The COVID-19 Burden of Disease on Refugees and Immigrants

Source: Tarik Endale

COVID-19 has affected so many vulnerable communities in our world. Refugees and immigrants are two such groups who have had to bear the burdens of this disease, ultimately affecting their finances, families, and mental wellbeing. Mental health programs worldwide have converted to telehealth services to help address some of these needs.

Tarik Endale is the Program Manager of the Kovler Center Child Trauma Program (KCCTP), a program of Heartland Alliance International in Chicago that provides mental health and social services to immigrant and refugee youth who have experienced trauma. He has an MSc in Global Mental Health from the London School of Hygiene and Tropical Medicine and King’s College London and a Bachelor of Science in International Health and Psychology from Georgetown University. He will begin a Ph.D. in Clinical Psychology at Columbia University in the fall, working with Dr. Lena Verdeli in the Global Mental Health lab.

Jamie Aten: How did you first get interested in this topic?

Tarik Endale: I come from a family of refugees and immigrants from Ethiopia. Their, as well as my, experiences have been a major driver for my broad interest in public health approaches with refugees and immigrants in the US and abroad, specifically focusing on mental health. This paper came about after the Kovler Center Child Trauma Program’s (KCCTP) rapid transition from providing completely in-person mental health and social services for immigrant and refugee youth and their families in Chicago to a completely remote service provision model almost overnight. Knowing how much we scrambled for guidance, we thought it would be valuable to document our experience for others.

JA: What was the focus of your study?

TE: KCCTP works with immigrant and refugee youth between the ages of 6-21 who have had traumatic experiences, including but not limited to war, terrorism, forced migration, family separation, state-sponsored torture, and resettlement. In our first year of services in Chicago, KCCTP has seen an incredibly diverse set of youth and families, with 24 countries and 24 languages represented. Approximately half of our participants are Spanish-speaking, half are between the ages of 13-17, and slightly more than half were unaccompanied minors or experienced family separation and/or detention.

This population is particularly vulnerable during the COVID-19 pandemic as many are low-income, undocumented, may not have health insurance, face language and technology barriers to healthcare and education, and are excluded from government relief packages. Many are also part of minority groups that are disproportionately represented among the sick and dying, work in industries that put them at elevated risk of infection, and are particularly hard hit by the economic fallout of the pandemic. Immigrants and refugees are underrepresented in research, but what research exists indicates a high prevalence of posttraumatic stress symptoms and exposure to pre-migration trauma and post-migration stressors. This paper drew on the observations of KCCTP program staff and responses of program participants in the face of COVID-19.

JA: What did you discover in your study?

TE: Many of the parents and youth were laid off and had difficulties accessing resources such as unemployment insurance, leading to food and housing insecurity. Awareness and concern regarding COVID-19 itself were variable, but general levels of worry and anxiety increased. Social distancing and school and work closures led to increased boredom and isolation, negatively affecting youth wellbeing. Meeting basic and material needs was a priority for many youths and their families.

KCCTP’s response was comprised of four key components: information, active outreach, extensive case management, and telehealth/online communication. Early on there was a lack of accessible, accurate information on COVID-19, public health measures, and local resources in many families’ languages. So, an early and ongoing focus was finding or translating these materials and distributing them via text and WhatsApp. Therapists and case managers proactively reached out to youth and families, regularly checking in to assess wellbeing and mitigate isolation. Staff assessed needs and coordinated financial, food, housing, and educational services. Kovler Center also created a donation and distribution process to further mitigate these hardships. When possible, therapists continued intensive, evidence-based therapies via video conferencing platforms. They also provided lower-intensity but more frequent psychosocial support to youth with those platforms or on the phone, as well as running virtual groups to foster social connectedness and creating or sharing exercise, relaxation, meditation, or educational videos.

JA: Is there anything that surprised you in your findings or that you weren't fully expecting?

TE: From previous research literature and experience, we knew that despite the prevalence of posttraumatic stress symptoms and other mental health problems, refugee and immigrant families are often more focused on economic survival and experience significant mental health stigma, making positioning mental health services within a framework of supportive case management and coordination with school and other services important. However, it was still somewhat surprising the degree to which the stress of the social and economic fallout from COVID-19 surpassed the fear of the disease itself.

This experience has displayed the feasibility of telehealth with refugee and immigrant populations, while also highlighting key challenges such as technology access and literacy as well as privacy in large or multi-family homes. Moreover, while not surprising, working with these families during this pandemic highlighted inequalities in health, education, and economic opportunity as a result of racism and immigration policies.

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JA: How can readers use what you found to help others amidst this pandemic?

TE: The biggest takeaway from all of this is how important it is to pay attention to the structural and socioeconomic realities of those we work with, especially if they are part of a marginalized or vulnerable group. Without a conscious effort to account for these factors, it is easy to miss the needs and priorities of clients, which can reduce the effectiveness of traditional psychotherapy. We must acknowledge these barriers and do what we can to ameliorate their harms, while also acknowledging the strength and resilience it has taken to survive despite them.

JA: What are you currently working on that you might like to share about?

TE: During the pandemic, KCCTP has temporarily paused our standard battery of mental health and wellbeing assessments to respond to current needs. KCCTP has developed and been using a brief assessment of COVID-19’s effects on mental health, access to resources, and social connectedness in order to better serve those in our program. As we wrap up the second round of this assessment, we look forward to getting a better understanding of what these past months have been like on a group level.

Personally, I am working on a series of papers on drivers and challenges to implementing global mental health programs that draw on the experiences of dozens of innovators from around the world. I have learned a lot during this process, working with a team of folks affiliated with the Mental Health Innovation Network, and I am looking forward to sharing the past few years’ worth of work.