A Diverse Refugee Population Requires Complex Solutions

During the past two decades, the Twin Cities experienced an unprecedented increase in refugees from Southeast Asia, the Horn of Africa and Latin America. Most of these immigrants were political and war-zone refugees who arrived in the United States with a broad range of trauma-related injuries in addition to the problems attendant upon dislocation from one's homeland and traditional culture. The Community-University Health Care Clinic (CUHCC), in a poverty-line neighborhood in Minneapolis, was designated as the major primary health care facility to develop medical, psychiatric and outreach services for these refugee populations. The CUHCC represents a joint academic and community enterprise committed to providing care for a traditionally underserved urban neighborhood. The clinic is funded by a variety of federal, state, county and private foundation grants.

The life experiences encountered by most disaster-zone refugees can be divided into several phases of varying duration and duress (Table 1). The last phase (demoralization) occurs among the less successfully assimilated families as the early hopefulness of the refugee family and the generosity and patience of the host country wane.

In thinking about refugee health problems and planning and implementing various types of services, there is a dynamic interaction between the commonality of all refugees by virtue of their humanness and their exposure to invasion, occupation, violence, lawlessness, persecution and loss and the differences between the refugee groups in terms of national, ethnic and cultural history and customs; vastly different trauma and escape experiences; and different degrees of preparedness for the accommodations necessary to survive and flourish in the United States (Kroll et al., 1989). Finally, there are individual differences among human beings in constitution, life experience, personality and resilience, as well as cohort differences such as in the case of Southeast Asian refugees whether one emigrated to the United States in the first waves in the early 1980s or came belatedly 15 to 20 years after these initial groups (Bowman, 1999; Brewin et al., 2000; Westermeyer, 1987).

This article will present the clinical experience of the different ethnic and national refugee groups at CUHCC. Our experience with Latin American refugees is very limited; therefore, this group will not be discussed. The only caveat to bear in mind is the inherent problem in making generalizations about national characteristics and experiences; however, generalizations are as necessary as individualization to clinical research and work.

Cultural Influences on PTSD

Despite our awareness that the countries of Europe are very different from each other, Americans might have thought of the peoples of Indochina as essentially homogeneous prior to the Vietnam War. On the contrary, the prewar culture and the experience of the war were vastly different for each of the ethnic groups comprising Southeast Asia. There were differences between the Cambodian four-year experience of the Khmer Rouge killing fields; the Hmong experience of (from their point of view) working for the Central Intelligence Agency and the U.S. government until they were abandoned in 1975 and thereafter moving from village to village in the jungle under Communist attack; the Lao experience of ground warfare against the Communists alternating with heavy aerial bombardment from U.S. forces; and the Vietnamese experience of heavy ground warfare against a very disciplined army while contending with a demoralized home front. In addition, surviving Lao and Vietnamese military officers and government officials were sent to Communist re-education camps in wilderness areas for many years to clear jungles and build irrigation systems. The families of the men interned at these camps faced economic and social persecution.

An obvious, but often overlooked, individual difference between refugees is their age at the time of each phase of the war and at the time of escape. For example, a cohort of Cambodians born between 1972 and 1978, now in young adulthood, experienced fetal and childhood starvation conditions. While studies just from the Hunger Winter (1944-1945) in the Netherlands suggested increased morbidity of psychiatric illness of those in gestation during this famine (Brown et al., 2000), we have seen almost no Hmong with schizophrenia in our 25 years at the clinic. We would welcome comments and feedback from other clinical centers about this observation.

The Somali experience of the Civil War of 1991 and its aftermath is vastly different from the Southeast Asian wars. There was sporadic violence and lawlessness and a repressive regime in Somalia prior to 1991. Then, with the sudden collapse of all government authority, the country erupted into anarchy and unchecked internecine slaughter between clans. Somali patients seen at the clinic fall into two very different categories. The majority of Somali patients are middle-aged women whose experience, if it were not so horrific, sounds very stereotypical. A band of marauders break into a house, shoot and kill the menfolk in front of the women, and then beat and rape the women sometimes literally next to the dead male bodies. This may be a hit-and-run assault or the marauders may stay for hours to days, with repeated sexual assaults. Occasionally, the younger women are abducted when the bandits leave, usually not to be seen again. The surviving family members, usually women and children, flee by whatever means possible, often without the opportunity to bury their dead.