U.S. troops completed a chaotic – and at times, deadly – evacuation of Afghanistan on August 30, 2021, ending America’s 20-year presence in the country and kicking off a massive effort to resettle Afghan nationals around the globe.
Since then, approximately 70,000 Afghans have arrived in the U.S. as part of the Department of Homeland Security’s (DHS’s) Operation Allies Welcome. After two decades of war and economic hardship, these refugees are arriving with medical conditions that are rarely seen by North American health care workers like vitamin deficiencies, parasitic infections, and latent tuberculosis, as well as undiagnosed chronic conditions like hypertension and diabetes.1,2 The U.S. Centers for Disease Control and Prevention (CDC) issued a health alert advising clinicians to be on the lookout for cases of measles, mumps, leishmaniasis, and malaria among evacuees from Afghanistan.3 Common hematologic conditions in this population include anemia and beta thalassemia.
ASH Clinical News spoke with experts about what clinicians should expect as they address the medical needs of recent evacuees, including the effects of trauma and difficulty accessing housing, employment, and medical care with limited resources.
Hematologic Considerations
For hematologists who treat Afghan refugees, conditions such as iron deficiency anemia and beta thalassemia should be at the top of the differential diagnosis when screening a new patient at a consultative visit.
“Afghanistan is certainly very much a part of the beta thalassemia belt that extends from Southern Europe through the Middle East through Iraq and Iran, Afghanistan, Pakistan, and Western India,” said Sujit Sheth, MD, chief of the division of pediatric hematology/oncology and professor of clinical pediatrics at Weill Cornell Medicine in New York.
While the exact prevalence of beta thalassemia in Afghanistan is unknown, it is estimated that 1 to 1.5 million people carry beta thalassemia trait.4
“Refugees from Afghanistan may suffer from some degree of malnutrition and thus may have iron deficiency, which is the most common cause of anemia worldwide. However, it is important to keep in mind that these individuals may also have thalassemia trait,” Dr. Sheth explained. “The two could co-exist, but you need to think about both of those conditions when you’re looking at [a patient] who has anemia.”
Medical history taking is a critical part of making this diagnosis.
“If you take a history from [patients] and it appears that their diet is adequate in iron, then it’s much less likely that they’re iron deficient and it’s more likely that they have thalassemia trait, in which case you can go directly to testing for thalassemia trait,” Dr. Sheth added.
A history of consanguinity and blood transfusions would also indicate beta thalassemia, he explained.
In November 2021, Alan R. Cohen, MD, and colleagues at the Children’s Hospital of Philadelphia’s division of hematology were treating two children who had been evacuated from Afghanistan, both with beta thalassemia. It’s critical to get patients with chronic blood disorders into an appropriate treatment program as soon as possible so that their interruption of care is brief, Dr. Cohen said. In some cases, that means adding therapies, such as iron chelation therapy, that were not readily available in Afghanistan.
One of the immediate challenges of treating evacuees with chronic blood disorders is the lack of readily available medical records. Even for patients and families who are knowledgeable about their conditions, clinicians won’t necessarily have transfusion data on acquired red cell antibodies, for instance, which would typically be available before beginning therapy for a new patient.
“We normally like to have that level of information so that we know if there are problems that we should be on the lookout for,” said Dr. Cohen, who is a professor of pediatrics in the Perelman School of Medicine at the University of Pennsylvania.
Down the road, Dr. Cohen said he is most concerned about ensuring that patients can access comprehensive hematologic care, possibly at centers with specialized teams, once they leave temporary housing on U.S. military bases and settle in communities around the country.
For the two children initially treated at Children’s Hospital of Philadelphia, they have each been resettled and connected with pediatric hematologists who have experience caring for children with thalassemia.
Disease Severity
Hematologists should also be prepared to see patients presenting with more severe disease than is typically seen in the U.S. because their conditions may have gone undiagnosed or untreated due to a lack of resources in Afghanistan.
“You may have unique complications of undertreated disorders,” said Courtney Thornburg, MD, medical director of the Hemophilia and Thrombosis Treatment Center at Rady Children’s Hospital in San Diego.
“We have to think a little bit more about the natural history of these conditions,” explained Dr. Thornburg, who is also a professor of pediatrics at the UC San Diego School of Medicine. “For example, in patients with beta thalassemia major, in the U.S. they receive regular transfusions and chelation and there’s a burden of treatment, but they do very well.” However, if these patients are not transfused or are inadequately transfused, she continued, then they can have complications including poor growth, skeletal changes, and extramedullary hematopoietic masses (i.e., lung and spine lesions).
Another unique consideration for recent evacuees from Afghanistan is the potential for high blood lead levels. There are some cultural practices in Afghanistan that increase lead exposure, especially in children and pregnant women, so clinicians need to be vigilant about checking blood lead levels, explained Rachael Truchil, MD, MPH, an associate professor of clinical medicine at the Perelman School of Medicine and medical director of the Refugee Clinic at the Penn Center for Primary Care. Dr. Truchil explained that some people in Afghanistan use a black powder mixed with water to paint around the eyes of children and pregnant women to improve eyesight and ward off evil, but the powder has been found to contain lead contaminants.
Accessing Care
Physicians who work near arrival locations and U.S. military bases temporarily housing evacuees have likely treated Afghan refugees already. However, it could be months before most refugees would be able to access subspecialty care from a hematologist, according to Farishta Rafiqi, an employment specialist at the International Rescue Committee.
Ms. Rafiqi said evacuees can access basic care and screening when they arrive at U.S. military bases, but they must obtain a social security card or other government identification before they can apply for health coverage through federal programs. That process can take months and delays access to care.
The road to resettlement for Afghan evacuees can be long and cumbersome. As the U.S. military wrapped up its evacuation of Afghanistan, President Biden tapped DHS to take the lead in coordinating federal efforts to resettle Afghan citizens in the U.S. That effort, dubbed Operation Allies Welcome, includes the initial processing of Afghans through U.S. military bases abroad. DHS deployed about 400 intelligence, law enforcement, and counterterrorism professionals to Bahrain, Germany, Kuwait, Italy, Qatar, Spain, and the United Arab Emirates to process Afghan refugees using biometric and biographic screenings. Additionally, all Afghan refugees are required to complete vaccinations for measles/mumps/rubella, varicella, polio, COVID-19, and other infectious diseases before entering the U.S.5
Once evacuees are cleared for entry to the U.S., those without visas are taken to one of eight military bases in Indiana, New Jersey, New Mexico, Texas, Virginia, and Wisconsin. From there, staff from the Department of State and the Department of Health and Human Services’ Office of Refugee Resettlement work to match refugees with non-government resettlement agencies that provide job and housing assistance. Refugees can also apply for health insurance coverage through federal programs such as Medicaid and the Children’s Health Insurance Program (CHIP).
Most of the Afghan citizens who arrived in the U.S. as part of the August 2021 evacuation were granted a humanitarian status, which allows them to live in the U.S. for two years. Other Afghans who had started the immigration process before the evacuation may be eligible to enter the U.S. under a Special Immigrant Visa (SIV). Afghans who completed the process and are SIV holders can enter the U.S. immediately. Refugees with SIV status are considered lawful permanent residents. However, those whose SIV status is in process and parolees must wait at U.S. military bases abroad for additional screening.
DHS estimates that more than 40% of Afghans who arrived in the U.S. as part of Operation Allies Welcome are eligible for SIVs because they took significant risks to support U.S. military and civilian personnel in Afghanistan, were employed by the U.S. government, or are family members of someone who falls into those groups.
Afghans who receive this humanitarian status may be eligible for cash assistance and medical coverage, employment preparation, job placement, English language training, and other services through the Office of Refugee Resettlement. However, cash and medical assistance are limited to no more than eight months; other services, such as employment assistance, are available for five years. Some parolees may be eligible to apply for federal benefits in their state, such as Temporary Assistance for Needy Families (TANF), health insurance through Medicaid, and food assistance through the Supplemental Nutrition Assistance Program (SNAP).6
Language Barriers, Cultural Differences
Although Afghans with SIV and humanitarian status will have access to health insurance, the unfamiliar process of accessing medical care can be daunting. Ms. Rafiqi, who immigrated to the U.S. from Afghanistan several years ago, said that Afghanistan doesn’t have a health insurance system and people pay out of pocket for all health services. As a result, refugees are not familiar with insurance concepts like providers networks or copayments.
There is also little preventive care in Afghanistan, since health care is expensive and difficult to access for those in rural areas.
“People will wait until they have pain or have some issues and then they will consult the doctor,” Ms. Rafiqi said. “This terminology of preventive care really does not exist [in Afghanistan].”
These factors combine to create a general lack of health awareness and many patients only learn about diseases when they are diagnosed.
Clinicians can help bridge the gap by connecting refugees to resources and support groups in their local communities, Dr. Thornburg advised. She also encouraged physicians to spend time with patients to determine their level of knowledge about the condition they have been diagnosed with.
“We could take for granted if it’s a 15-year-old or a 25-year-old coming in a with a blood condition that they would know everything about it and how to treat it, but that’s really unlikely to be the case,” she said.
It’s also important to speak with patients about their perception of their condition.
“Different cultures attribute illness to religious beliefs or environmental exposures and not necessarily the underlying biology, and so you want to have an understanding of that,” Dr. Thornburg said. “Going through some references or talking to people who have that understanding is a good idea so that you can better approach the initial visit.”
Dr. Truchil recommended planning to spend more time on patient education, including making sure that patients understand the instructions for their medication regimens. For instance, she learned that in the Afghan community, nodding is often done out of politeness and doesn’t necessarily represent understanding or agreement. At the refugee clinic, providers use a team approach including pharmacists who participate in the education and follow-up related to medication administration.
“Seeing patients frequently to ensure they are taking medications appropriately and getting recommended evaluations is key because it is a much more vulnerable population and things may be lost to follow-up more easily because of misunderstanding,” Dr. Truchil said.
Language barriers are another issue that physicians should prepare for before seeing an Afghan refugee, most of whom speak either Pashto or Dari. Though many of the current refugees have a family member who speaks English, having worked as an interpreter for the U.S. military or contractors, that person isn’t necessarily the best translator.
“The very best thing you can do is to use trained medical interpreters, not a family member,” said Lois Wessel, DNP, a family nurse practitioner and assistant professor of nursing at Georgetown School of Nursing and Health Studies in Washington, D.C., who works to address the health needs of refugees entering the U.S. It can be difficult to discuss sensitive personal matters with a family member in the room, she noted, and even if that person speaks English, they likely don’t have literacy around medical terminology.
While it’s ideal to have an unrelated in-person interpreter, that may not always be an option. Patients should be consulted about who the interpreter is and be able to choose another option, advised Kathleen Miller, MD, a staff physician in the adolescent medicine and gender health program at Children’s Minnesota who has written about trauma-informed care of immigrants and refugees.
For instance, in small refugee communities, the interpreter could be someone who sees the patients socially or goes to their mosque. In that case, a virtual option could be a better fit, Dr. Miller said. Physicians should also be mindful of the gender of the interpreter, since the patient may not be comfortable speaking with someone of another gender. Virtually all hospital systems contract with language lines that have multiple interpreter options, and even small practices can gain access to these virtual services, she said.
Trauma-Informed Care
Afghan refugees arriving in the U.S. today have experienced decades of war and likely had just hours to decide whether to leave their home country. After leaving Afghanistan, they could spend weeks or months in temporary housing on a U.S. military base before being resettled in a community where they might experience discrimination.
“Once you’re finally resettled in the United States, the trauma doesn’t end the moment you arrive here,” Dr. Miller said.
For these reasons, physicians are advised to practice trauma-informed care when treating refugees. That approach to care is broader than simply being kind and empathetic, she said, although that is also important.
Some trauma-informed best practices for immigrants and refugees include creating an immigrant-friendly health care environment throughout the medical facility, including signage that welcomes patients in multiple languages. Physicians can also promote trust by letting the patient guide the prioritization of care and asking for permission to discuss difficult topics.7
Applying these principles to treatment may affect how physicians take a medical history, for instance.
“In medicine we’re always thinking, ‘I need the full history so I know what happened and I can determine what kind of testing and treatment this patient needs.’ But getting some of that history can be really traumatizing,” Dr. Miller said. Instead, she said, think about “What do I need to know right now to make sure this person can safely access the care that they need versus what is something I don’t necessarily need to know right now that can wait until I have a relationship with this patient?”
Even asking about family can be sensitive for patients if they were separated from their loved ones or had family members killed by the Taliban, Dr. Truchil said. She offers sympathy about a patient’s situation but, to help put the patient at ease, doesn’t push for details of personal experiences.
She added, “We assume that these people have been through very traumatic events and want to create a safe environment for them where they can associate feeling safe with receiving health care.”
References
- The White House. Remarks by President Biden on the end of the war in Afghanistan. August 31, 2021. Accessed November 9, 2021. https://www.whitehouse.gov/briefing-room/speeches-remarks/2021/08/31/remarks-by-president-biden-on-the-end-of-the-war-in-afghanistan/.
- S. Department of Homeland Security. DHS announces fee exemptions, streamlined processing for Afghan nationals as they resettle in the U.S. Department of Homeland Security. November 8, 2021. Accessed November 10, 2021. https://www.dhs.gov/news/2021/11/08/dhs-announces-fee-exemptions-streamlined-processing-afghan-nationals-they-resettle.
- Centers for Disease Control and Prevention. Guidance for clinicians caring for individuals recently evacuated from Afghanistan. CDC Health Alert Network (CDCHAN-00452). September 20, 2021. Accessed November 10, 2021. https://emergency.cdc.gov/han/2021/han00452.asp
- DelacourH, Brondeix A, Kedzierewicz R, et al. β-thalassemia carriers in Afghanistan: a prevalence estimate. Ann Biol Clin (Paris). 2013;71(4):503-504.
- Department of Homeland Security. Operation allies welcome. Accessed November 9, 2021. https://www.dhs.gov/allieswelcome.
- Centers for Medicare & Medicaid Services. Health coverage options for Afghan evacuees. November 1, 2021. Accessed November 10, 2021. https://www.medicaid.gov/medicaid/eligibility/downloads/hlth-cov-option-afghan-evac-fact-sheet.pdf.
- Miller KK, Brown CR, Shramko M, Svetaz MV. Applying trauma-informed practices to the care of refugee and immigrant youth: 10 clinical pearls.Children (Basel). 2019;6(8):94.
