Afghan refugees in North Carolina face challenging health care system

America’s healthcare system can be confusing, even for people who grew up in this country. Imagine being new here and trying to find your way around.

By Nadia Batool Bokhari

Azita Razai has lived in Raleigh for 24 years, settling with her husband, mother and three children Ali Razai, 22, Kauser Razai, 15, Sakina Razai, 7.

His trip to North Carolina from his native Afghanistan more than two decades ago included a stop in Pakistan before arriving there as a refugee. Like many refugees arriving here today, she fled the Taliban in her home country.

Her memories of leaving her home in Kabul are still painfully fresh. Her family left with little more than the clothes they could wear.

Her father quickly took her and her sisters to the Pakistani border, trying to protect her daughters from Taliban soldiers who had a reputation for raping girls and young women. They were trying to get to a relative who was also an Afghan refugee and who was already living in Pakistan.

For almost a year and a half, Razai lived in Pakistan near the Afghan border, commuting between parents’ homes and a refugee camp with his mother and siblings.

The conditions were tough.

Sometimes there could be up to seven family members living together in a room. At the camp, there were around 20 refugee tents, each with eight to nine people living inside.

For the more than 150 refugees camping there, Razai said, there was not even a single doctor. There was only one nurse, an Afghan refugee, she added, bearing the brunt of health care for all pregnant women and other camp residents who fell ill.

“There was only one nurse and no one from the World Health Organization,” Razai recalls. “My younger brother caught malaria… The children were often sick.

Now in North Carolina, more than two decades later, Razai remembers his time in those camps and his early days in that state.

Since the US military withdrawal from Afghanistan last month, once again disrupting the country at the “crossroads of Asia,” North Carolina and other states have been bracing for a wave of Afghan refugees.

shows two adults and three young people, sitting and smiling at the camera
Former Afghan refugee Azita Razai and her family. Photo courtesy of: Azita Razai

Those who find themselves in North Carolina will arrive in a state where the Delta variant of SARS-COV-2 is raging. They will be confronted with this global threat to public health while learning to navigate a very different health system that is difficult to understand even for people here..

North Carolina expects 1,169 Afghan refugees in the coming month, according to the Associated Press, and Razai is raising contributions to help them. This is part of her work with Lutheran Services Carolinas, where she works as an interpreter and translator.

Razai was hired weeks ago to be an assistant case manager for the agency to help relocate families coming to the state.

His own experiences will help him guide a new generation of Afghan refugees through the complexities of the new systems and bureaucracies they will encounter during the difficult times of fresh start in a foreign country.

A different health system

The health care system in Afghanistan is very different from that in the United States.

The World Health Organization, or WHO, warned on September 22 that a system that had become fragile in recent years was on the verge of collapse. Much of the international aid that flowed into the country before the Taliban took power has been held back in recent weeks by countries and organizations uncertain about the new regime.

Even before the Taliban takeover, there were disparities in access to health care for residents of metropolitan areas and rural provinces of Afghanistan, even more pronounced than similar disparities in North Carolina. In 2018, according to a WHO report, there were 3,135 functional health facilities, ensuring that nearly 87% of the country had access to care within a two-hour drive of their home.

There are public hospitals and emergency care centers where residents have to pay very little to queue for care. Many don’t have the latest advances in medical technology, and some aren’t as clean as healthcare facilities in the United States, Razai said. There are also private clinics and hospitals that charge more for patients. Doctors who work in public facilities sometimes work by moonlight in private health centers, which pay more and set different rates for procedures and treatments.

Health insurance is a foreign concept in Afghanistan.

This will not be the case for refugees in North Carolina. They will find a health care system that requires heaps of paperwork and can seem almost prohibitive without Medicaid and Medicare, government insurance plans, or private insurance plans that employers often supplement.

In this country, the type of health care a person receives is often too closely tied to their income and personal wealth.

Because many refugees have had to leave a lot of things behind and may not immediately find well-paying jobs, Razai predicts that accessing health care will be a huge challenge for new Afghan refugees.

Local clinics are preparing

Emily Esmaili is a pediatrician who works at the Lincoln Community Health Center in Durham.

In late August, Durham Mayor Steve Schewel said the city had already taken in several Afghan refugee families and expected many more to settle there in the coming months.

shows young woman in blue shirt smiling at camera, doctor ready to deal with Afghan refugees
Lincoln Community Health Center pediatrician Emily Esmaili said her organization was preparing to help Afghan refugees. Photo courtesy of: Emily Esmaili

In a recent interview, Esmaili said workers at Lincoln Center did not know how many refugees were coming to North Carolina. Primary care providers in Lincoln will likely be notified 24 to 48 hours before refugees arrive.

She said her clinic would provide temporary Medicaid to Afghan refugees, which could last between six and nine months. But that could be complicated as many arrive in this country as evacuees, unable to obtain the assistance typically provided to refugees through the federal Department of Health and Human Services, according to the Associated Press.

The Biden administration has called on Congress to act to make newcomers eligible for such assistance.

Nonetheless, Lincoln has a low-cost pharmacy, where Afghan refugees in Durham region could get whatever medicine they might need.

Lincoln does not offer any different financial assistance programs beyond a sliding income-based fee scale. At the end of short-term Medicaid benefits, refugees can reapply for the program, if they qualify for Medicaid, they will get it again.

In July, North Carolina had about 90 refugees receiving Medicaid, but by September that number had risen to 149.

Esmaili, the daughter of Iranian immigrants, says she can easily understand the language barrier and some of the cultural barriers that Afghan refugees will face. She has also treated other refugees in Lincoln before.

For those who do not speak English, the clinic may need to seek help from relocation agencies to arrange interpretation into a particular language.

“We have access to a system of telephone interpreters which is able to reach interpreters from all over the country, and although it is often difficult to find interpreters for the rarer languages,” Esmaili said.

Rod Jenkins, director of County Durham’s public health department, said his staff were ready to welcome the refugees. But he did not know the precise number of refugees arriving in Durham. He said he had heard from different sources that between 60 and 150 families were coming.

Many Afghan refugees were airlifted to Dulles International Airport. The Federal Emergency Management Agency set up a COVID vaccination site nearby and offered refugees the single-dose Johnson & Johnson vaccine, according to news reports.

By the time the refugees arrive in Durham and other places in North Carolina, Jenkins said, they should already be vaccinated against COVID in Virginia. Otherwise, Jenkins added, “we always invite everyone to get the vaccine without any kind of discrimination like race, nationality, religion, color.”

The minority community is part of the influx

Some of the Afghan refugees likely to arrive in North Carolina are from the Hazara minority community. The Hazaras make up 15 to 20 percent of the total population of Afghanistan, and they are Shia Muslims, while most Afghan Muslims are Sunnis.

Many Hazaras, who attach great importance to education and have higher literacy rates than most other Afghans, have worked as translators, cooks, drivers and other service positions for the United States military. These relationships put them in danger.

Additionally, sectarian differences meant the community was targeted by the Taliban during their previous period in power.

Their language is Hazargi and many do not understand Pashto, Dari or Persian, the other languages ​​spoken in Afghanistan. Razai said that in North Carolina there were few Hazaragi language interpreters.

Jenkins said his department will access a language line to translate the health issues of Afghan refugees.

“But we don’t have any type of program to hire short-term or permanent Afghan refugee interpreters for our system,” he said.

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