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Refugee Health Care

An Essential Medical Guide

Aniyizhai Annamalai
Editor
Second Edition

123
Refugee Health Care
Aniyizhai Annamalai
Editor

Refugee Health Care

An Essential Medical Guide

Second Edition
Editor
Aniyizhai Annamalai
Departments of Internal Medicine & Psychiatry
Yale University School of Medicine
New Haven, CT
USA

ISBN 978-3-030-47667-0    ISBN 978-3-030-47668-7 (eBook)

https://doi.org/10.1007/978-3-030-47668-7

© Springer Nature Switzerland AG 2020

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation,
broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
does not imply, even in the absence of a specific statement, that such names are exempt from the relevant
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The publisher, the authors and the editors are safe to assume that the advice and information in this book
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Dedicated to all those who suffer persecution
in any form
AND
To my family who taught me to be sensitive
to those who suffer injustice
Preface

Refugees have always been a part of human existence for as long as we’ve had wars
and political instability. Refugee health as a medical discipline has only advanced in
the last few decades. Refugees are found all around the world and consequently,
clinical care occurs in a multitude of settings. However, much of the research in
refugee health has tended to be in resettled refugees. Consequently, evidence based
guidelines for treating refugees have been developed in the USA and other countries
that resettle the majority of refugees. Refugee health as a field is growing rapidly as
evidenced by the formation of the Society of Refugee Healthcare Providers and the
large attendance at the annual North American Refugee Health Conference
(NARHC).
Political changes affect refugee migration and resettlement, and refugee numbers
may be high or low at any given time. But numbers change quickly and clinical
providers more likely than not will encounter people who have migrated from
regions of conflict and experienced persecution. Refugees are a heterogeneous
group as they originate from different parts of the world and each refugee’s path to
resettlement is different. Risk factors for illness are not uniform among all refugee
populations, but there are some shared features among those who have experienced
being a refugee.
Refugees come from parts of the world where illness demographics are often
different from those of the countries they resettle in. Certain infectious diseases and
nutritional deficiencies are more common in some countries of origin. Increasingly,
we are also seeing refugee populations with a cardiovascular risk profile compara-
ble to that of the western world. Chronic pain is a common condition in many refu-
gees. By nature of the refugee experience, they acquire many risk factors for mental
illness. Regardless of the particular health conditions they experience, provision of
culturally sensitive care is of paramount importance for this culturally heteroge-
neous population.
Primary care providers are usually the first point of contact for refugees within
the US health care system when they are seen for a screening medical examination
soon after arrival in the country. The book is intended as a reference book for these
primary care practitioners as well as mental health professionals who treat refugees.

vii
viii Preface

As in any area of medicine, knowledge base is expanding rapidly and recommenda-

tions are constantly updated. Senior experts in the field have gathered together the
latest evidence based information for busy clinicians to use when seeing refugee
patients. In this edition, we have split the section on chronic pain as a separate chap-
ter from chronic disease management, reflecting the vast amount of material in
these areas. We have also added an additional chapter on care at the end of life for
refugees.
In addition to clinical use, this book can also be a reference text for refugee and
immigrant health curricula in health professional schools including medical schools,
residency programs, and public health schools.
Refugees are a uniquely vulnerable population. With appropriate support, many
refugees can and do succeed in their new society. Providing appropriate physical
and mental health care can go a long way in helping refugees in their journey to a
healthy and productive life. My hope is this book will contain the necessary infor-
mation for professionals who provide health care for refugees.

New Haven, CT, USA Aniyizhai Annamalai

Acknowledgments

I want to thank Springer Science + Business Media for inviting me to update the
first edition of this book and for patiently waiting for me to complete the work. I am
very grateful to all the experts who have contributed to this book and been gracious
with their time. I thank them and the community of refugee health care providers
from whom I have learned much. I appreciate all the hard work of the Yale residents
without whom I could not sustain a clinic for refugees. Finally, I thank my family –
my mother, father, sister, and husband – for their support and encouragement not
only in my work with refugees but in everything I do.

ix
Contents

Part I Introduction
1 Introduction to Refugees ������������������������������������������������������������������������    3
Kelly Hebrank and Alexine Casanova
2 Culturally Appropriate Care������������������������������������������������������������������   17
Aniyizhai Annamalai and Genji Terasaki
3 Domestic Health Assessment������������������������������������������������������������������   29
Aniyizhai Annamalai and Paul L. Geltman
Part II Infectious Diseases
4 Immunizations������������������������������������������������������������������������������������������   45
Julia Rosenberg, Erika Schumacher, and Camille Brown
5 Tuberculosis����������������������������������������������������������������������������������������������   63
Andrew T. Boyd
6 Parasitic Infections����������������������������������������������������������������������������������   75
Megan Shaughnessy, Anne Frosch, and William Stauffer
7 Viral Hepatitis������������������������������������������������������������������������������������������   97
Douglas J. Pryce
8 Malaria������������������������������������������������������������������������������������������������������ 119
Kristina Krohn and William Stauffer
9 HIV and Other Sexually Transmitted Infections���������������������������������� 127
Amir M. Mohareb and Emily P. Hyle
Part III Primary Care
10 Chronic Disease Management���������������������������������������������������������������� 143
Bryan Brown, Astha K. Ramaiya, and Peter Cronkright

xi
xii Contents

11 Chronic Pain�������������������������������������������������������������������������������������������� 169

Bryan Brown, Astha K. Ramaiya, and Peter Cronkright
12 Palliative and End-of-Life Care�������������������������������������������������������������� 181
Alexandra Molnar and Margaret Isaac
Part IV Mental Health
13 Risk Factors and Prevalence of Mental Illness�������������������������������������� 195
Paula C. Zimbrean and Rabin Dahal
14 Mental Health Screening ������������������������������������������������������������������������ 215
Susan Heffner Rhema, Sasha Verbillis-Kolp, Amber Gray,
Beth Farmer, and Michael Hollifield
15 Treatment of Mental Illness�������������������������������������������������������������������� 229
Andrea Mendiola Iparraguirre, Maya Prabhu,
and Aniyizhai Annamalai
16 Torture and Violence�������������������������������������������������������������������������������� 241
Mara Rabin and Cynthia Willard
Part V Special Groups
17 Women’s Health �������������������������������������������������������������������������������������� 259
Geetha Fink, Tara Helm, and Crista E. Johnson-Agbakwu
18 Primary Care of Refugee Children�������������������������������������������������������� 285
Sural Shah, Meera Siddharth, and Katherine Yun
19 Medical Evaluation of Asylum Seekers�������������������������������������������������� 303
Katherine C. McKenzie

Index������������������������������������������������������������������������������������������������������������������ 311
Contributors

Aniyizhai Annamalai, MD Departments of Internal Medicine & Psychiatry, Yale

University School of Medicine, New Haven, CT, USA
Andrew T. Boyd, MD Division of Global HIV and TB, Centers for Disease
Control and Prevention, Atlanta, GA, USA
Bryan Brown, MD General Internal Medicine, Yale School of Medicine, New
Haven, CT, USA
Camille Brown, MD Yale School of Medicine, New Haven, CT, USA
Alexine Casanova, BA, MA Integrated Refugee & Immigrant Services (IRIS),
New Haven, CT, USA
Peter Cronkright, MD Upstate Medical University, Medicine, Syracuse, NY, USA
Rabin Dahal, MD Department of Psychiatry, Yale University, New Haven, CT, USA
Beth Farmer, LICSW International Rescue Committee, Refugee, Asylum, and
Integration Programs, Seattle, WA, USA
Geetha Fink, MD, MPH Obstetrics & Gynecology, Swedish First Hill Medical
Center, Seattle, WA, USA
Anne Frosch, MD, MPH Department of Medicine, Hennepin Healthcare,
Minneapolis, MN, USA
Department of Medicine, University of Minnesota, Minneapolis, MN, USA
Paul L. Geltman, MD, MPH Boston University School of Medicine, Department
of Pediatrics, Jamaica, MA, USA
Massachusetts Department of Public Health, Division of Global Populations and
Infectious Disease Prevention, Jamaica, MA, USA
Amber Gray, PhD Restorative Resources Training and Consulting, LLC, Santa
Fe, NM, USA

xiii
xiv Contributors

Kelly Hebrank, BA Integrated Refugee & Immigrant Services (IRIS), New

Haven, CT, USA
Tara Helm, MPH, MSN One Medical, Phoenix, AZ, USA
Michael Hollifield, MD President and C.E.O., War Survivors Institute, Long
Beach, CA, USA
Emily P. Hyle, MD, MSc Division of Infectious Diseases, Massachusetts General
Hospital, Harvard Medical School, Boston, MA, USA
Andrea Mendiola Iparraguirre, MD Connecticut Mental Health Center, Yale
School of Medicine, New Haven, CT, USA
Margaret Isaac, MD Harborview Medical Center, General Internal Medicine and
Palliative Care, Seattle, WA, USA
Crista E. Johnson-Agbakwu, MD, MSc, FACOG Obstetrics & Gynecology,
Valleywise Health, Phoenix, AZ, USA
Kristina Krohn, MD Departments of Medicine and Pediatrics, University of
Minnesota, Minneapolis, MN, USA
Katherine C. McKenzie, MD, FACP Yale Center for Asylum Medicine, Yale
School of Medicine, New Haven, CT, USA
Amir M. Mohareb, MD Division of Infectious Diseases, Massachusetts General
Hospital, Harvard Medical School, Boston, MA, USA
Alexandra Molnar, MD Harborview Medical Center, General Internal Medicine,
Seattle, WA, USA
Maya Prabhu, M.D., LL.B Division of Law and Psychiatry, Connecticut Mental
Health Center, Yale School of Medicine, New Haven, CT, USA
Douglas J. Pryce, MD General Internal Medicine, Hennepin County Medical
Center, University of Minnesota, Minneapolis, MN, USA
Mara Rabin, MD Utah Health and Human Rights, Salt Lake City, UT, USA
Astha K. Ramaiya, DrPH Johns Hopkins University, Bloomberg School of Public
Health, Population, Family and Reproductive Health, Baltimore, MD, USA
Susan Heffner Rhema, PhD, LCSW, MSW Kent School of Social Work,
University of Louisville, Louisville, KY, USA
Julia Rosenberg, MD Yale School of Medicine, New Haven, CT, USA
Erika Schumacher, MD Franklin Memorial Hospital, Pediatrics, Farmington,
ME, USA
Sural Shah, MD, MPH Internal Medicine-Pediatrics, Olive View-UCLA Medical
Center, David Geffen School of Medicine, Sylmar, CA, USA
Contributors xv

Megan Shaughnessy, MD, MS Department of Medicine, Hennepin Healthcare,

Minneapolis, MN, USA
Department of Medicine, University of Minnesota, Minneapolis, MN, USA
Meera Siddharth, MD Refugee Health Program, Children’s Hospital of
Philadelphia, Philadelphia, PA, USA
William Stauffer, MD Departments of Medicine and Pediatrics, Infectious Diseases
and International Medicine, University of Minnesota, Minneapolis, MN, USA
Genji Terasaki, MD Harborview Medical Center, Department of Medicine,
University of Washington, Seattle, WA, USA
Sasha Verbillis-Kolp, LCSW, MSW Health and Human Services Consulting,
Portland, OR, USA
Cynthia Willard, MD, MPH Public Health, White Memorial Community Health
Center, Los Angeles, CA, USA
Katherine Yun, MD Perelman School of Medicine and Children’s Hospital of
Philadelphia, Philadelphia, PA, USA
Paula C. Zimbrean, MD Department of Psychiatry, Yale University, New
Haven, CT, USA
 Part I
Introduction
Chapter 1
Introduction to Refugees

Kelly Hebrank and Alexine Casanova

Who Are Refugees?

Every year, thousands of refugees enter the United States as documented immi-
grants. They have fled horrible persecution, repressive governments, or death
threats. They are invited to the United States to start their lives over, continuing the
country’s long-standing tradition of welcoming persecuted people.
Refugees did not always get a lot of attention, but especially over the past few
years, they have become a recurring and often controversial topic of political dis-
course in the United States and around the world.
In September 2015, as refugee numbers reached their highest levels ever [1], the
crisis was brought into particular focus by a now famous image of a young Syrian
boy who had drowned and washed up on a Turkish beach after he and his family had
fled civil war in their country and attempted to reach safety in Europe in a small boat
that capsized [2]. The huge numbers of refugees and other migrants arriving in
Europe during that year, over 1.1 million according to the International Organization
for Migration [3], created a major international political issue. This attention led to
heightened interest in refugee issues and an outpouring of support in many places.
But at the same time and for many reasons, nationalistic and xenophobic move-
ments were gaining increasing political power in many countries eventually leading
to fewer opportunities for resettlement and backlash in some places like Germany
who had welcomed large numbers [4].
Refugees have gotten caught up in debates about immigration policy and national
security. Yet they are still little understood by the general public. Often, their stories
are lost among the statistics of the nearly 44 million foreign-born people who live in
the United States [5].

K. Hebrank · A. Casanova (*)

Integrated Refugee & Immigrant Services (IRIS), New Haven, CT, USA
e-mail: [email protected]

© Springer Nature Switzerland AG 2020 3

A. Annamalai (ed.), Refugee Health Care,
https://doi.org/10.1007/978-3-030-47668-7_1
4 K. Hebrank and A. Casanova

Historical Context

As long as there have been wars, persecution, and political instability, there have
been refugees. However, the two World Wars in the first half of the twentieth cen-
tury left millions of people forcibly displaced or deported from their homes, neces-
sitating the collaboration of the international community in drafting guidelines and
laws related to their status, treatment, and protection. The United Nations High
Commissioner for Refugees (UNHCR) was established in 1950 to lead and coordi-
nate international action to protect refugees. In July 1951, the United Nations con-
vened a diplomatic conference in Geneva to “revise and consolidate previous
international agreements” related to refugee travel and protection, and the legal
obligations of states, based on principles affirmed in the Universal Declaration of
Human Rights. This 1951 Convention Related to the Status of Refugees defined a
refugee as someone who, “owing to well-founded fear of being persecuted for rea-
sons of race, religion, nationality, membership of a particular social group or politi-
cal opinion, is outside the country of his nationality and is unable or, owing to such
fear, is unwilling to avail himself of the protection of that country” [6].
This definition initially applied only to people displaced “as a result of events
occurring before 1 January 1951,” and some signatories further limited the scope of
the definition to refugees from Europe. In 1967, acknowledging that “new refugee
situations have arisen since the Convention was adopted,” a Protocol Relating to the
Status of Refugees was signed, which removes the geographical and time limits of
the original 1951 Convention.
Refugee assistance has changed dramatically since it was first organized over 60
years ago, with the mission of aiding European refugees from World War II. Today’s
refugees originate from countries throughout the world and seek asylum—tempo-
rary or permanent—in countries throughout the world.
Recent debates have brought the limits of existing definitions and treaties into
light as more and more people leave their countries seeking safety from various
forms of violence and persecution.

Other People Seeking Refuge

It is not simple to define and classify the status of people seeking refuge, but here
are a few more categories of note:
Palestinian refugees are a specific category of refugees. They are descendants of
those people who resided in Palestine prior to the 1948 conflict and lost both home
and livelihood as a result of it [7]. Another UN agency, the United Nations Relief
and Works Agency for Palestine Refugees (UNRWA), was created in 1949 specifi-
cally to support them.
Internally displaced people have been forced to flee their homes but remain
within the borders of their countries of origin [8]. Because of this, there is often little
specific support available to them.
1 Introduction to Refugees 5

Asylum seekers, like refugees, leave their homeland and seek safety in another
country. The difference between asylum and refugee status is linked to the different
ways that countries deal with immigration. In some countries, the UNCHR is autho-
rized to screen immigrants and grant refugee status to those deemed eligible. This
status may give the refugees rights or access to services in that host country. In other
countries, including the United States, Canada, and some in Europe, the UNHCR
does not play the same role. These countries have their own national authorities to
whom immigrants can apply for asylum, and each has its own criteria and process
for determining who qualifies. The UNHCR likens asylees, people who have been
granted asylum, to refugees and includes them as such in their reports and statistics
but is not able to count people awaiting asylum decisions (asylum seekers) as refu-
gees. In the United States, asylees are eligible for many of the same public services
as refugees, but no public assistance is provided to people during the period when
their asylum applications are pending, even if they meet the international definition
of a refugee.

Global Burden

It is staggering to consider the number of refugees and displaced people in the world
today. The United Nations reports that at the end of 2018, there were over 70 million
people in the world uprooted because of conflict or persecution. Of these, over
25.9 million are refugees, including 5.5 million Palestinians; 3.5 million are await-
ing a decision on their application for asylum, and 41.3 million people have been
internally displaced [9].
According to estimates, in 2019, refugees from Syria represented 32.8% of the
global refugee population, or 6.7 million of the 20.4 million persons under UNHCR’s
responsibility. Afghanistan was the second largest country of origin of refugees
(2.7 million), followed by South Sudan (2.3 million); Myanmar, formerly Burma
(1.1 million); and Somalia (0.9 million) [9].
Turkey hosted the highest number of refugees at the end of 2018, totaling 3.7 mil-
lion. Other major countries of asylum included Pakistan (1.4 million), Uganda
(1.2 million), Sudan (1.1 million), and Germany (1.1 million) [9]. Lebanon contin-
ued to host the largest number of refugees relative to its national population, where
one in six was a refugee. The movement of Venezuelans across the region has
resulted in a refugee situation with 3.4 million of them outside the country by the
end of 2018. With each new conflict, these numbers can change dramatically. Before
its civil war began in 2011, Syria was among the countries hosting the largest num-
bers of refugees [10].
Of the 2.1 million new asylum claims submitted to individual countries in 2018,
the highest number (254,300) was submitted in the United States though this repre-
sents a decline from 2017. As a result of the crisis in Venezuela, Peru became the
second largest recipient of asylum applications globally with 192,500. Germany
was the third largest recipient with 161,900 followed by France (114,500), Turkey
(83.800), and Brazil (80,000) [9].
6 K. Hebrank and A. Casanova

Long-Term Solutions

People who work in refugee resettlement are often asked, “Are you resettling refu-
gees from [insert here the political crisis currently in the media]?”
And the answer, sadly, is usually, “No.”
Resettlement—a nation’s government inviting refugees to move to its country,
access rights given to nationals, and obtain permanent residency leading to citizen-
ship [11]—is usually a last resort and an option for very few. Each year, less than
1% of the world’s refugees will be offered resettlement in a third country [12]. For
a comprehensive look at the history, challenges, and benefits of resettlement on a
global scale, see UNHCR report by Piper et al. [13].
Before resettlement, other durable solutions are considered. UNHCR first pur-
sues the possibility of voluntary repatriation, a refugee returning to his or her coun-
try of origin if it became safe. Another option is local integration, a refugee
remaining in the country to which he or she has fled and integrating into the local
community.
For a small percentage of the world’s refugees for whom the above options are
not viable, resettlement becomes a possibility. In 2018, the UNHCR estimated that
1.4 million refugees were in need of resettlement [9].
Currently, 29 countries participate in the UNHCR’s resettlement efforts [9].
Though some programs are limited in scope, this increase from 26 participating
countries in 2010 reflects an overall increased diversity of global resettlement
actors [9].
Three countries—Canada, the United States, and Australia—continue to resettle
a significant percentage of refugees though the numbers are down from over 90%
just a few years ago [14, 15]. The United States previously resettled more refugees
than all other countries combined, but in 2018, the 22,900 refugees resettled in the
United States represented only 24.7% of the 92,400 refugees resettled around the
world [9]. This total number marked a 51% drop in the record 189,300 refugees
resettled globally in 2016 [9], a result of declining resettlement quotas globally.

US Resettlement Process

Referral Process

Oftentimes, the decision of which refugees to admit is heavily influenced by politi-

cal, economic, and social factors [16]. Unlike many other countries, the United States
does not discriminate in its acceptance of cases based on a refugee’s likely ability to
integrate. While other nations may reserve resettlement for refugees deemed to have
high “integration potential”—based on their age, education, work experience, and
language skills—the United States accepts refugees regardless of their socioeco-
nomic status, employment history, medical history, or family composition [16].
1 Introduction to Refugees 7

Therefore, a refugee resettlement agency in the United States is as likely to serve a

single mother from Somalia with five children as it is to serve a highly skilled engi-
neer from Iraq and his schoolteacher wife. It may welcome as many refugees with
chronic or serious health problems as it does healthy refugees. Cases may be a single
individual or a family of ten. This practice ensures that the most vulnerable refugees
have access to protection and resettlement in the United States.
Most refugees who are considered for resettlement in the United States are
referred to the federal government by UNHCR, but in some cases, a US Embassy
or a trained nongovernmental organization makes the referral. The Department of
State’s Bureau of Population, Refugees, and Migration (PRM) oversees refugee
assistance, including resettlement. PRM funds and manages nine Resettlement
Support Centers (RSCs) throughout the world, which process refugee applications
for resettlement in the United States. In some regions, refugees must physically
present themselves to an RSC in order to receive assistance, but in other areas,
RSC staff conduct “circuit rides” through vast territories to serve refugees in
remote locations. After meeting with RSC staff, refugees are interviewed by offi-
cers from United States Citizenship and Immigration Services (USCIS, within the
Department of Homeland Security) to determine if they will be granted resettle-
ment. The Department of Homeland Security conducts thorough background
checks to ensure the refugees will not pose a threat to security. Refugees receive a
health screening (known as the overseas health assessment) to identify conditions
that might make them a public health risk; refugees with active infectious diseases
would need to complete treatment prior to gaining admission to the United States.
Approved refugees are then ready to travel to the United States—at their own
expense, thanks to an interest-free loan from the International Organization for
Migration. Figure 1.1 shows the different steps in the US refugee resettlement
program.
The length of this process varies based on a refugee’s location and other factors.
In early 2017, it was taking up to 2 years for people to be referred, screened, and
admitted [16], but the process is taking even longer, and fewer refugees have been
able to come in 2018 and 2019 since the current administration reduced the number
of overseas interviews taking place [17]. Moreover, most refugees have already
waited years—and some for more than a decade—just to access the resettlement
process and reach the point of a UNHCR referral. UNHCR estimates that at the end
of 2018, 15.9 million refugees were in a “protracted refugee situation”—defined as
25,000 or more refugees of the same nationality living in exile for 5 years or longer
in a given asylum country [9].

Refugee Numbers

Each year, the president, in consultation with Congress, sets the numerical goals for
refugee admissions during the upcoming fiscal year. This Presidential Determination
is a ceiling rather than a floor and includes the total maximum number of refugees
8 K. Hebrank and A. Casanova

• Refugees flee their country seeking safety and protection. In most cases
it is the UN High Commissioner for Refugees (UNHCR) determines if an
individual qualifies as a refugee under international law.
Becoming a
refugee

• A refugee that meets one of the criteria for resettlement in the United
States or another country can be referred to that country’s government
by the UNHCR. The United States also accepts some referrals for
Referral to the US resettlement form US embassies or a trained non-governmental
for resettlement organizations.

• The Resettlement Support Center (RSC) meets with refugees to compile

their personal data and background information the security
clearance process and the US Department of Homeland Security’s (DHS)
Resettlement in-person interview.
processing begins

• All refugees must undergo an interview with a refugee officer form the
DHS’ United States Citizenship and Immigration Services (USCIS). A
trained refugee officer travels to the host country to conduct a
In person detailed, fact-to-face interview with each refugee being considered for
interview resettlement.

• Each approved refugee undergoes a medical screening and most are

offered cultural orientation. The refugee undergo additional
security checks. Finally the refugee is supplied with a travel loan that
Orientation and must be repaid.
medical screening

• Every refugee is assigned to one of nine Resettlement Agencies in the

United States. These include Church World Service, Episcopal
Migration Ministries and International Rescue Committee. These RAs
Travel and place refugees with a local partner agency or office that will assist the
preparations refugees upon their arrival in the US.

• Upon arrival to the US at a designated airport, a Customs and Border

Protection (CBP) officer reviews the refugee’s documentation. Refugees
are met by local resettlement staff and/or friends and family to start a
Arrival and new life in America. They are provided with basic services and expected
reception to become self-sufficient as quickly as possible.

Fig. 1.1 How refugees get to the United States

1 Introduction to Refugees 9

120,000
110,000

100,000
85,000 Presidential
80,000 84,994 Determination
70,000
69,987 Refugee Arrivals
60,000
53,716 45,000
40,000
30,000

20,000 30,000
22,491

0
FY15 FY16 FY17 FY18 FY19

Fig. 1.2 Refugee admissions in last 5 years (28)

the United States will resettle in the coming year (18,000 in FY20), as well as a
breakdown by geographic region.
Over the past 5 years, refugee admissions have averaged 60,224 individuals but
have ranged from a high in FY2016 of 84,994 to a low in FY2018 of 22,491 [18].
In FY2017, although the ceiling was set at 110,000, just 53,716 refugees were
admitted to the United States. In FY19, the ceiling had been reduced to 30,000 (see
Fig. 1.2). The states that resettled the most refugees in FY2019 were Texas (2227
individuals), Washington (1930), Ohio (1288), California (1802), and New York
(1617) (18). Figure 1.3 shows refugee admissions across states in FY19.
In FY19, the top countries, three nationalities, accounted for over 65% of all refu-
gee admissions: Democratic Republic of Congo (11,152 individuals), Myanmar
(4681), and Ukraine (4013). The remaining 35% came from a total of 66 countries [18].

Special Immigrant Visa Program

The Special Immigrant Visa (SIV) program was created in 2006 to enable certain
Iraqi and Afghan nationals to resettle in the United States as permanent residents
after having been employed by or on behalf of the US government in Iraq or
Afghanistan [14]. They apply for the visa through the US Embassy in their country.
Once they obtain the visa, they can choose whether to make their own travel arrange-
ments and request resettlement services after arriving in the United States. Or they
can enter the refugee resettlement program so that travel and placement with a reset-
tlement agency can be arranged as it is for refugees.
10 K. Hebrank and A. Casanova

Fig. 1.3 FY19 refugee arrivals by state (28)

The maximum number of Special Immigrant Visas that can be issued is deter-
mined by law each year. SIV arrivals are separate from and do not count toward the
numbers of refugee arrivals set by the president. By the end of FY2019, 79,347
individuals had been resettled through the program including 18,582 Iraqis and
60,765 Afghans. Over the past 5 years, SIV arrivals have averaged 11,862 with a
low of 7226 in FY2015 and high of 19,321 in FY2017 (see Fig. 1.4). While they
have resettled across the country, SIVs have been especially concentrated in just
three states—California, Texas, and Virginia—which have welcomed 30.0%,
17.5%, and 11.6% of the total number, respectively (28).

Domestic Resettlement Pathway

In the United States, refugees and SIVs are similarly assisted through a unique
public-private partnership. At the federal level, the Department of State and the
Department of Health and Human Services (HHS) work together to welcome
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