Keywords

Who Are Refugees?

They are not likely to be mentioned in a State of the Union address or in other public speeches.

They are usually not referenced in the debate about immigration reform.

They are rarely included in a school curriculum.

But they should be.

Every year, up to 75,000 refugees enter the United States as documented immigrants. They have fled horrible persecution, repressive governments, or death threats. They are invited to the United States to start their lives over, continuing the country’s long-standing tradition of welcoming persecuted people.

But often, their stories are lost among the statistics of the nearly 40 million foreign-born people who live in the United States [1].

Historical Context

As long as there have been wars, persecution, and political instability, there have been refugees. However, the two World Wars in the first half of the twentieth century left millions of people forcibly displaced or deported from their homes, necessitating the collaboration of the international community in drafting guidelines and laws related to their status, treatment, and protection. In July 1951, the United Nations convened a diplomatic conference in Geneva to “revise and consolidate previous international agreements” related to refugee travel and protection, and the legal obligations of states, based on principles affirmed in the Universal Declaration of Human Rights. This 1951 Convention relating to the Status of Refugees defined a refugee as someone who, “owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country” [2].

This definition initially applied only to people displaced “as a result of events occurring before 1 January 1951,” and some signatories further limited the scope of the definition to refugees from Europe. In 1967, acknowledging that “new refugee situations have arisen since the Convention was adopted,” a Protocol Relating to the Status of Refugees was signed, which removes the geographical and time limits of the original 1951 Convention.

Global Burden

It is staggering to consider the number of refugees and displaced people in the world today. The United Nations reports that at the end of 2010, there were over 43 million people in the world uprooted because of conflict or persecution [3].

Of these, over 15.3 million are refugees, who—in accordance with the 1951 Convention definition—are outside the country of their nationality. The United Nations High Commissioner for Refugees (UNHCR), established in 1950 to lead and coordinate international action to protect refugees, includes 10.55 million refugees in its “population of concern” [4], and 4.82 million Palestinian refugees fall under the responsibility of another UN agency, the United Nations Relief and Works Agency for Palestine Refugees (UNRWA). Almost 27.5 million people—known as internally displaced persons (IDPs)—have also been forced to flee their homes, but remain within the borders of their home countries [3].

Refugee assistance has changed dramatically since it was first organized over 60 years ago, with the mission of aiding European refugees from World War II. Today’s refugees originate from countries throughout the world and seek asylum—temporary or permanent—in countries throughout the world.

According to estimates, in 2010, refugees from Afghanistan represented 29 % of the global refugee population or 3.05 million of the 10.55 million persons under UNHCR’s responsibility. Iraq was the second largest country of origin of refugees (1.7 million), followed by Somalia (770,000), the Democratic Republic of the Congo (477,000), and Myanmar, formerly Burma (416,000) [5].

Pakistan hosted the highest number of refugees at the end of 2010, totaling 1.9 million. Other major countries of asylum included the Islamic Republic of Iran (1.1 million), the Syrian Arab Republic (1 million; Government estimate), Germany (594,000), Jordan (451,000; Government estimate), and Kenya (403,000) [5]. With each new conflict, these numbers can change dramatically. By March 2013, more than 1.1 million refugees from Syria were being assisted in neighboring countries such as Jordan, Lebanon, and Turkey [6]. Approximately 100,000 Syrian residents fleeing violence there have taken refuge in northern Iraq [7], even as Iraq continues to produce its own refugees.

Long-Term Solutions

People who work in refugee resettlement are often asked, “Are you resettling refugees from [insert here the political crisis currently in the media]?”

And the answer, sadly, is usually “No.”

Resettlement—a nation’s government inviting refugees to move to its country, access rights given to nationals, and obtain permanent residency leading to citizenship [8]—is usually a last resort and an option for very few. Each year, less than 1 % of the world’s refugees will be offered resettlement in a third country. For a comprehensive look at the history, challenges, and benefits of resettlement on a global scale, see UNHCR report by Piper et al. [9].

Before resettlement, other durable solutions are considered. UNHCR first pursues the possibility of voluntary repatriation, a refugee returning to his or her country of origin if it became safe. Another option is local integration, a refugee remaining in the country to which he or she has fled and integrating into the local community.

For a small percentage of the world’s refugees for whom the above options are not viable, resettlement becomes a possibility.

Currently, 26 countries have indicated a willingness to resettle refugees, but many of the programs are nascent and very limited in scope.

In fact, just three countries—the United States, Canada, and Australia—welcome 90 % of resettled refugees [10]. The United States alone resettles more refugees than all other countries combined.

Oftentimes, the decision of which refugees to admit is heavily influenced by political, economic, and social factors [9]. Unlike many other countries, the United States does not discriminate in its acceptance of cases based on a refugee’s likely ability to integrate. While other nations may reserve resettlement for refugees deemed to have high “integration potential”—based on their age, education, work experience, and language skills—the United States accepts refugees regardless of their socioeconomic status, employment history, medical history, or family composition [9]. Therefore, a refugee resettlement agency in the United States is as likely to serve a single mother from Somalia with five children as it is to serve a highly skilled engineer from Iraq and his schoolteacher wife. It may welcome as many refugees with chronic or serious health problems as it does healthy refugees. Cases may be a single individual or a family of ten. This practice ensures that the most vulnerable refugees have access to protection and resettlement in the United States.

United States Resettlement Process

Most refugees who are considered for resettlement in the United States are referred to the federal government by UNHCR, but in some cases a United States Embassy makes the referral. The Department of State’s Bureau of Population, Refugees, and Migration (PRM) oversees refugee assistance, including resettlement. PRM funds and manages nine Resettlement Support Centers (RSCs) throughout the world, which process refugee applications for resettlement in the United States. In some regions, refugees must physically present themselves to an RSC in order to receive assistance, but in other areas, RSC staff conduct “circuit rides” through vast territories to serve refugees in remote locations. After meeting with RSC staff, refugees are interviewed by officers from the United States Citizenship and Immigration Services (USCIS, within the Department of Homeland Security) to determine if they will be granted resettlement. The Department of Homeland Security conducts thorough background checks to ensure the refugees will not pose a threat to security. Refugees receive a health screening (known as the overseas health assessment) to identify conditions that might make them a public health risk; refugees with active infectious diseases would need to complete treatment prior to gaining admission to the United States. Approved refugees are then ready to travel to the United States—at their own expense, thanks to an interest-free loan from the International Organization for Migration.

The length of this process varies based on a refugee’s location and other factors, but the average time it takes for a refugee referred by UNHCR to actually arrive in the United States is from 12 to 15 months [11]. However, most refugees have waited years—and some for more than a decade—just to access the resettlement process and reach the point of a UNHCR referral. UNHCR estimates that at the end of 2010, 7.2 million refugees were in a protracted refugee situation—meaning that 25,000 or more refugees of the same nationality had been in exile for 5 years or longer in a given asylum country [12].

Each year, the President, in consultation with Congress, sets the numerical goals for refugee admissions during the upcoming fiscal year. This Presidential Determination is a ceiling rather than a floor and includes the total maximum number of refugees the United States will resettle in the coming year (70,000 in FY14), as well as a breakdown by geographic region.

Over the past 5 years, refugee admissions have ranged from 56,424 to 74,654 individuals per year. In FY12, although the ceiling was set at 76,000, just 58,238 refugees were admitted to the United States (see Fig. 1.1). The states that resettled the most refugees were Texas (5,925 individuals), California (5,177), Michigan (3,601), New York (3,528), Pennsylvania (2,810), and Georgia (2,520) [13]. Figure 1.2 shows refugee admissions across states in FY12.

Fig. 1.1
figure 1

Refugee admissions in the last 5 years. Refugees admitted to the US FY08–FY12 (data from Refugee Processing Center [14])

Full size image
Fig. 1.2
figure 2

Refugee arrivals by state, FY12 (October 1, 2011–September 30, 2012)

Full size image

In FY12, three nationalities accounted for 71 % of all refugee admissions: Bhutan (15,070 individuals), Burma (14,160), and Iraq (12,163). The remaining 29 % came from a total of 63 countries [14].

In the United States, refugees are assisted through a unique public–private partnership. At the federal level, the Department of State and the Department of Health and Human Services (HHS) work together to welcome refugees, by providing basic needs support and services to help them integrate into their new communities and become economically self-sufficient. The federal government contracts with nine national nongovernmental agencies; each has a network of affiliates (not-for-profit organizations) across the country—about 350 in total—which carry out the work of resettlement. There are resettlement agencies in nearly all 50 states. Large metropolitan areas, such as Houston, Minneapolis, and Atlanta, are often home to multiple resettlement agencies. If a refugee approved for resettlement in the United States knows someone already in the country—a relative or close friend—they can often be resettled in the same city. Without this connection, called a United States tie, the refugee would be randomly assigned to a city and resettlement organization that has the capability to serve refugees of their nationality and language group.

Because they have already had to share their persecution story numerous times—first to be granted refugee status by UNHCR, then to United States government officials—once refugees arrive in the United States, the resettlement agency focuses on helping them move forward and start life over.

Each affiliate organization adheres to the same federal regulations and must provide the same basic services delineated in a Cooperative Agreement signed yearly with PRM. The initial resettlement period, called the Reception and Placement (R&P) program, is for 30–90 days after arrival, during which the agency must provide housing, food, clothing, and other basic needs; enrollment in benefits such as food stamps, medical insurance, and social security cards; help accessing health care, English class, and employment services; and cultural orientation including instruction on United States laws and customs. One federal requirement stands out among the others, a reminder of the importance of offering hospitality to refugees: when refugees arrive to their new home, the resettlement agency must provide them with a hot, culturally appropriate meal [15].

Funding to affiliate agencies is on a per capita basis; for each refugee resettled, the affiliate receives $1,925 (as of FY14), $1,125 of which is to be given to or spent on behalf of the refugee for basic needs and $800 of which is for the agency’s expenses including program staff and operating expenses. This government funding is not meant to cover the total cost of resettlement; each affiliate must raise private funds to supplement and relies heavily on community members who volunteer their time and donate in-kind goods.

Many organizations operate additional programs and services funded by the Office of Refugee Resettlement (ORR, an office within HHS) and other government and private sources. Overall, financial assistance to refugees usually lasts no more than 6 months after arrival, although more limited services might be available for years after arrival. Regardless of the city in which a refugee resettles, an urgent priority is that he or she finds work quickly after arrival and becomes economically self-sufficient. Refugees are expected to apply for legal permanent residency after 1 year in the United States (commonly known as receiving a green card) and for citizenship after 5 years in the United States.

When they arrive, refugees are eligible for many of the safety net programs available to low-income United States citizens, including the Supplemental Nutrition Assistance Program (SNAP, commonly referred to as “food stamps”). A refugee family with children will likely be eligible for cash assistance through the Temporary Assistance for Needy Families (TANF) program and for medical insurance through Medicaid. Refugees determined ineligible for TANF and Medicaid may be eligible for Refugee Cash Assistance (RCA) and Refugee Medical Assistance (RMA) for up to 8 months from the date of arrival in the United States [16]. The Refugee Act of 1980 (which created the Office of Refugee Resettlement and formalized the federal refugee resettlement program) allows for the federal government to reimburse states for RCA and RMA for up to 3 years after a refugee’s arrival in the United States [17]; unfortunately, over the years funding for this program has reduced steadily, to the current provision of only 8 months of benefits.

Refugees and the Health Care System

Having Medicaid coverage does not necessarily make it easy for refugees to access medical care. Refugees face many barriers in accessing care, including lack of English language ability, cultural differences in approaches to health, and unfamiliarity with the American health care system. The federal government recognizes the importance of caring for the health needs of refugees and mandates that refugee resettlement agencies help clients receive a comprehensive health exam, initiated within 30 days of arrival. The purpose of this domestic health assessment is to ensure follow-up of any serious conditions identified during the overseas medical examination, identify conditions of public health importance, and diagnose and treat health conditions that may adversely affect resettlement. Each state, however, implements these guidelines differently—often based on the public health capacity of the state—so the scope and organization of health assessments vary widely from state to state [18]. Some states have public health departments that provide this initial screening; in states that do not, the resettlement agency must find a community health center or other health-care provider who will screen and treat refugees.

In many states, it is difficult to find appointments for refugees at health clinics that accept Medicaid and consistently provide interpretation services. In these situations, the resettlement agency might need to make special arrangements with a health-care provider. Since refugees may lose their Medicaid coverage after just 8 months in the United States, it is essential for them to receive not only primary care but also specialty care and any procedures or surgeries they need, within this time frame. Refugees are eligible for Affordable Care Act (ACA) benefits and this may increase refugees’ access to health insurance in the coming years.

A refugee’s ability to access health care and address their health needs is one factor in his or her ability to successfully become self-sufficient in their new homes. The work of refugee resettlement is both big—helping a refugee learn English, find work, and support themselves in a new country—and nuanced, such as teaching someone the difference between prescription and over-the-counter medication, how to discern between official mail and junk solicitations, and why they should not pick flowers from their neighbor’s front yard.

Though the United States currently welcomes fewer than one-half the refugees it did in decades past, it is also important to remember that it provides more than half of the world’s resettlement. Assisting these refugees in their path to self-sufficiency and citizenship requires the commitment of federal, state, and local governments, as well as the contributions of money, volunteer time, professional skills, and friendship of thousands of residents across the country.