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In a global pandemic, Afghan refugees in NC face a challenging health care system

A child looks at the aircraft as he is strolled towards his flight during an evacuation at Hamid Karzai International Airport, Kabul, Afghanistan, Aug. 24.
U.S. Marine Corps/ Sgt. Samuel Ruiz
A child looks at the aircraft as he is strolled towards his flight during an evacuation at Hamid Karzai International Airport, Kabul, Afghanistan, Aug. 24.

This story originally was published by North Carolina Health News.

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

Her journey to North Carolina from her native Afghanistan more than two decades ago included a stop in Pakistan before arriving in this country as a refugee. Like many of the refugees coming here today, she fled the Taliban in her home country.

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

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

For nearly a year and a half, Razai lived in Pakistan near the Afghanistan border, shuttling between the homes of relatives and a refugee camp with her mother and siblings.

Conditions were difficult.

At times, there could be as many as seven family members living in one room together. At the camp, there were about 20 refugee tents, each one with eight to nine people living inside them.

For the more than 150 refugees encamped there, Razai said, there was not even a single doctor. There was only one nurse, an Afghan refugee, she added, shouldering the weight of providing health care to all the pregnant women and other camp residents who became ill.

“There was only one nurse and no one from the World Health Organization,” Razai recalled. “My younger brother got malaria. … Children were often sick.”

Now in North Carolina, more than two decades later, Razai has been reminded of her time in those camps and her early days in this state.

Since the U.S. military pullout of Afghanistan last month, roiling the country at the “crossroads of Asia” again, North Carolina and other states have been preparing for a swell of Afghan refugees.

Those who end up in North Carolina will arrive in a state where the delta variant of SARS-COV-2 rages. They will face this global public health threat while also learning to navigate a very different health care system that’s challenging to understand even for people who are from here.

North Carolina is expecting 1,169 Afghan refugees, in the coming month, according to the Associated Press, and Razai is gathering contributions to help them. It’s part of her job 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 with the resettlement of families coming to this state.

Her own experiences will help guide her in coaching a new generation of Afghan refugees through the complexities of the new systems and bureaucracies they will encounter during the difficult times of starting anew in a strange land.

Different health care system

The health care system in Afghanistan is vastly different from the American one.

The World Health Organization, or WHO, cautioned on Sept. 22 that a system that had grown fragile in recent years was on the verge of collapse. Much of the international aid that had been flowing into the country before the Taliban took over the government has been held back in recent weeks by countries and organizations unsure about the new regime.

Even before the Taliban takeover, there were disparities in health care access for residents in the metropolitan regions 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 care facilities, ensuring that nearly 87% of the country had access to care within a two-hour drive from their home.

There are government hospitals and emergency care centers where residents have to pay very little to get in line for care. Many lack the latest advances in medical technology and some are not as clean as health care centers in the U.S., Razai said. There also are private clinics and hospitals that charge patients more. Doctors who work at government facilities sometimes moonlight at the private care centers, which pay more and set different rates for procedures and treatments.

Health insurance is a foreign concept in Afghanistan.

That won’t be the case for refugees in North Carolina. They will find a health care system that requires mounds of paperwork and can seem almost prohibitive to access without Medicaid and Medicare, the government-based 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 of the refugees had to leave much behind and may not immediately find high-paying jobs, Razai predicts that health care access will be a huge challenge for the incoming Afghan refugees.

Local clinics get ready

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

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

In a recent interview, Esmaili said workers at Lincoln Center did not know how many refugees were coming to North Carolina.

Some Afghan refugees might have access to Medicaid. But that could be complicated since many are arriving in this country as evacuees, unable to get the assistance typically provided to refugees through the federal Department of Health and Human Services, according to the Associated Press.

The Biden administration has asked Congress to act to make the new arrivals eligible for such assistance.

Nonetheless, Lincoln has a low-cost pharmacy, where Afghan refugees in the Durham area could get medicines they might need.

Lincoln has a number of financial assistance programs, making it the medical home for many of the most disadvantaged in the community such as refugees, Esmaili said.

In July, North Carolina had about 90 refugee Medicaid recipients, but by September, that number had grown to 149 people.

Esmaili, the daughter of Iranian immigrants, says she can easily understand the language barrier and some of the cultural barriers the Afghan refugees will have to face. She’s also treated other refugees at Lincoln before.

For those who don’t speak English, the clinic sometimes has to get help from resettlement agencies to arrange interpretation for a particular language.

“We have access to a phone interpreter system that is able to reach interpreters from across the nation, and while it is often difficult to find interpreters of the rarer languages” Esmaili said.

Rod Jenkins, director of the Durham County Department of Public Health, said his staff was ready to welcome the refugees. But he did not know the precise number for how many refugees are coming to Durham. He said he had heard from different sources that between 60 to 150 families were coming.

Many of the Afghan refugees were flown to Dulles International Airport. The Federal Emergency Management Agency set up a COVID-19 vaccination site nearby and offered the refugees the single-dose Johnson & Johnson vaccine, according to news reports.

By the time refugees arrive in Durham and other places across North Carolina, Jenkins said, they should already be vaccinated against COVID-19 in Virginia. If not, Jenkins added, “we always welcome everyone to get vaccinated without any type of discrimination like, race, nationality, religion, color.”

Minority community part of influx

Some of the Afghan refugees likely to arrive in North Carolina are from the minority Hazara community. Hazaras are 15 to 20 percent of the total population of Afghanistan, and they’re Shia Muslims, whereas most Afghani Muslims are Sunni.

Many of the Hazaras, who highly prize education and have a higher literacy rate than most other Afghanis, worked as translators, cooks, drivers and other service positions for the U.S. military. Those relationships have put them at risk.

In addition, sectarian differences meant the community was targeted by the Taliban during their prior time 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 are few Hazaragi language interpreters.

Jenkins said his department will access a Language Line to translate Afghan refugees’ health problems.

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

North Carolina Health News is an independent, non-partisan, not-for-profit, statewide news organization dedicated to covering all things health care in North Carolina. Visit NCHN at northcarolinahealthnews.org.

article first appeared on North Carolina Health News and is republished here under a Creative Commons license.