Even when refugees resettle in a safe environment, they often continue to face physical and emotional hardships and are at increased risk for mental disorders and other harm. According to a study published in the AMA Journal of Ethics, clinicians serving refugee patients need to pay special attention to the social determinants of health and should use a capabilities approach to support this population.
In a case study, Julie M. Aultman, PhD, program director of the Medical Ethics and Humanities Program and professor of medical ethics and humanities at Northeast Medical University in Rootstown, Ohio, sought to evaluate the social determinants of refugee health that either promoted or diminished freedom to achieve well-being.
Dr Aultman applied the capabilities framework to analyze a case scenario involving a teenage resettled refugee, RJ, who presented with vitamin B12 deficiency, anemia, and symptoms of mental illness. RJ further reported difficulties in assimilating feelings of isolation and depression, which may have stemmed from physical and emotional trauma endured during migration and 4 years living in a refugee camp.
Dr Aultman suggested that the therapeutic relationship of refugees with their treating physicians should be established in a broader social context. Besides understanding their general health conditions, it is important to understand social determinants of health — the relationship of a patient’s environment to their health status — and to recognize the rights of individuals seeking asylum and how past abuses and human rights violations contribute to their social, emotional, and physical condition.
The capabilities approach asks, what is RJ able to do? What resources for resettlement can enable RJ to fully function? And what social determinants prevent his ability to fully function? This theoretical framework attempts to align how a refugee like RJ values his own health with his other values, such as supporting his family and finding work. For example, malnourishment and fatigue can negatively affect employment opportunities or the ability to work. Furthermore, an integrated team approach to refugee health can provide valuable information and resources, including social workers and case managers that help refugees secure long-term health care benefits, access to healthy foods, and community support.
Mental health is often a sensitive topic among resettled refugees and clinicians need to understand refugees’ perceptions of mental illness and their unwillingness to seek help. Continued isolation increases suicide risk and mental health care should be framed in ways that are sensitive to the refugees’ values and beliefs. For example, rather than explain depression as a mental disorder, health care providers may explain the condition in physiological or neurochemical terms.
The capabilities framework can guide clinicians caring for resettled refugees and recommends promoting their capabilities and acknowledging their emotional and social circumstances. The author writes, “Framing health and disease around what patients understand and value can contribute to a better therapeutic relationship and serve as a starting point for improving refugee health.”
Aultman JM. How should health care professionals address social determinants of refugee health? AMA J Ethics. 2019; 21: E223-E231.