In a Global Pandemic, Afghan Refugees in N.C. Face a Challenging Health Care System

This story originally published online at N.C. 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 September 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 percent 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

Lincoln Community Health Center pediatrician Emily Esmaili said her organization is getting ready to help Afghan refugees. 

In a recent interview, Esmaili said workers at Lincoln Center did not know how many refugees were coming to North Carolina. Primary care providers at Lincoln will likely be informed 24 to 48 hours prior to refugees’ arrival.

She said her clinic will provide temporary Medicaid to the Afghan refugees, which may last between six and nine months. 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 does not offer different financial assistance programs, beyond a sliding fee scale based on income. When the short term Medicaid benefits end, the refugees can reapply for the program, if they meet the requirements for Medicaid they will get it again.

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 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 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.

Do you want to help? 

“Any help is always accepted, such as groceries, gifts cards, linens and other household items, baby formula, new baby items or gently used, toiletries, and kitchen items,” Razai wrote in a WhatsApp message. “Also Halal restaurants’ gift cards will be perfect.”

Contact: Lutheran Services Carolinas in Raleigh

Call: 1 800 HELPING

Volunteer: Contact: volunteer@LSCarolinas.net

Donate to refugee services 

Support independent local journalism. Join the INDY Press Club to help us keep fearless watchdog reporting and essential arts and culture coverage viable in the Triangle. 

Comment on this story at backtalk@indyweek.com.