#3: Care of refugees, migrant workers, asylum seekers

Population health

Systems thinking

-how a person or group connects with other organizations or systems

-how different parts work together and how one change can affect others

Upstream thinking

-focus on interventions that promote health or prevent illness

-fix the root cause, stop illness before it starts

Determinants of health

client or environmental factors that influence (cause) health outcomes

Community empowerment

-Enables communities to identify health problems and act to resolve them

-One of key strategies to address health disparities throughout the world

-One of five principles of primary health care promoted by W H O

Empowerment

transferring power from those with power to those without

Powerlessness

Antithesis of empowerment

What does empowerment do?

-Leads to increased community capacity and competence

-Often associated with public participation and community engagement

Levels of empowerment

-Individual community members, organizations within the community, and community as a whole

-Pop health nurses can be involved at all levels

Horizontal empowerment

-Internal to the community

-Reflected in community's ability to solve problems mobilizing its own resources

Vertical empowerment

-Involves efforts to change power structures outside the community

-Leverages outside power and resources to address community concerns

Community strengths and needs assessment

-Understand the elements of strength and dimension of culture

-Engage members of community

What should holders of power want for community empowerment?

Holders of power must want the community to be more self-reliant and must be willing to cede power to community members.

How are trained facilitators incorporated in community empowerment?

A trained facilitator is needed to guide the community in its efforts to be more self-reliant

How should assistance be offered for community empowerment?

Assistance should be offered in the form of a collaborative partnership rather than charity and should be designed to promote increased self-reliance and capacity in the community

Where does community empowerment start?

Empowerment starts where community members are and does not try to force change on the community

Adversity in community empowerment

Struggle and adversity strengthen social organizations and communities when they are overcome through community activity

Decision making in community empowerment

-Hands-on participation in decision making and problem resolution increases problem-solving capabilities.

-Decisions need to be made by community members, not for them by others, however well-intentioned

Long term sustainability in community empowerment

-The community should supply a substantial portion of the resources needed for problem resolution or project implementation to promote long-term sustainability.

-Community empowerment activities should be designed from the beginning to achieve the ultimate goal of community control of and responsibility for decision making and actions taken

Migrants

-A person who moves away from his or her place of usual residence, whether within a country or across an international border, temporarily or permanently, and for a variety of reasons.

-The term includes a number of well-defined legal categories of people, such as migrant workers; persons whose particular types of movements are legally-defined, such as smuggled migrants; as well as those whose status or means of movement are not specifically defined under international law, such as international students

Migrant worker

-A person who is to be engaged, is engaged or has been engaged in a salaried / paid activity in a State of which he or she is not a national

-The average life expectancy of a Migrant worker is 51 years of age, which is aging for this population

Migrant employment

-Seasonal and migrant workers often employed in farming and agriculture

-May have temporary home during employment, also paying for family to live in different/permanent home

-Agricultural workers are not covered under common labor laws

-Minors 12 y/o and older are not covered under Child Labor Act and can work with family members under hazardous conditions

Migrant documentation

-Many migrant farmworkers have permanent residence

-Annually, 250,000 to 300,000 additional workers are given temporary foreign certification through H2A

-Others attempt unauthorized crossing of US-Mexico border

Migrant injuries and illness

-Greater mortality and morbidity compared to general population due to poverty

-Limited access to health care, hazardous working conditions, lack of regulations

Migrant health care access

-Not required to be provided by employer

-Those lawfully present can purchase coverage under ACA, or qualify for Medicaid

-Application process often complicated

-HRSA funded health centers provide care to over 1 million workers and families

Refugee

-A person who, owing to a well-founded fear of persecution for reasons of race, religion, nationality, membership of a particular social group or political 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; or who, not having a nationality and being outside the country of his former habitual residence as a result of such events, is unable or, owing to such fear, is unwilling to return to it

US refugee eligibility requirements

(1) be of special humanitarian concern to the United States

(2) meet the refugee definition as set forth in section 101(a)(42) of the INA

(3) be admissible under the INA (or be granted a waiver of inadmissibility)

AND

(4) not be firmly resettled in any foreign country

Refugee application process

-The U.S. Refugee Admissions Program (USRAP) establishes processing priorities that identify individuals and groups who are of special humanitarian concern to the US and therefore eligible for refugee resettlement consideration

-Once applicants are referred or granted access to USRAP under any of these categories, must still meet all other eligibility criteria

-Multiple security checks must be completed before a request for refugee status is approved + a medical exam

Refugee priority 1

individuals referred by the United Nations High Commission on Refugees (UNHCR), a U.S. Embassy, or certain non-governmental organizations (NGO)

Refugee priority 2

groups of special humanitarian concern

Refugee priority 3

family reunification cases

Asylum seekers

-An individual who is seeking international protection.

-someone whose claim has not yet been finally decided on by the country in which he or she has submitted it.

-Not every asylum seeker will ultimately be recognized as a refugee, but every recognized refugee is initially an asylum seeker

Process for admitting refugees under REFUGEE RESETTLEMENT

18–24 months of vetting while living in refugee camps or urban settings abroad

Refugee admissions → maximum number set each year by the President

  -The U.S. has set a ceiling of 125,000 refugee admissions for FY 2025

Process for admitting refugees under ASYLUM

-Any person currently in the US or arrives at the US border can apply for asylum. An asylum seeker may initially enter with legal documents(tourist visa) or after being caught inside the USA by immigration authorities, and may have to pursue their asylum claims while in detention

-To be granted asylum, an individual must meet the refugee definition and that none of the various bars to asylum apply (e.g., “serious” criminal conduct, persecution of others, or terrorist ties)

-Burden of proof is on the asylum applicant, no right to free counsel

Refugee status

-Applied for outside the U.S.

-Typically through the United Nations High Commissioner for Refugees (UNHCR) or a U.S. embassy

-Applicants must be outside their home country and unable or unwilling to return due to persecution

-Once approved, refugees are resettled to the U.S. through the U.S. Refugee Admissions Program (USRAP)

-Includes pre-arrival vetting, health screenings, and cultural orientation

Asylum status

-Applied for inside the U.S. or at a U.S. port of entry

-Asylum seekers may already be in the country or arrive at the border seeking protection

-Must meet the same definition of a refugee: fear of persecution due to race, religion, nationality, political opinion, or membership in a particular social group

-Application must be filed within one year of arrival, unless exceptions apply

-If granted, asylum provides similar protections as refugee status, including work authorization and a path to permanent residency

Torture

-Any act by which severe pain or suffering, whether physical or mental, is intentionally inflicted on a person for purposes of punishment, coercion, obtaining information, or discrimination

-Physical or Psychological

Refugees and torture

An estimated 44% of refugees, asylum seekers, and asylees living in the United States have experienced torture—either directly or as secondary survivors (e.g., witnessing or being affected by torture of loved ones

Istanbul protocol

-Formally titled the Manual on the Effective Investigation and Documentation of Torture, the Istanbul Protocol:

-Sets international standards for how to assess, document, and report allegations of torture

-Provides guidance for medical professionals, lawyers, and human rights investigators

-Was first published in 1999 and most recently revised in 2022

Guidelines included in the Istanbul protocol

-Medical and psychological evaluation techniques to identify signs of torture

-Legal standards for documenting and presenting evidence in court

-Ethical guidelines for working with survivors

-Interviewing methods that prioritize trauma-informed care