“Little did I know that would be me a few years later,” said Bahige.

Bahige’s harrowing refugee journey began when he was kidnapped and forced to become a child soldier when war broke out in his country, which became the Democratic Republic of Congo in 1997. He escaped at age 15 to a Mozambique refugee camp, where he lived for five years until he arrived in Baltimore in 2004 through a .

Bahige, now 42, said the way he grew up was to “just buckle up and tough it out,” and he carried that philosophy into adjusting to life in the U.S. He worked multiple jobs and took community college classes until he went to the University of Wyoming on a scholarship. He is now an elementary school principal in Gillette, Wyoming, and said his coping strategy, then and now, is to keep himself busy.

“In retrospect, I don’t think I ever even dealt with my own trauma,” he said.

Refugees are arriving in the U.S. in greater numbers this year after resettlement counts reached . These new arrivals, like those refugees before them, are to have post-traumatic stress disorder, depression, and anxiety. Many of them, like Bahige, fled their homelands because of violence or persecution. They then must deal with the mental toll of integrating into new environments that are as different as, well, Wyoming is from Central Africa.

This has Bahige concerned about the welfare of the new generation of refugees.

“The type of system that a person lived in might be completely different than the new life and system of the world they live in now,” Bahige said.

While their need for mental health services is greater than that of the general population, refugees are much less likely to receive such care. Part of the shortfall stems from societal differences. But a big factor is the overall in the U.S., and the myriad obstacles and barriers to receiving mental health care that refugees encounter.

Whether they end up in a rural area like the Northern Rocky Mountains or in an urban setting such as Atlanta, refugees can face months-long waits for care, plus a lack of clinicians who understand the culture of the people they are serving.

Since 1975, have been admitted to the United States. The annual admissions dropped during the Trump administration from about 85,000 in 2016 to 11,814 in 2020, according to the State Department.

President Joe Biden raised the cap on refugee admissions to 125,000 for the 2022 federal fiscal year, which ends Sept. 30. With fewer than 18,000 arrivals by the beginning of August, that ceiling is unlikely to be reached, but the number of people admitted is increasing monthly.

Refugees receive mental health screening, along with a general medical assessment, within 90 days of their arrival. But the effectiveness of that testing largely depends on a screener’s ability to navigate complex cultural and linguistic issues, said Dr. Ranit Mishori, a professor of family medicine at Georgetown University and the senior medical adviser for Physicians for Human Rights.

Although rates of trauma are higher in the refugee population, not all displaced people need mental health services, Mishori said.

For refugees dealing with the effects of stress and adversity, resettlement agencies like the International Rescue Committee provide support.

“Some folks will come in and immediately request services, and some won’t need it for a few years until they feel fully safe, and their body has adjusted, and the trauma response has started to dissipate a little bit,” said Mackinley Gwinner, the mental health navigator for the IRC in Missoula, Montana.

Unlike Bahige’s adopted state of Wyoming, which has no refugee resettlement services, IRC Missoula has placed refugees from the Democratic Republic of the Congo, Syria, Myanmar, Iraq, Afghanistan, Eritrea, and Ukraine in Montana in recent years. A major challenge in accessing mental health services in rural areas is that very few providers speak the languages of those countries.

In the Atlanta suburb of Clarkston, which has a large population of refugees from Myanmar, the Democratic Republic of the Congo, and Syria, translation services are more available. Five mental health clinicians will work alongside IRC caseworkers under a new program by the IRC in Atlanta and Georgia State University’s Prevention Research Center. The clinicians will assess refugees’ mental health needs as the caseworkers help with their housing, employment, education, and other issues.

Seeking mental health care from a professional, though, can be an unfamiliar idea for many refugees, said Farduus Ahmed, a Somali-born former refugee mental health clinician at the University of Colorado School of Medicine.

For refugees needing mental health care, stigma can be a barrier to treatment. Some refugees fear that if U.S. authorities find out they’re struggling with mental health, they could face deportation, and some single mothers worry they will lose their children for the same reason, Ahmed said.

“Some people think seeking services means they’re ‘crazy,’” she said. “It’s very important to understand the perspective of different cultures and how they perceive mental health services.”

Long wait times, lack of cultural and language resources, and societal differences have led some health professionals to suggest alternative ways to address the mental health needs of refugees.

Widening the scope beyond individual therapy to include peer interventions can rebuild dignity and hope, said Dr. Suzan Song, a professor of psychiatry at George Washington University.

Spending time with someone who shares the same language or figuring out how to use the bus to go to the grocery store are “incredibly healing and allow someone to feel a sense of belonging,” Song said.

In Clarkston, the Prevention Research Center will soon launch an alternative allowing refugees to play a more direct role in caring for the mental health needs of community members. The center plans to train six to eight refugee women as “,” who will counsel and train other women and mothers using a technique called narrative exposure therapy to address complex and multiple traumas.

The treatment, in which patients create a chronological narrative of their lives with the help of a therapist, focuses on traumatic experiences over a person’s lifetime.

The therapy can be culturally adapted and implemented in underserved communities, said Jonathan Orr, coordinator of the clinical mental health counseling program at Georgia State University’s Counseling and Psychological Services.

The American Psychological Association, though, narrative exposure therapy for adult patients with PTSD, advising that more research is needed.

But the method worked for Mohamad Alo, a 25-year-old Kurdish refugee living in Snellville, Georgia, after arriving in the U.S. from Syria in 2016.

Alo was attending Georgia State while working full time to support himself when the covid-19 pandemic started. While downtime during the pandemic gave him time to reflect, he didn’t have the tools to process his past, which included fleeing Syria and the threat of violence.

When his busy schedule picked back up, he felt unable to deal with his newfound anxiety and loss of focus. The narrative exposure therapy, he said, helped him deal with that stress.

Regardless of treatment options, mental health is not necessarily the top priority when a refugee arrives in the United States. “When someone has lived a life of survival, vulnerability is the last thing you’re going to portray,” Bahige said.

But Bahige also sees resettlement as an opportunity for refugees to address their mental health needs.

He said it’s important to help refugees “understand that if they take care of their mental health, they can be successful and thrive in all facets of the life they’re trying to create. Changing that mindset can be empowering, and it’s something I am still learning.”

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Chaw, a recent refugee from Myanmar, received medical care at a community health center near her home in Clarkston, Georgia, a city of about 14,000 people. Her English is limited, but the center has an interpreter to translate health information into her native language, Burmese.

Her questions began to fade as a health worker sent her text messages about the vaccine in Burmese. She got the shots and then urged other refugees to get vaccinated, too.

“Some people have underlying diseases, like diabetes, and if they get [the virus], they can die,” she said. “If they have diabetes or high blood pressure, they should get vaccination more than other people.”

Public health officials and resettlement groups across the U.S. have used such community strategies to encourage newly arrived refugees and other vulnerable people to get vaccinated against covid. And in places like Clarkston, health officials say these kinds of grassroots efforts are working. The metro Atlanta city — the hub of refugee resettlement in Georgia — has a higher vaccination rate than its county or state.

Refugees generally have been disproportionately affected by covid.

Those newly resettled may experience living situations or employment conditions that increase their risk of contracting the virus. Some refugees enter the country with underlying medical conditions that increase their risk of developing severe illness, according to the . And in multigenerational households, protecting older family members in cramped housing arrangements can be difficult.

Some refugees face other significant hurdles to immunization, including language barriers, a lack of transportation, and irregular work schedules.

“We want to make sure that these pandemics aren’t disproportionately affecting folks of color, migrants, refugees, and other folks in vulnerable categories,” said Kat Kelley, senior director of migration and refugee services at Virginia-based . “If you have historically underserved communities, they’re going to remain underserved in any kind of crisis. You have to create a sustainable infrastructure that addresses those barriers.”

To create that infrastructure, the CDC for local health departments and community organizations that includes covid-related messaging on the disease and vaccines in more than 30 languages. It also for public health professionals, resettlement agencies, and employers on collecting data and work policies. And grassroots groups have hired bilingual, community-based workers to increase vaccination rates among refugees.

Unlike people who move to the U.S. from other countries by choice, refugees bound for the U.S. are to get vaccinations before they travel. Once in the country, all refugees receive a medical examination within 90 days of their arrival, during which providers discuss vaccinations.

The groups assisting the covid vaccine effort include the , a global nonprofit that provides emergency aid to refugees and has resettled more than 28,000 refugees in the Clarkston area over the past 40 years.

its diversity, with large populations of refugees from Myanmar, the Democratic Republic of Congo, and Syria. Community health workers and grassroots organizations there have been crucial in educating people about the covid vaccine, and organizers say their efforts have largely succeeded.

According to data compiled by the , 70% of Clarkston residents were fully vaccinated as of July. In DeKalb County, where Clarkston is located, that number was . The Georgia share, , is among the nation’s lowest.

The Georgia State center said Clarkston’s vaccination rate is estimated to be more than 20 percentage points higher than other DeKalb County areas that have similar , which assess communities on factors such as socioeconomic status; the density of housing; the availability of transportation and households; and race, ethnicity, and language. Outreach efforts in Clarkston are behind the higher vaccine rates there, said Mary Helen O’Connor, the center’s deputy director.

The Prevention Research Center at GSU hired five , each fluent in a different language, to promote the benefits of getting the covid vaccine. Kaeden Tun, of Myanmar, and Thomas Roger, of the Democratic Republic of Congo, are two of the workers serving the Clarkston area.

Roger said vaccine misinformation is a big challenge in Swahili-speaking communities, particularly among refugees from the Democratic Republic of Congo. Before resettling in Clarkston, Roger lived in a camp in Tanzania, and he said that that nation’s president, John Magufuli, who died in March 2021, denied the existence of covid and that many people were exposed to this misinformation on Facebook. Some people watched YouTube videos in Swahili linking the vaccine to satanic practices, Roger said.

He wasn’t surprised when people in Clarkston initially wouldn’t let him into their homes. At first, people saw him as an outsider. His friends associated him with the vaccine and wondered why he was getting paid to promote it. He developed strategies that worked best for the people he was trying to reach. To demonstrate that the shots are safe, he used his phone to record well-known members of the community as they got vaccinated.

Tun, who texted Chaw vaccine information, said he knew he was able to penetrate hard-to-reach communities when a family of Rohingya refugees — a people who historically have faced repression — recently attended a and got vaccinated.

“What surprised me the most is how receptive everybody has been with our work,” Tun said. “Because I can’t even imagine, with everything that’s been said about covid since it started, how confusing it might be for the community, especially with a language barrier.”

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Chaw es una refugiada que acaba de llegar a Estados Unidos desde Myanmar, y que recibe atención médica en un centro de salud comunitario cerca de su casa en Clarkston, Georgia, una ciudad de unos 14,000 habitantes. Su inglés es limitado, pero el centro cuenta con un intérprete para traducir la información sanitaria a su lengua materna, el birmano.

Sus dudas empezaron a disiparse cuando un trabajador de la salud le envió mensajes de texto sobre la vacuna escritos en birmano. Se vacunó y luego instó a otros refugiados a vacunarse también.

“Algunas personas tienen enfermedades subyacentes, como la diabetes, y si se contagian [del virus], pueden morir”, dijo. “Si tienen diabetes o presión arterial alta, deberían vacunarse antes que otras personas”.

Los funcionarios de salud pública y los grupos de reasentamiento en Estados Unidos han utilizado este tipo de estrategias comunitarias para animar a los refugiados recién llegados, y a otras personas vulnerables, a vacunarse contra covid. Y en lugares como Clarkston, los funcionarios de salud dicen que estas iniciativas de base están funcionando. La ciudad metropolitana de Atlanta —el centro de reasentamiento de refugiados en Georgia— tiene una tasa de vacunación más alta que la de su condado o el estado.

En general, covid ha afectado a los refugiados de forma desproporcionada.

Los recién reasentados pueden experimentar situaciones de vida o condiciones de trabajo que aumentan el riesgo de contraer el virus. Algunos refugiados llegan al país con condiciones médicas subyacentes que incrementan el riesgo de desarrollar una enfermedad grave, según los (CDC). Y en los hogares multigeneracionales, puede resultar difícil proteger a los miembros de la familia de más edad que conviven en viviendas reducidas.

Algunos refugiados se enfrentan a otros obstáculos importantes para la inmunización, como las barreras lingüísticas, la falta de transporte y los horarios de trabajo irregulares.

“Queremos asegurarnos de que estas pandemias no afecten de forma desproporcionada a las comunidades de color, a los inmigrantes, a los refugiados y a otras personas vulnerables”, señaló Kat Kelley, directora de servicios de migración y refugiados de , con sede en Virginia. “Si hay comunidades históricamente desatendidas, van a seguir estándolo en cualquier tipo de crisis. Hay que crear una infraestructura sostenible que enfrente esas barreras”.

Para crear esa infraestructura, los CDC desarrollaron un conjunto de para los departamentos de salud locales y las organizaciones comunitarias que incluye mensajes sobre covid y las vacunas en más de 30 idiomas. También se estableció para los profesionales de la salud pública, las agencias de reasentamiento y los empleadores sobre la recopilación de datos y las políticas de trabajo. Y los grupos de base han contratado a trabajadores comunitarios bilingües para aumentar las tasas de vacunación entre los refugiados.

A diferencia de las personas que se trasladan a Estados Unidos desde otros países por decisión propia, los refugiados que se dirigen a Estados Unidos antes de viajar. Una vez en el país, todos los refugiados reciben un examen médico en los 90 días siguientes a su llegada. En ese momento, los proveedores hablan de las vacunas.

Entre los grupos que colaboran en la campaña de vacunación contra covid se encuentra el , una organización global sin fines de lucro que proporciona ayuda de emergencia a los refugiados y que ha reubicado a más de 28,000 personas en el área de Clarkston en los últimos 40 años.

, con grandes poblaciones de refugiados de Myanmar, la República Democrática del Congo y Siria. Los trabajadores sanitarios de la comunidad y las organizaciones de base de la zona han sido cruciales a la hora de educar sobre la vacuna contra covid, y aseguran que sus esfuerzos han tenido mucho éxito.

Según los datos recopilados por el (GSU), el 70% de los residentes de Clarkston estaban totalmente vacunados en julio. En el condado de DeKalb, donde se encuentra Clarkston, esa cifra era del . El porcentaje de Georgia, , está entre los más bajos del país.

El centro estatal de Georgia comunicó que la tasa de vacunación de Clarkston se sitúa más de 20 puntos porcentuales por encima de la de otras áreas del condado de DeKalb con puntuaciones similares en el , que evalúa a las comunidades en función de factores como el estado socioeconómico, la densidad de vivienda, la disponibilidad de transporte y hogares; y la raza, la etnia y el idioma. Los esfuerzos de alcance comunitario en Clarkston se traducen en tasas de vacunación más altas, según Mary Helen O’Connor, subdirectora del centro.

El Centro de Investigación sobre la Prevención de la GSU contrató a , cada uno de los cuales habla con fluidez un idioma diferente, para que promovieran los beneficios de vacunarse contra covid. Kaeden Tun, de Myanmar, y Thomas Roger, de la República Democrática del Congo, son dos de los trabajadores que prestan servicio en la zona de Clarkston.

Roger dijo que la desinformación sobre la vacuna es un gran problema en las comunidades de habla suahili, especialmente entre los refugiados de la República Democrática del Congo. Antes de reasentarse en Clarkston, Roger vivió en un campamento en Tanzania, y contó que el presidente de esa nación, John Magufuli, que murió en marzo de 2021, negó la existencia de covid y que muchas personas estuvieron expuestas a esta desinformación en Facebook. Algunas personas vieron videos de YouTube en suahili en los que se relacionaba la vacuna con prácticas satánicas, explicó Roger.

No le sorprendió que algunas personas en Clarkston no le dejaran entrar en sus casas. Al principio, la gente lo veía como un extraño. Sus amigos lo asociaban con la vacuna y se preguntaban por qué le pagaban por promoverla. Desarrolló estrategias que funcionaban mejor para las personas a las que intentaba llegar. Para demostrar que las vacunas son seguras, utilizó su teléfono para grabar a conocidos miembros de la comunidad mientras se vacunaban.

Tun, que envió un mensaje de texto a Chaw con información sobre la vacuna, se dio cuenta de que era capaz de penetrar en comunidades de difícil acceso cuando una familia de refugiados rohingya —un pueblo que históricamente ha sido víctima de represión— asistió recientemente a y se vacunó.

“Lo que más me ha sorprendido es lo receptivos que han sido todos con nuestro trabajo”, expresó Tun. “Porque no puedo ni imaginar, con todo lo que se ha dicho sobre covid desde que empezó, lo confuso que puede ser para la comunidad, especialmente con la barrera del idioma”.

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