refugee health in the united states refugee health in the united states refugee health in the united states focuses on the health, treatment, and healthcare barriers of migrants to the united states who have relocated from their country of origin, often because of factors such as political instability, war, or natural disaster. special considerations are needed to provide appropriate medical treatment for these individuals, who often face extreme adversity, violent and/or traumatic experiences, and travel through perilous regions. such considerations include screenings for communicable diseases, vaccinations, posttraumatic stress disorder, and depression. this article is about refugee health in the united states. for refugee health globally, see refugee health. a nurse tends to a woman in an arizona migrant camp, 1961. the united states has rigorous health screening guidelines for refugees and immigrants entering the country. the 1980 federal refugee act enabled the us public health service to facilitate health screenings for all immigrants and refugees before they depart their country of origin. the screening effort is overseen by the office of refugee resettlement (orr), housed in and funded by the u.s. department of health and human services (hhs). both in their countries of origin and after arriving in the u.s., refugees often face obstacles in accessing medical care. in their countries of origin, weak healthcare infrastructure and a scarcity of medical resources may prevent them from obtaining needed care prior to their departure. often, that lack of adequate healthcare contributes to an increased likelihood of major diseases as compared to other immigrants. upon arrival in the u.s., healthcare barriers including cognitive, structural, and financial barriers can limit access to timely, appropriate, and culturally competent care. programs like video interpretation services, preventative care, and english language classes have been suggested to combat these barriers. special health considerations for refugees because of the often hasty circumstances of their departures from their origin countries, refugees usually lose access to their medical records, and continuity of care is difficult to establish upon entry to the united states. in addition, the living conditions of resettlement or housing insecurity upon coming to the united states further impact refugees' health by inserting them into communities or situations where access to care is limited. this is a significant problem, especially for refugees with chronic and mental health conditions. unlike most of the immigrant population, refugee health is of particular concern because the conditions of their immigration include experiences that may negatively impact their physical or mental health. further, after arrival in the u.s., refugees may face obstacles to accessing care because of limited english proficiency and uncertainty of how to navigate the u.s. healthcare system. once accessing care, ensuring that the treatment refugees receive is culturally appropriate may serve as another obstacle to maintaining a healthy life after resettlement. there are various barriers to both accessing healthcare and achieving treatment or services that many refugees experience upon entering the country. in efforts to access care, having the correct documentation may make it difficult to qualify for care in the first place. with documentation, navigating the healthcare system and their health insurance policies can make obtaining treatment confusing and difficult. the us health insurance system is complicated - especially for refugees - in that they only receive 8 months of general care after resettlement and there are many different federal, private, and nonprofit organizations that are involved in this process. if individuals need any form of more specialized care, it is difficult to obtain. once gaining coverage, utilizing the available care introduces other obstacles. language may serve as another complication, because if an individual is unable to communicate with their medical provider, receiving appropriate treatment is difficult. having access to an interpreter and one that speaks the appropriate language is generally uncommon. many find it difficult to have the money and the means of transportation to get coverage and treatment, as well. in the case of treatment, especially among individuals with chronic or mental health conditions, having care that is culturally appropriate can impact the refugee experience with healthcare too. differences in cultural background and experience can mean that refugees may have different ideas about when to ask for care, assessing health concerns and associated treatment. as a result, many refugees are less inclined to access care because the united states healthcare model may not align with their cultural beliefs or values. in a 2017 study, a somali woman's struggle to get pills that were kosher in order to respect her religious beliefs is an example of how culturally appropriate care and treatment is a barrier to refugee individuals adequately being treated by the healthcare system. with these barriers in mind, there are steps being taken to improve the process for acquiring care and promote a positive healthcare experience. for instance, there are individuals who act as "cultural brokers" to help refugees to access medical services, locate pharmacies, learn about their medications, and schedule follow-up treatment. establishing communication between policymakers, frontline providers of refugee medical care, and refugees can allow for improvements in refugee health policy outcomes. also, making sure that refugees receive continuing, thorough assessments of their mental and physical health, health promotion materials in their own language, and access to specialist services (especially in cases of torture or violence) can improve the standard of health among refugee populations. the main healthcare refugees receive is public insurance rather than private, and the majority of this healthcare is available immediately upon arrival and resettlement, but is harder to access later down the line. mental health as of 1997, states are required to provide a comprehensive health screening for all newly arrived refugees in the united states, which includes a mental evaluation, as well as a physical examination. this approach has resulted in a significant number of mental health referrals and treatments, indicating a need for increased psychological support for newly arrived refugees. the most frequently diagnosed mental condition in refugee populations is post-traumatic stress disorder (ptsd), which is commonly a result of violence. experts have found that drug therapy, through the use of serotonin uptake inhibitors, as well as cognitive therapy have been effective treatments during resettlement. however, there still exists a lack of culturally appropriate psychiatric care that prevents adequate treatment. the mental health of refugees remains an issue long after their resettlement in the united states. refugees often experience further mental trauma after migrating due to hostility from native citizens, or even authorities at detention centers and ports of entry, which is further exacerbated by long wait times for asylum application decisions. this process generally takes anywhere from 18 months to well over two years. in a study of cambodian refugees (one of the largest refugee groups in the united states), it was found that, despite the passage of more than two decades since the end of the cambodian civil war and refugee resettlement in the us, members of the group continue to have high rates of psychiatric disorders associated with trauma. within the cambodian refugee group, higher rates of ptsd and major depression were associated with factors such as old age, having poor english-speaking proficiency, unemployment, being retired or disabled, and living in poverty. researchers have identified a number of factors contributing to mental illness in refugee populations, including language barriers, family separation, hostility, social isolation, and trauma prior to migration. however, few doctors in the us are equipped to address these issues, and thus, there have been calls for a refugee-specific strategy for health care that ensures equal access to services for refugees, as well as universal training for physicians to handle refugee-specific conditions and circumstances. several barriers prevent western mental health protocols and categorizations from effectively evaluating and treating refugees. for example, bereavement and demoralization are often labeled as depression in western mental health. moreover, access to mental health resources is often time-limited for newly arrived refugees, which poses another challenge for health professionals attempting to deliver effective and culturally appropriate care, which takes into account the unique history and cultural diversity of the refugee population. according to a study in 2013, latino (mexican, cuban, puerto rican, or other) women were significantly affected by pre-migration measures (migration itself and unplanned migration) that resulted in higher levels of psychological distress, but not latino men. the study also found that both men and women were more likely to report fair or poor physical health if they migrated to the united states in an unplanned manner. dental health poor oral health is the most common health-related issue among refugee children and is the second most common health issue among refugee adults. poor oral health has a negative effect on quality of life and can increase the risk for chronic diseases through common risk factors mechanism dental caries, or tooth decay puts refugee children at a higher risk for experiencing oral pain, abnormal eating patterns, slow weight gain, speech issues, and learning difficulties. refugees from hispanic and asian origins are at the highest risk for dental caries, followed by those from african, eastern european and middle eastern countries. refugee children in the u.s. have been shown to have poorer oral health on average, due to many factors including country of origin, parent knowledge, inevitable diet change, access to traditional oral health tools from their home country, time spent in refugee camps, english language skills, and access to dental care once in the u.s. in the larger u.s. population, access to preventative and restorative dental services plays an important role in oral health status. due to the complexity of these barriers, oral health problems are often diagnosed late and children receive little aftercare. health access is influenced by factors such as limited literacy, socioeconomic status and insurance. there is limited evidence supporting current oral health interventions for refugee children in the united states, with lack of participation being a major barrier. lead poisoning lead poisoning is an important health issue for children all around the world. the prevalence of elevated blood lead levels (i.e., blls ≥ 10 µg/dl) among newly resettled refugee children is substantially higher than the 2.2% prevalence for us children. a 2001 massachusetts study found as many as 27% of newly arrived refugee children with elevated blls, making refugees one of the highest risk groups. refugees may be exposed to lead from a number of sources which can include: leaded gasoline, herbal remedies, cosmetics, spices that contain lead, cottage industries that use lead in an unsafe manner, and limited regulation of emissions from larger industries. the detrimental effects of lead on children may occur with no overt symptoms and blood lead testing is the only way to determine exposure or poisoning. lead poisoning is typically treated by identifying the lead source, eliminating that source, and regularly receiving testing to ensure that blood lead levels are decreasing. for extremely high blood lead levels (i.e., blls ≥ 45 µg/dl), chelation therapy may recommended for refugee children. the cdc recommends lead testing for newly arrived refugee children younger than 16 years of age. guidelines for testing vary among states, ranging from testing children younger than six years of age to the cdc age limits of testing those younger than 16 years of age. infant mortality a study done in 2007 found that infants born to mexican-immigrant women in the united states had a 10% lower mortality rate than infants born to non-hispanic women in the united states. this research further support for the hispanic paradox. although palestine refugee communities face socioeconomic hardship and have high fertility rates, their infant and childhood mortality rates are among the lowest in the arab world. the causes of neonatal mortality among palestine refugees are proportionally similar to those found in the most developed regions of the world. non-communicable diseases are the leading causes of infant, and particularly neonatal deaths, among palestine refugees, as they are among industrialized countries in europe and north america. poor oral health has a negative effect on quality of life and can increase the risk for chronic diseases through common risk factors mechanism. poor oral health has a negative effect on quality of life and can increase the risk for chronic diseases through common risk factors mechanism. diet us refugees have elevated rates of chronic diseases, including obesity, diabetes, hypertension, malnutrition, and anemia, compared with us-born residents or first-generation immigrants. first, refugees encounter language barriers: they need