More than 45 million refugees, immigrants, and migrants (RIM populations) in the US, disproportionately affected by the COVID-19 outbreak, were joined in 2021 by nearly 300,000 new refugees recently evacuated from Afghanistan, Syria, and Iraq, and who are currently housed at U.S. army bases across the country.
According to health experts, immunization rates are lower in these communities due to language barriers and shortages of health services. But new immigrants also fear the vaccine due to misinformation, religious beliefs, or lack of awareness. That puts recent arrivals at higher risk of exposure to COVID-19, said the CDC.
Advocates warned that new refugees still dealing with the trauma of escaping war-torn countries struggle with getting a vaccine.
“Escaping war doesn’t mean you totally survive,” cautioned Syrian refugee Rehab Alkadi, at a CDC Roundtable on Dec 9, where representatives from Afghan, Syrian, and Iraqi refugee communities discussed the challenges of vaccine access.
“Here I started my life from scratch.” Alkadi, who came to the US in 2015, is a medical case manager with the Syrian Community Network in Dearborn, MI. “I tried hard to adapt to a new culture, new country, and new language. This is the situation for all Syrian refugees who came to the United States.”
Her community of recent Syrian evacuees are people “with fear planted inside them,” said Alkadi. “They have lost their trust in the system. Too many people are still suffering after the war.”
Dr. Fahim Pirzada, a public health expert who came to the US from Afghanistan in 2014, agreed. “Afghan society was really hit hard by their refugee status during the pandemic.
Pirzada, a Visiting Professor of Public Health at UC Davis School of Medicine works with the Afghan refugee community in Sacramento.
“Like many other minority groups, they are disadvantaged in terms of accessing culturally competent services, healthcare, and education.”
“Covid pandemic information for our society was always second hand, by word of mouth,” said Pirzada. “Since the information was not provided in Dari and Pashto, their primary language, “not everyone in the community had access to correct information.” Limited language access was complicated by the low literacy rate in women (29 % in Afghanistan), and their dependency on men in their families for information.
So, “a lot of interventions are complicated.”
Pirzada said he checked the CDC for facts before getting his Covid shot so he could explain its efficacy in his native language to family, friends, and community and encourage them to get vaccinated. “I was able to read English, not everyone does,” he said.
Misinformation and conspiracy theories have made it more difficult to convince communities the vaccine is safe, said Pirzada.
“The biggest challenge is false information,” said Omar Al Dabagh, a staff analyst with Houston’s health department. “There are false messages spreading in the community that the vaccine’s not effective and has side effects.”
People are hesitant to get immunized because “Anti western elements in Afghanistan were trying to say that vaccines modify your beliefs,” added Pirzada.
In the conservative Afghan community, people were suspicious of a vaccine they regard as ‘haraam’ (forbidden by their religion), explained Rona Popal, despite reassurances from Imams and religious leaders that Islam does not forbid vaccinations. Popal, Executive Director of the Afghan Coalition in Fremont, said that the vaccine rollout last year coincided with the holy month of Ramadan when people who were already fasting all day, did not want to get a vaccination.
In Lincoln, Nebraska, Juma Ali Nazari, a 2016 arrival, works as a case manager at the Nebraska State Penitentiary. He said recent newcomers would “not be willing to get the vaccination because some people believe that life and death belong to Allah, to God. How do you convince them to get vaccinated?”
“The Afghan community is very traditional, and they believe so strongly in Islam, so faith organizations play a very crucial role,” in clarifying the benefits of the vaccine,” noted Pirzada.
But Popal warned that recent Afghan arrivals leaving US army bases “are not thinking right now about how to get vaccinations or how to stay healthy.” As they leave their tented cities and seek resettlement. “Housing is the most critical issue.”
Afghan newcomers were suffering “mental health, anxiety and desperation,” observed Popal, because “they are on the verge of homelessness.”
The Afghan Coalition houses newcomers in AirBnBs and shelters for one or two months, but after that “It’s really a big question what they’re going to do,” Popal added. “Health issues or vaccinations are at the bottom of their list.”
“How can a family focus on vaccines when they do not have a home?” remarked Mizgon Zahir, a consultant with the Afghan Coalition.
Though some newcomers were vaccinated at army camps, noted Popal, others did not believe in vaccinations. Controversial messaging on social media has created doubters.
“They believe it is some sort of medication you give to people to control them,” said Hazim Raskawka, a Yazidi refugee outreach coordinator for Lincoln Asian Center, who is based in a Kurdish camp. “Some just don’t believe there is a virus.”
AJ Fallah, a 29-year-old Iraqi refugee, simply refuses to see COVID-19 as a real threat.
He told the panel, “I’m not the kind of person who likes to take medicine for everything. I like to keep my body natural.” Fallah works in medical transportation in Detroit and has resisted taking Covid 19 shots. He resents vaccine mandates for healthcare workers.
Fallah wears a mask every day to prevent transmitting the virus but said he doubts the vaccine’s efficacy because he has seen breakthrough infections happen to people who are already vaccinated.
Though Fallah caught the virus last August, he claimed “It wasn’t that bad for me,” rating his bout with Covid a 2 on a scale of 1 to 10.
In 2020, Nazari and his wife got Covid. “It was not a good experience,” he said.
Moustafa Aldiba, a taxi driver in Detroit, and his wife Fatima Mohamad Ali said their entire family caught Covid when their children were exposed to the virus at school. The severity of the disease among the unvaccinated in their community convinced the family to get their shots. “Covid 19 does not discriminate. It affects everybody, young or old,” they said.
Getting new arrivals vaccinated is proving harder than expected for the CDC. Advocates said that linguistically and culturally appropriate messaging could facilitate interventions in vaccine-hesitant communities.
“We really need to educate them about this vaccination. The way they are not believing in the system, it will take time. It will take a lot of outreach,” declared Popal.
“How we can help this society, our women especially, is through local organizations and local interventions,” said Pirzada. “We have a large number of qualified immigrants here who are able to help.
When the pandemic hit, Alkadi collected facts about Covid 19 and designed her own communications in Arabic to help vulnerable Syrian newcomers overcome distrust of the vaccine.
In April 2021, she posted Arabic translations on the SCN website and formed an Arabic WhatsApp group to encourage her community to get vaccinated. She featured Arabic-speaking health experts on Zoom meetings and video recordings, and also hosted an imam who ‘spoke about the vaccine from an Islamic perspective,” to reassure her community. Alkadi said she scheduled 100 vaccine appointments through these efforts.
Nazari, who leads a network of 180 Dari-speaking Hazaris, urged the CDC to share in language information through workshops and door-to-door conversations with immigrants.
Dabagh, the president of Houston’s Iraqi-American community, recommended in-language messaging by Arab and Afghan community health employees.
A good messaging strategy should focus on emotional connections, said Raskawka whose wife and daughter remain in a displacement camp. “The point that convinces people to take the vaccine talks about love for the family.”
Communication could cut through vaccine fears, added Alkadi, by focusing on the vaccine’s benefits and why staying unvaccinated is dangerous. Messaging should emphasize that by “protect yourself first and then protect your community and loved ones.”
In the next 12 months, the US expects to resettle up to 125,000 refugees. But the CDC is prepared said Dr. Emily Jentes, an epidemiologist at the CDC’s Immigrant, Refugee, and Migrant Health (IRMH) Branch. She has led a collaboration with the University of Minnesota National Resource Center to develop communication materials around COVID-19 and vaccinations that would resonate with RIM communities.”
The NRC-RIM has built vaccine confidence campaigns that are free to use and available in 40 languages. Their MAKESPACE website offers linguistically and culturally appropriate designs to help communities create and customize their own covid campaign materials.
“It’s really changed the way we think at CDC about creating communication material” for COVID-19 messaging said Jentes. “We’re really trying to build materials that are designed for inclusivity.”