brien, director of community engagement for IRIS, said once a refugee arrives, he or she is a legal permanent resident and is free to move from state to state, so there is no way to know how many live in Connecticut at any given time. Refugees who move into Connecticut within five years of arrival can receive services from the resettlement agencies.

O’Brien recently said the latest estimate has IRIS welcoming 700 refugees between now and September 2022, with at least 300 Afghans, likely more, in the next three months.

The Yale program is vital to the resettlement efforts, O’Brien said.

“When refugees first arrive … one of our litany of federal contract requirements is an RHA, a refugee health assessment,” which must be completed within 30 days, she said.

“We have a health care coordinator that gets apprised of a new family coming,” O’Brien said. “Once the family is assured that they’re definitely coming, I believe she may set the appointment” before the family arrives.

“Very often, refugees will have ignored many, many health conditions fleeing their country or [have] been in a refugee camp.” The Yale program will set up follow-up visits and arrange necessary medical care.

O’Brien described one refugee who had been beaten in a camp and “they just had constant jaw pain that was keeping them up at night.”

“They need help with those visits, even if they speak perfect English,” she said. “No matter what country they’re from, they need a little TLC.”

O’Brien said Yale’s program benefits the refugees because of the specialized type of medicine they need. It also is helpful because IRIS’ staff knows the patients can be seen during specified time slots, “rather than our staff being on the phone trying to book appointments. They’re wonderful partners and they help us open doors for specialist visits if something needs special attention.”

Children, besides being given a physical exam, receive their required immunizations for school. Federal requirements mean “we have to have little butts in little seats in less than 30 days,” O’Brien said.

Dr. Camille Brown, who directs the pediatric division of the program, said, “in pediatrics, what is different from adults is more of our families tend to be large families,” with as many as eight children.

“My team will help with navigating a large family” into what Brown called a “medical home,” a primary care clinic such as the Cornell Scott Hill Health Center or Fair Haven Community Health Care, which are part of a consortium at the Sargent Drive center with Yale New Haven Health.

Beyond offering primary care, “I think we see it as a little bit more … that we are supporting families with their medical needs but also their social needs.” With interpreters, social workers and others, “we have quite a multidisciplinary team,” Brown said.

“We also have the ability to work with care coordinators that can help families navigate the health care system,” Brown said. “We do a lot of outreach to the school system.” Many of the children “have had disrupted schooling or have not had schooling back at home,” she said. “They need to have their first evaluation with us before they can start school.”

Caregivers at the program “make sure the kids assimilate well,” Brown said. “They’re not only learning a new language. They’re also integrating into a new American school system.” If there are problems, school and medical teams must determine: “Is this a language issue? Is this a learning issue?”

As IRIS works to find affordable housing for newly arrived refugees, “unfortunately, we do run into lead and unsanitary living conditions here,” Brown said. And many children already have cognitive issues because of lead exposure before they arrive. “Afghanistan is one of the countries that has one of the highest lead burdens in their environment” without “access to specialists and the care that we would have here,” she said.

O’Brien said the agency does its own lead screenings of apartments it finds for its clients.

Brown said some children arrive with untreated medical conditions, including rare ones like PKU, in which a baby lacks the enzyme needed to break down an amino acid. “We’ve had a child come devastated neurologically,” she said. “There’s some simple changes in diet that could be done when a baby is born.”

In addition, the team works with the children’s “behavioral health needs, understanding the best way, culturally sensitive, culturally humble way to manage the needs of the children of the families,” Brown said.

Refugees also arrive with emotional trauma and feelings of loss. “They’ve mostly lived with extended family,” Brown said. “Only a portion of that family will be resettled. There’s fear and worry for the family members who are back at home.”

Annamalai said adults, “more than children, tend to suffer from the consequences of trauma. Children tend to be adaptable and flexible.” Refugees may carry guilt that they escaped while extendedfamily members were left behind.

“I think we’re going to see more of that now because of the situation in Afghanistan,” Annamalai said. “The U.S. does resettle people as family units … but often they’ve left a brother or a sister that are as much in danger as they were in.” The special immigrant visas given to Afghans who worked with the U.S. military to emigrate only include immediate family members.

After living in war zones and then possibly for years in a camp, arriving refugees may have untreated injuries. “We saw one family that had severe burn injuries,” Annamalai said. They required reconstructive surgery.

“In the Afghani refugees, because we’ve been seeing the special immigrant visa holders … those tend to be a little bit younger demographic” but they, too, are “vulnerable to the effects of trauma and physical injuries,” she said.

The mental and emotional traumas, as well, can be difficult for refugees. With people coming from the Democratic Republic of Congo, “sometimes we get people with more extensive traumas because of the level of the violence there,” Annamalai said. Afghans, on the other hand, may be “receiving threatening letters or their houses being bombed or family members threatened that they will be harmed,” she said.

Adult refugees come here with diseases that Americans also suffer from, including diabetes and high blood pressure, Annamalai said, but they also may have latent tuberculosis because “they were exposed at some point in their life to TB but never got the preventive treatment.” That can be treated with anti-tuberculosis drugs, she said.

“For the people coming from the Democratic Republic of Congo and Sudan, some of the African countries, we tend to see more of intestinal parasitic disease,” Annamalai said. One is lymphatic filariasis, also known as elephantiasis, caused by parasitic roundworms and spread by mosquitoes. It can cause significant swelling of the legs, according to the World Health Organization .

Refugees also worry whether they are “going to create a life here and become financially independent,” Annamalai said. “Adults are coming from a place of good professional status in their countries,” Annamalai said, finding that they can only get jobs as dishwashers or cooks here, “and especially if you’re not at least reasonably proficient in English, it is tough.”

“Beyond the refugee program, I think internal medical faculty have been very active … reaching out to the Afghan patients … even those who have been here for a while,” Annamalai said.