REFUGEES' INEQUITABLE access to health care, information, and health-promoting resources in high-income countries is well documented1 and poses unique challenges during coronavirus disease 2019 (COVID-19). Recent attention to addressing refugees' COVID-19 prevention, risk mitigation, and access to care and health-promoting resources has been concentrated in low- and middle-income countries where most of the world's refugees reside.2 Although fewer than 1% of refugees are ever resettled to a third country,2 refugees have comprised a sizeable portion of new immigrants to the United States (US) for more than 50 years. COVID-19 has been described as an “equal opportunity” contagion by the US media, an assertion that obscures the complex social and structural determinants of health that exacerbate the effects of COVID-19 for minoritized communities. Poverty, inadequate health care, and economic deprivation are examples of nonmedical health determinants rooted in legacies of settler colonialism and racism that deepen existing health disparities3,4 and increase risks for poor health associated with COVID-19 among communities of color.5 We highlight how refugees residing in the rural United States may be disproportionately affected by COVID-19 by providing a brief review of the relevant social and structural determinants of health and describing how these intersect to deepen structural vulnerabilities among refugees. We then identify strategies to improve refugees' health and well-being related to COVID-19.
SOCIAL DETERMINANTS OF HEALTH
The social determinants of health (SDoH) broadly refer to the social and structural forces that affect health and well-being. The structural health determinants are “upstream” or “distal” factors that drive inequity (eg, national economic or welfare policies).6,7 Braveman and Gottlieb8 have referred to these determinants as the “causes of the causes.” The proximal material, behavioral, and psychological conditions of daily living—“risk factors” in public health lexicon—constitute the social determinants of health.6,7 Linking these aforementioned structural and social lenses enables critical public health to contribute to a nuanced understanding of health inequities or differences in health outcomes that are avoidable, unfair and unjust.9 In the following sections, we use a structural-social framework to provide a brief overview of the nested layers of context that exacerbate refugees' vulnerability to poor COVID-19 health outcomes and social well-being in rural settings.
Rural health inequities
Despite long-term public health efforts to address geographic health inequities, these remain a significant challenge for the 60 million residents, or 1 in 5 Americans, who reside in rural areas.10 In almost every health category, rural health indicators reveal a higher disease burden than urban counterparts, including higher rates of diabetes, heart disease, chronic respiratory disease, accidental injuries, depression, substance use, and domestic violence.11–13 Access to quality health care has been identified as a significant challenge, complicated by poverty, unemployment and underemployment, geographic distance to health providers, and lack of insurance coverage.11–13 Although 19% of the US population resides in rural communities, the nation's health workforce is concentrated in urban and suburban locations: only 9% of physicians and 16% of nurses practice in rural areas.11 In addition to reducing overall life expectancy and exacerbating poor health, rurality is an important determinant related to COVID-19. Rural-urban disparities in testing have been documented despite increased risk factors (eg, underlying conditions, aging populations) for poor COVID-19 health outcomes in rural states and settings.14 Rural-residing individuals are also at increased risk for poor mental health, including suicide, due to decreased access to social support as a result of geographic spread and physical distancing measures, social isolation, perceived burdensomeness, and loneliness.15
Ethnoracial health inequities
Racial and ethnic health inequities persist across the United States. In a meta-analysis of data from 293 studies, mostly from the United States, researchers found that racism as a determinant of health was associated with poorer general well-being as well as physical and mental health.16 Bailey and colleagues emphasized the importance of examining structural racism beginning “with the experiences of Black people and the Indigenous people of North America [because] it was on these two groups that the initial colonisers of North America ... first promulgated genocide and enslavement, and created both legal and tacit systems of racial oppression.”3(p1454) The authors demonstrated how structural racism has been enacted in the United States over centuries, including the conceptualization of “race” as a manufactured category to justify systems of oppression, interconnected policies that reinforce racism across sectors (eg, health, housing, education), and de facto workplace segregation resulting in wage disparities.3 Although race is a social construct, the embodiment of racism and discrimination has real health consequences for minoritized individuals and communities. Black, Indigenous, and People of Color (BIPOC) in the United States contend with personally mediated racism4 by medical and public health professionals, poorer quality care, and misdiagnoses of serious health conditions compared with white counterparts, intergenerational and psychosocial trauma, social and political exclusion and economic deprivation, maladaptive coping behaviors, and exposure to state-sanctioned violence.3,16,17
Ray18 illuminated the role of these social and structural determinants in rendering Black Americans more susceptible to COVID-19 transmission and death. Ray also noted Black men's challenges related to engaging in prevention efforts: “Black men report being stopped in stores by police for wearing personal protective equipment (PPE). Though a mask should signal health precaution, it signals potential criminal behavior if a person is Black, particularly if they are male.”18 Researchers have also described how undocumented Latinx communities in rural factories often lack health insurance and workplace protections as well as the limitations of the Indian Health Service (IHS) to effectively address COVID-19 in American Indian tribes across the United States.19 Politicians have used xenophobic, particularly Sinophobic (anti-Chinese sentiment), rhetoric to scapegoat immigrants and Americans of Asian descent for both the origins and spread of the virus that causes COVID-19.20 High-ranking government officials have referred to the virus as the “Chinese virus” and “kungflu,” sparking increased reports of verbal harassment, physical assault, and other discriminatory acts against individuals of Asian descent.21
Refugee health inequities in a US resettlement context
The United States has played a major role in third-country refugee resettlement, with the first legislation to admit displaced Europeans following World War II dating to 1948.22 Refugees identified for US resettlement do not decide where they will live23 and have historically arrived to larger cities where they receive temporary assistance with housing, employment, and medical insurance.24,25 Although urban centers are arguably more diverse and have a greater number of cultural resources and employment opportunities, refugees' experiences in the metropolitan United States have been at best uneven. Reports on refugees in US cities have revealed urban health disparities such as poverty, poor housing conditions, food insecurity, urban isolation, exposure to violence, and poor access to physical and mental health services.26–28 Refugees' experiences of xenophobia, discrimination, and cultural insensitivity in both medical and nonclinical settings affect overall health and pose barriers to accessing health information and resources.29,30 As Hadley and Patil noted, “[r]efugees who have been resettled in the USA are at a particularly high risk of discrimination because they show many outward signs of their minority status, including dress, skin color, language, neighborhood of residence, religion and socioeconomic status.”29(pp505-506)
SDoH INTERSECTIONS AND INEQUITIES: RURAL-RESIDING REFUGEES' HEALTH AND WELL-BEING DURING COVID-19
Formal refugee resettlement in smaller cities and suburban towns is a relatively recent endeavor31,32 and has occurred in tandem with refugees' secondary migration and self-settlement in rural locations for steadier employment, access to welfare benefits, lower cost of living, more peaceful and familiar environments, and increased opportunities to connect with both ethnic and host communities.32–34 Despite increasing urban to rural migration among refugees over the past 3 decades, this is a largely underacknowledged phenomenon. With few exceptions, research in the United States on im/migration and rural health disparities has centered on Latinx im/migrants. Yet, ensuring refugees with diverse backgrounds are included in COVID-19 planning and preparedness efforts is essential as there are a number of determinants that affect refugees' vulnerability to poor health related to COVID-19.
Refugees residing in rural settings contend with additional COVID-19–related risks. Infectious disease prevention, mitigation, and management assume the ability to practice physical distancing and access health information and resources. Although refugees may find affordable housing in rural towns compared with larger cities where they were initially resettled,33 lower-wage employment may result in individuals sharing bedrooms or in multiple families occupying a single home, as has been shown with Latinx im/migrants in similar contexts in the United States.35,36 In addition, intergenerational living accommodations with extended family are typical among some refugee groups; such arrangements have been associated with enhanced social support and quality of life among older adults who live with adult children and grandchildren.37,38 Although intergenerational living is a potentially positive aspect of resettlement, older adults are disproportionately affected by the burden of COVID-19 morbidity and mortality; therefore, precaution is necessary to reduce exposure in intergenerational households. An additional health consideration is the high prevalence of diabetes among refugees,39,40 as this is an underlying condition associated with a higher risk for severe illness from COVID-19. It should be noted that although refugees receive health coverage for their initial 8 months in the United States, many are uninsured after this period.41
In addition to immediate health risks and poor access to care, refugees contend with threats to their social well-being such as discrimination and xenophobia. Addressing an outbreak in South Dakota, a spokesperson for Smithfield Foods, a meat processing plant that relies on a significant refugee workforce,42 blamed foreign workers and their families for COVID-19 outbreaks, stating, “Living circumstances in certain cultures are different than they are with your traditional American family.”43 Framing disease as “other” or “foreign” vilifies refugees—as well as immigrants and communities of color—as disease carriers. In addition, the misuse of “culture” as a proxy for social inequity promotes a victim-blaming orientation that holds refugees responsible for their own illness and, in the case of infectious diseases, for placing communities at risk. This also diverts attention from the structural conditions responsible for disease exposure and transmission. Despite interim guidance from the Centers for Disease Control and Prevention (CDC) and the Occupational Health and Safety Administration (OSHA) to protect meat processing plant workers' safety,44 gaps between policy and implementation have included failure to provide adequate PPE and promote physical distancing.45,46 Workers have also reported being encouraged to continue working while sick.45 In addition to physical health, xenophobia and discrimination are associated with poor mental and psychosocial health.47 Increased discrimination against foreigners from all backgrounds may increase refugees' social isolation and reduce their ability to access health-promoting resources.
IMPLICATIONS FOR PRACTICE
Lessons to address refugees' COVID-19–related health disparities in rural settings can be gleaned from the global health and rural health literatures, as each provides insight into leveraging community assets in limited resource contexts. An example that spans both bodies of literature is the community of practice (COP) model. A COP is a group of people addressing a common concern, engaging in mutual learning, and improving their practice through regular collaboration and communication.48 Rural US COPs have addressed a range of health issues, including suicide prevention,49 mental health,50 childhood obesity,51 and health provider education.52 Such COPs typically include stakeholders from formal community institutions (eg, hospitals and clinics, service organizations, religious institutions). The Awah et al53 development of a COP to address a neglected tropical disease in West Africa is notable in its inclusivity of stakeholders: community health workers, former patients, and traditional healers were represented on the COP alongside hospital staff. We recommend similarly broad inclusion criteria for COPs designed to promote refugees' health during COVID-19 as health perceptions and practices are culturally mediated. Efforts should be made to identify trusted refugee community leaders. Health and human service organizations often hire im/migrant and refugee staff based solely on language skills; these individuals may or may not be respected leaders within their communities. Immediate- and longer-term actions a COP or coalition can undertake to address the disproportionate effects of COVID-19 on refugees include the following:
- Identifying vulnerable subgroups. Stakeholders with refugee backgrounds have insight into vulnerable individuals and families in their communities (eg, older adults who live alone, caregivers, essential workers with young children) and the expertise to identify culturally meaningful resources.
- Coordinating outreach and support efforts. Groups advised to stay at home could benefit from coordinated grocery or meal deliveries. Ethnic community-based organizations in larger cities have organized such efforts; in rural towns, religious institutions may be well suited to coordinate volunteer outreach, including interfaith efforts to reach religious minorities in rural settings.
- Providing remote support. There is a danger for stay-at-home and physical distancing measures to result in refugees' social isolation, particularly as this pandemic has spanned several religious holidays. Remote tools (eg, Zoom, WhatsApp) offer opportunities to provide formal and informal psychosocial and logistical support. (SwitchboardTA provides multilingual tutorials on how to use Zoom and other online platforms.54) For example, telehealth and telepsychiatry have recently become an important tool in meeting the mental health needs of refugees and im/migrants. In Somalia, tele-consultation was used effectively in increasing the capacity of clinicians to manage complicated cases, which improved the quality of care for children in a conflict setting.55 In Denmark, Mucic56 evaluated the acceptability of telepsychiatry in a cross-cultural context among asylum seekers, refugees, and migrants; clients expressed high levels of acceptance and satisfaction with this modality, resulting in a willingness to use it again and recommend it to others. It is also possible to support groups using remote resources. Lessons from the global health sector include a recent adaptation of a Youth Life and Employability Skills (LES) training curriculum to WhatsApp and Facebook platforms during COVID-19 by Catholic Relief Services (CRS).57 WhatsApp was participants' preferred platform and helped overcome literacy barriers as facilitators can send brief voice messages to group members. Program facilitators recommended not more than 15 to 20 participants, as groups may become difficult to manage beyond that point.57
- Countering xenophobia. Refugees are vulnerable due to increased xenophobia. The International Organization for Migration (IOM) recently issued a statement that combatting xenophobia is a key strategy in COVID-19 recovery.58 A COP should work to dispel dangerous myths in the host community about the origin and spread of the virus that causes COVID-19. Examples include correcting individuals and groups who use place-names for COVID-19 (eg, “Chinese virus”),59 partnering with local and state attorneys general to prevent and stop hate crimes,59 developing professional development for COP members and community organizations that highlight the perspectives and lived experiences of refugees (eg, panels, films),60 and strengthening the visibility of anti-racist and anti-xenophobic policies and procedures in local organizations and centers (eg, churches, hospitals, and clinics) to make a more inclusive environment.60
- Conducting research and evaluation. Community-engaged and participatory research and evaluation approaches that consider the broader SDoH are critical to the short- and long-term support of refugees. Although much traditional research on health disparities has utilized race and ethnicity as variables, Williams challenged researchers to question these categories and move beyond cultural and racial explanations for COVID-19 morbidity and mortality as such “narrative[s] place responsibility on socially disadvantaged groups.”61 Using the social and structural determinants to frame research and evaluation has the potential to make meaningful systemic changes. Data collection and dissemination should focus on how different nationalities and cultural groups interact with the social and structural determinants to provide nuance and enable meaningful policy and practice shifts.
There are existing, free-of-charge resources for working with im/migrant and refugee populations. These include the CDC's Communication Toolkit for Migrants, Refugees, and Other Limited-English-Proficient Populations,62 a searchable tool-kit with links to updated resources. SwitchboardTA is a resource hub for refugee resettlement providers supported by the US Office for Refugee Resettlement. SwitchboardTA has curated resources in multiple languages,63 including Know Your Rights fact sheets, videos on managing stress and anxiety during COVID-19, and resources on helping refugee children and parents cope.
COVID-19 has exposed the deep fissures of inequity that undermine health and well-being among structurally vulnerable communities. The social and structural determinants of health provide an important critical lens through which to examine these nested layers of health inequities. Ameliorating COVID-19 health disparities requires more than the public health strategy of securing refugees' trust. Addressing the “causes of the causes” requires broad inclusion of refugees themselves as key stakeholders to promote and enforce safer workplace practices, dispel harmful xenophobic myths, and provide support within refugee communities. Mobilizing coalitions that value local and cultural expertise is critical for addressing COVID-19 in the short term and eliminating disparities more broadly. As the rural United States braces for future waves of COVID-19, refugees must not be seen as part of the problem but instead as part of the solution.
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