Building a Community of Solution with Resettled Refugees

The crisis of migrants across the globe is of increasing concern, and communities in every nation are faced with providing competent, equitable and culturally appropriate services for resettling refugees. Communities seeking solutions often find that health centric disciplines are not enough to meet the challenges presented by these newly arriving populations. In this article, we present the “Communities of Solution” model proposed in the 1966 Folsom Report, Health is a Community Affair . The Folsom report recognized that healthy communities can be achieved with strong community partnerships, person-centered health care and a focus on public health. In retrospect, Folsom focused firmly on the determinants of health that today shape our thinking about health, health care, and mitigation of disparities. In this article, one community’s efforts demonstrate a multi-faceted approach that is revitalizing an area.


Introduction -Resettling Refugees in America
A refugee has "been forced to flee his or her country because of persecution, war, or violence, and … a well-founded fear of persecution for reasons of race, religion, nationality, political opinion or membership in a particular social group" [1]. As of 2015, the United Nations High Commissioner for Refugees (UNHCR) reports that the number of forcibly displaced people is approximately 59.5 million persons, due to global conflicts and a "world at war" [2].
Approximately 70,000-80,000 refugees are resettled annually in the United States, with an increase of 10,000 for displaced Syrian families requested of Congress for the next fiscal year. In 2014, the United States accepted a total of 69,986 refugees, with greater numbers settling in Texas (7214), California (6108), New York (4082), Michigan (4006) and Florida (3519). Other states resettled between single numbers and over 2,000 refugees in the same year [3]. Several voluntary organizations "VolAgs" and their affiliated agencies work closely with the U.S. State Department and the federal Office of Refugee Resettlement (ORR) to provide needed resources to refugee individuals and families in their new neighborhoods [4].
Currently, resettled refugees receive an array of services, including health insurance for up to 8 months (after the eight-month period, refugee individuals and families have access to the health marketplace, under the Affordable Care Act); with affiliated agencies in individual communities helping refugees in the first months by welcoming them upon arrival (often meeting them at airport, train or bus stations), arranging housing, linking to health assessments and health care, providing access to English as a Second Language (ESL), and helping children and adults enroll in school [3]. An important component of refugee resettlement is job skills training, and connections to the local work force (Figures 1 and 2). Around the country, ORR helps to fund a network of Centers for Survivors of Torture, as many refugees have witnessed, or undergone, extreme forms of torture within their home countries. The ORR website offers many multi-lingual resources for refugees and agencies alike, including newsletters and up-to-date information on resettlement issues [5]. However, as more refugees enter U.S. cities each year, there are ongoing concerns about local capacity to provide adequate support services [6].Challenges exist in the on-going delivery of social services, health care, job opportunities, housing, education and other realms, all within culturally and linguistically appropriate contexts. In each locality, based on the strengths, talents and resources available, solutions must be formed in answer to the specific needs of resettled refugee communities.

Communities of Solution
The 1966 Folsom Report, "Health is a Community Affair" presents a blueprint for the integration of public health and medical care in order to develop and sustain healthy communities. The Report was prompted by ideas within President Lyndon B. Johnson's "Great Society", and spearheaded by Marion Folsom, a U.S. Secretary for Health, Education and Welfare [7]. The authors of Folsom recognized that healthy communities can be achieved with strong community partnerships, person-centered health care and a focus on public health. In retrospect, Folsom focused firmly on the determinants of health that today shape our thinking about health, health care, and mitigation of disparities [8]. A compelling aspect of Folsom was the call to encourage civil discourse: "Underlying the mood of a community's action is its attitude concerning the rights of individuals and groups and their acceptance of each other. This civility of relationships, or its lack, is a significant factor in the health problems of a community…a pattern of friction among ethnic groups, socio-economic levels, or sub-regions of the city may adversely affect concerted community action" [7]. 50 years later in our 21st Century, the Institute of Medicine and other bodies echo these sentiments, citing multiple evidence-based studies that health disparities are most evident among minority communities. The 2013 CDC report on health disparities in our nation cites that "approximately 30 communities in the United States indicate that residents in mostly minority communities continue to have lower socioeconomic status, greater barriers to health-care access, and greater risks for, and burden of, disease compared with the general population living in the same county or state" [9]. Causes of disparities range from the way health systems are organized and care is delivered (for example, the lack of professional interpreters and translators for non-English speaking persons); patients' attitudes and levels of health literacy; and inherent biases and lack of cultural awareness among providers themselves [10].  In a re-look at Folsom, a group commissioned by the American Board of Family Medicine acknowledged that the Folsom goals of "transforming personal and population health" have pointed relevance for the challenges faced by today's communities; and re-emphasized the Folsom idea of a "Community of Solution" -where community boundaries define a framework within which health and public health problems can "be identified, dealt with and solved" [11]. In the current U.S. health and medical arena, increasing emphasis is placed on the importance of population health, the integration of public health and primary care, and collaborations between disciplines not traditionally health centric. The concept of a Community of Solution provides a dynamic structure within which diverse communities, such as resettling refugee populations, may address problems by a coalescence of grass roots gatherings, University and college based professionals, community organizations and agencies, governmental bodies, and citizens.

Integrating Diversity -Evolving Solutions
In 2015, New York State remained the 3rd largest resettlement destination after Texas & California. In 2014-2015, New York took 3,904 refugees, most of whom (1,320 or 33.8%) resettled in Buffalo [12].
Countries of origin for most recent arrivals are Burma, Bhutan, Iraq, Somalia and Sudan. With four resettlement agencies, Buffalo has a strong tradition and long experience in welcoming immigrants and refugees; the Western New York region offers more affordable housing and lower costs of living than are available in downstate New York areas. As in many other U.S. cities where refugees resettle, in Buffalo a community of solution is developing around these "new Americans" [13].
Because of a strong economic revival, the city of Buffalo has been signaled as one of the top "rising cities" in America, in part due to its vibrant immigrant and refugee communities [14-16].
A 2014 report, Strengthening the Western New York Safety Net, assessed the urban West Side of Buffalo, where the majority of incoming refugees initially settle [17]. Acknowledging that refugees have become a source of increased population and community revitalization, the report recognizes struggles relating to poverty, transportation, employment, health and mental health care, and use of adequate, trained interpreters. Recommendations from the report specifically targeting refugee populations include: raising awareness of the law mandating use of trained interpreters for individuals of limited English proficiency, advocacy for a longer benefit window for newly resettled refugees, and improved access to health and mental health services, as well as enhanced provider training in cultural awareness.
Similar challenges and recommendations for change came out of two Buffalo Refugee Health Summits (2014, 2015), sponsored by the Office for Global Health Equity (OGHE) in the School of Public Health and Health Professions, University at Buffalo [18]. The OGHE pursues research, scholarship and evaluation locally and globally, with its local focus on the health and wellness of refugees and immigrants. A Refugee Strategic Advisory Group convenes community stakeholders, and facilitates the Refugee Summits (Table 2).
Participants in the 2014 Summit described barriers to mental health and a lack of trauma informed care, poor understanding on the part of medical providers about cultural differences about health care within refugee communities, suboptimal interpreter services, particularly by pharmacies and insurers, poor care coordination among health providers, and an overall deficiency in cultural education for both refugee individuals providers of care and community members.
The Strategic Advisory Group for Refugee Health was created out of an expressed need for a small advisory group advocating for culturally-engaged health care provision for refugees in Buffalo and Western New York. The advisory group is composed of representatives from resettlement agencies, health care providers, community support centers, and University at Buffalo faculty. It is funded and facilitated by the University at Buffalo School of Public Health and Health Professions' Office of Global Health Initiatives.

Contributing agencies include:
Buffalo  In the 2015 Summit, recommendations focused on five areas, with each area co-led by a University and a refugee community member; 1) developing a community health worker network, hiring and training refugees, 2) enhancing research, education, training and best practices in cultural and linguistic competency, 3) improving culturally and linguistically appropriate mental health services, 4) understanding current health status and needs of refugees for preventive and wellness care, and 5) expanding the local provider recruitment and referral network [19].
Working groups for each of these five areas meet on a routine basis to move projects forward. These projects are complemented by an array of other area working groups, representing education, employment, the arts, health and mental health care, law, government,

Education
For example, local colleges and academic institutions are fostering academic-community partnerships, as well as educating students from many disciplines about global challenges and local solutions. On-going research in many University and college departments seeks to identify and address problems and questions centered on diverse populations and health disparities.
Buffalo's public school, #45, or the International School, serves children in grades pre-k through 6th -representing over 30 countries, with 70 different languages spoken.

Government
The city government has sponsored an Office for New Americans (ONA), modeled after the New York State initiative, with a goal of supporting new Americans and giving them the tools they need to succeed [20]. The Office is closely connected to the courts system and works with the police department, to ensure appropriate use of trained interpreters, and culturally relevant services. ONA leads a "refugee roundtable" which focuses on issues beyond healthcare, bringing in diverse groups interested in working toward discovering service gaps and working with the community to develop solutions.

Health care
In addition to two existing Federally Qualified Community Health Centers in Buffalo, primary care is supported by a third, newly acquired Federally Qualified Health Center with a focus on refugees, the Jericho Road Community Health Center [20]. All three centers provide on-site interpretive services. Jericho Road uses a practice model by hiring within refugee communities, and offering special services such as the HOPE Refugee Drop In Center and the Priscilla Project. The Priscilla Project, in particular, links medical students with refugee women recruited from the local community who are anticipating their first birth experience in the United States or are having at-risk pregnancy. The students help the women navigate through the steps of prenatal care, often an unfamiliar experience for many of the pregnant refugee women.
The Western New York Center for Survivors of Torture is a program of Jewish Family Service of Buffalo and Erie County in collaboration with the University at Buffalo Department of Family Medicine and Journeys End Refugee Services [21]. Now funded through the Office of Refugee Resettlement, the center seeks to "address the consequences of refugee trauma and political and state-sponsored torture experienced by survivors living in Western New York; an intensive, strength-based, client-centered, care coordination model that supports individuals and their families in their healing process and empowers them through community-based collaboration. " One facet of the Center is to provide medical and psychiatric forensic examinations for refugees seeking asylum in the United States.

Students
Many students from all health trainee schools of higher education in Buffalo are involved with refugee populations as volunteers, as students in training, and as mentors. For instance, medical students and residents in the Jacobs School of Medicine and Biomedical Sciences are involved at each level of their training. Global health initiatives often include a local component. As mentioned, medical students may serve as mentors for refugee women throughout their pregnancies. One medical student group, the Jacobs School of Medicine and Biomedical Sciences Human Rights Alliance is closely connected with the Center for Survivors of Torture. Students and physicians have received training in asylum work from Physicians for Human Rights, and Health Right International. Serving as scribes, the students work with Attending physicians conducting forensic exams of clients. Students then help in the preparation of affidavits for clients and their immigration attorneys.

Resettlement
Four resettlement agencies work closely with refugee clients and families, and with each other, to provide support and education, and empower refugees in their new surroundings. Agencies are closely connected to the social services network, maintain connections with refugee support centers and support the Buffalo Immigrant Refugee Empowerment Coalition (BIREC) [22]. Resettlement leaders are an integral part of the Refugee Strategic Advisory Group, and the annual Refugee Health Summits.

Community action agencies
Partnership for the Public Good (PPG) [23] provides "research and advocacy support to a broad array of partners who share a communityoriented vision of a revitalized Buffalo-Niagara (region). " PPG has been instrumental in partnering with refugee communities to highlight issues and provide educational resources and raise community awareness. Two goals in their 2016 Community Agenda speak to refugee needs: language access across the county; and targeted hiring for disadvantaged workers on projects that receive public funding.
HEAL International [24] or Helping Everyone Achieve Livelihood, helps to "bridge the cultural divide" for new arrivals. Programs include Centers for youth and education, conflict resolution, women empowerment and economic development. HEAL is a supporting agency of the Refugee Strategic Advisory Group.
The Westminster Economic Development Initiative, Inc. (WEDI), founded by the Westminster Presbyterian church, exists to empower disadvantaged populations on the West Side of Buffalo, the area of most refugee resettlement [25]. WEDI offers the "Energy" literacy program, business training and technical assistance, and business microloans. One of its programs, the West Side Bazaar, offers commercial retail space particularly for foodservice and service industries, geared toward helping recently arrived refugees to learn and start new businesses in Buffalo. Over fifty refugee-initiated small businesses have been started with WEDI's support. The Bazaar has been featured on NPR, and in Katie Couric's "Rising Cities" [16].
Buffalo String Works (BSW) is an organization that "aims to benefit an under-served population on Buffalo's West Side by creating an enriching musical community-providing high-quality instruction on stringed instruments and performance opportunities" [26]. The agency recognizes that many of the children served are refugees: "because we serve a community that comprises recently displaced families from all over the globe, we recognize the importance to our students and our community of music as a universal language. Thus we are encouraged by the creative outlet we provide for children searching for a sense of belonging in a new community. "

"Folsom" Forward
Strong community partnerships, person centered health care and a focus on public health, civility of relationships and a goal of disparity reduction, all echoes of the Folsom Report, are part of Buffalo's resurgence; its evolving community of solution for refugee individuals and families. Evaluation and assessment of policies and programs contributing to refugee health and wellness are taking place at many levels. One of the important goals of the Office for Global Health Equity is to focus on a "cycle of progress" that facilitates research, implementation and evaluation centered on equity in global health and well-being [27]. Local foundation funding sponsors on-going work in evaluating programs, developing projects and facilitating community action. At the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, interprofessional education, research and practice trains and assesses future health care workers from health science disciplines. Over the past 30 years, Buffalo has developed a network of services and a pattern of civility in action that has allowed the "city of good neighbors" to become a promising community of solution for resettled refugees. Predicated on Folsom, Buffalo's new frontier is embracing partnerships working toward solutions.