Michigan is home to about 40,040 refugees who have resettled in the state since 2008 (1), mainly originating from Iraq, Syria, and Democratic Republic of Congo (2). Substantial refugee populations reside in major city centers of Michigan, especially in metro-Detroit (3), Dearborn (3), and Lansing (4). Refugees face unique health challenges due to pre- and post-migration stressors (Fig. 1), such as violence that prompted migration and language barriers upon arrival3. These challenges influence both mental and physical health outcomes.
A social and political climate hostile to refugees and immigrants can exacerbate such stressors. National policy decisions, most notably various iterations of the “Muslim Ban” (Executive Orders 13769 and 13780) (5), increased enforcement actions from border patrol and Immigrations and Custom Enforcement (ICE) (6), and stricter limits to the number of refugees the U.S. will accept (7) have already begun to shape Michigan’s refugee population at the state level.
While Michigan welcomed the 4th most refugees of all U.S. states in 2016, it now ranks 13th for number of refugee resettlements. Refugee resettlements, or transfers of refugees to the United States for permanent residence, are at their lowest levels in Michigan since 2006 (1). Demographically, numbers of refugees from Middle Eastern countries such as Iraq and Syria have dramatically decreased (1,5) and higher proportions of resettled refugees in the last three years originate from the Democratic Republic of the Congo. While Congolese refugees do not have the same level of establishment in Michigan as Middle Eastern refugees, Congolese communities in Grand Rapids and Lansing are growing (7).
Though refugees are not subject to deportation by ICE or border patrol, the increase in enforcement activities can be a stressor that contributes to poor health outcomes for the wider community, especially since such activities are often conducted on the basis of racial profiling (8,9) rather than evidence. Even singular raids can be associated with lower self-rated health and higher immigration enforcement stress at the local level (8) and low birth weight for both immigrant and U.S.-born Latina mothers at the state level (9) according to studies surveying Latino populations. The entirety of Michigan lies within the “100-mile border zone” that falls under border patrol jurisdiction (10) making it easier to carry out raids and other enforcement activities. The latest reports suggest Michigan has the second highest rate of ICE arrests of immigrants (6).
Figure 1. Model for the various ways in which refugee status impacts health.
The Michigan Department of Health & Human Services (MDHHS) offers the Refugee Assistance program to help those admitted into the United States as refugees that meet a certain eligibility become self-sufficient post-arrival. Among their services they promote healthcare through the Kent County Health Department, the Ingham County Health Department, and the Arab-American and Chaldean Council (ACC). The MDHHS also offers health screenings in geographic areas of major resettlement through the ACC, the Calhoun County Health Department, the Ingham County Health Department, the Kent County Health Department, and the Jewish Family Services of Washtenaw County. (11) Currently, refugee services in Michigan that receive the most support focus on the English language and translation while refugee services that receive the least support are in healthcare. This lack of healthcare access to refugee communities is mainly due to an inequitable program allocation and geographical distribution of resources across the state, availability of funding, and a shortage of staff that are qualified to meet the needs of these communities. Healthcare in the United States is largely “family-based” which presents additional challenges to refugees such as adults that have yet to be naturalized with U.S.-born children, or those having some children born in the U.S. and others born in another country.
Call to Action
Healthcare workers can improve accessibility to healthcare for local refugee communities by being specific in target funding, collaborating with diverse perspectives (e.g. grant writers, leaders in the community, and service providers), develop priority services within specific geographical regions, collaborate between service organizations, and lead advocacy efforts at a local, state, and national level. To limit a lack of access, it is also essential for healthcare workers to know to what capacity aid organizations can fulfill locally as the quality and types of services available differ drastically from institution to institution. Health professionals in Michigan can aid in advocacy work by partnering with local organizations that support immigrant and refugee populations - especially those that face high socioeconomic disparities. Some current examples include the Michigan Immigrants Rights Center, the Arab Community Center for Economic and Social Services (ACCESS), the Children's Hospital of Michigan Hamtramck School-Based Health Center (HSBHC), the Office of Global Michigan, Global Detroit, and Welcoming Michigan.
Warikoo N. Number of refugees in Michigan plunges as Trump restricts immigration. Detroit Free Press. https://www.freep.com/story/news/local/michigan/2018/10/15/refugee-admissions-drops/1607544002/. Published October 15, 2018. Accessed October 18, 2019.
Tanner K. Raw Data: Refugees in Michigan, by the numbers. Detroit Free Press. https://www.freep.com/story/opinion/contributors/raw-data/2017/01/31/raw-data-refugees-michigan-numbers/97238722/. Published January 31, 2017. Accessed October 18, 2019.
Pampati S, Alattar Z, Cordoba E, Tariq M, Leon CMD. Mental health outcomes among Arab refugees, immigrants, and U.S. born Arab Americans in Southeast Michigan: a cross-sectional study. BMC Psychiatry. 2018;18(1). doi:10.1186/s12888-018-1948-8
Frequently Asked Questions about Refugees. Refugee Development Center. http://refugeedevelopmentcenter.org/mission-statement/frequently-asked-questions-about-refugees-in-lansing/. Accessed October 18, 2019.
Public Sector Consultants, Community Foundation for Southeast Michigan, The Kresge Foundation, The Skillman Foundation. A Landscape Scan of Immigrant- and Refugee-Supporting Organizations in Southeast Michigan. Public Sector Consultants; 2019. https://cfsem.org/wp-content/uploads/2019/08/Landscape-Scan-of-Immigrant-and-Refugee-Supporting-Organizations-in-Southeast-Michigan.pdf. Accessed October 18, 2019.
Warikoo N. Michigan has 2nd highest rate of ICE arrests of immigrants. Detroit Free Press. https://www.freep.com/story/news/local/michigan/2019/06/27/michigan-ice-arrests-immigrants/1513170001/. Published June 27, 2019. Accessed October 18, 2019.
Rahal S. Michigan becomes haven for Congo refugees. The Detroit News. https://www.detroitnews.com/story/news/local/michigan/2019/04/12/michigan-becomes-haven-congo-refugees/3287895002/. Published April 11, 2019. Accessed October 18, 2019.
Lopez WD, Kruger DJ, Delva J, et al. Health Implications of an Immigration Raid: Findings from a Latino Community in the Midwestern United States. Journal of Immigrant and Minority Health. 2016;19(3):702-708. doi:10.1007/s10903-016-0390-6
Novak NL, Geronimus AT, Martinez-Cardoso AM. Change in birth outcomes among infants born to Latina mothers after a major immigration raid. International Journal of Epidemiology. 46(3):839-849. doi: 10.1093/ije/dyw346
Shoichet CE. The US border is bigger than you think. CNN. https://www.cnn.com/2018/05/23/us/border-zone-immigration-checks/index.html. Published May 24, 2018. Accessed October 18, 2019.
MDHHS: Assistance Programs. Refugee Assistance. Michigan Department of Health & Human Services. https://www.michigan.gov/mdhhs/0,5885,7-339-71547_72126---,00.html Published 2019. Accessed October 18, 2019
*Augmented text for the example boxes in Fig. 1.
Pre-migration stressors examples: war1,2, natural disaster1, torture1, mass violence1, discrimination1, kidnapping1, witnessing violence or aftermath of violence1,2, displacement/homelessnes1, contaminated water2, threats2, decreased access to food and medicine2, religious persecution6, environmental exposure8 to lead or other toxins
Refugee Resettlement Process: “transitional limbo during asylum process,”6 length of asylum process6, navigation of legal system in asylum application process6
Post-migration stressors: acculturation (difficulty adjusting to a new society and culture)3,5 including language difficulty and difficulty shopping5, unemployment2, discrimination3, food insecurity5, economic insecurity6, high healthcare needs without high healthcare utilization6, housing6, lack of transportation6,7, immigration services navigation6, child care6, access to health insurance6, cost of healthcare7, lack of healthcare systems knowledge7
Physical Health Outcomes: dietary changes3, increase in BMI3, hypertension3, heart disease3, diabetes3, chronic disease3,7, elevated blood lead levels8
Mental Health Outcomes: emotional distress7, anxiety7, depression7, PTSD7, stigma associated with mental illness9
Health-care interventions: resilience promoting programs1, programs promoting social support3, nutritional support3, interventions to increase resource/healthcare utilization6, interventions cognizant of changing needs over time6, interpreters → both medical & administrative staff7, blood lead level screenings8, Potential health-care interventions: Incorporation of refugee health into medical school curricula10, incorporation of refugee health education in post-medical school professional development, adapt mental health screening tools to be more culturally relevant for different refugee populations11
Protective factors: resilience1,3,4, social support3
Figure 1 References
Wright AM, Talia YR, Aldhalimi A, et al. Kidnapping and Mental Health in Iraqi Refugees: The Role of Resilience. Journal of Immigrant and Minority Health. 2017;19(1):98-107. doi:10.1007/s10903-015-0340-8
Jamil H, Nassar-Mcmillan S, Lambert R, Wang Y, Ager J, Arnetz B. Pre- and post-displacement stressors and time of migration as related to self-rated health among Iraqi immigrants and refugees in Southeast Michigan. Medicine, Conflict and Survival. 2010;26(3):207-222. doi:10.1080/13623699.2010.513655
Jen K-LC, Zhou K, Arnetz B, Jamil H. Pre- and Post-displacement Stressors and Body Weight Development in Iraqi Refugees in Michigan. Journal of Immigrant and Minority Health. 2015;17(5):1468-1475. doi:10.1007/s10903-014-0127-3
Arnetz J, Rofa Y, Arnetz B, Ventimiglia M, Jamil H. Resilience as a Protective Factor Against the Development of Psychopathology Among Refugees. The Journal of Nervous and Mental Disease. 2013;201(3):167-172. doi:10.1097/nmd.0b013e3182848afe
Hadley C, Zodhiates A, Sellen DW. Acculturation, economics and food insecurity among refugees resettled in the USA: a case study of West African refugees. Public Health Nutrition. 2007;10(4):405-412. doi:10.1017/s1368980007222943
Wright AM, Aldhalimi A, Lumley MA, et al. Determinants of resource needs and utilization among refugees over time. Social Psychiatry and Psychiatric Epidemiology. 2015;51(4):539-549. doi:10.1007/s00127-015-1121-3
Taylor EM, Yanni EA, Pezzi C, et al. Physical and Mental Health Status of Iraqi Refugees Resettled in the United States. Journal of Immigrant and Minority Health. 2013;16(6):1130-1137. doi:10.1007/s10903-013-9893-6
Kaplowitz SA, Perlstadt H, Dziura JD, Post LA. Behavioral and Environmental Explanations of Elevated Blood Lead Levels in Immigrant Children and Children of Immigrants. Journal of Immigrant and Minority Health. 2015;18(5):979-986. doi:10.1007/s10903-015-0243-8
Kira IA, Lewandowski L, Ashby JS, Templin T, Ramaswamy V, Mohanesh J. The Traumatogenic Dynamics of Internalized Stigma of Mental Illness Among Arab American, Muslim, and Refugee Clients. Journal of the American Psychiatric Nurses Association. 2014;20(4):250-266. doi:10.1177/1078390314542873
Dussán KB, Galbraith EM, Grzybowski M, Vautaw BM, Murray L, Eagle KA. Effects of a refugee elective on medical student perceptions. BMC Medical Education. 2009;9(1). doi:10.1186/1472-6920-9-15
Shoeb M, Weinstein H, Mollica R. The Harvard Trauma Questionnaire: Adapting a Cross-Cultural Instrument for Measuring Torture, Trauma and Posttraumatic Stress Disorder in Iraqi Refugees. International Journal of Social Psychiatry. 2007;53(5):447-463. doi:10.1177/0020764007078362
Ferdowsian H, McKenzie K, Zeidan A. Asylum Medicine: Standard and Best Practices. Health and Human Rights Journal. 2019;21(1):215-225. https://www.hhrjournal.org/2019/05/asylum-medicine-standard-and-best-practices/. Accessed November 18, 2019.