The U.S. withdrawal from Afghanistan and the subsequent evacuation of 123,000 civilians has created another wave in the ongoing refugee crisis. Historically, refugees and displaced persons have faced a number of challenges, including finding access to housing, school, healthcare and other social determinants of health.

Inadequate services, language barriers and the transient nature of refugee status can often prevent these individuals from having their medical needs met. 

Today a number of innovators, doctors and NGOs are looking to help these populations access medical services digitally. Whether it be enabling telehealth visits from a refugee camp or helping folks find housing, technology has become a popular way to tackle some of the biggest issues in refugee health.

Challenges with caring for refugee groups

The world was in the midst of a refugee crisis before the Taliban takeover in Afghanistan. According to the U.N. Refugee Agency, more than 82 million people worldwide were forcibly displaced in 2020. 

The agency reports 86% of the world’s refugees, and Venezuelans displaced abroad, move to developing countries, and most end up in countries neighboring their homes. 

John Casillas is executive director of GlobalRise, a nonprofit that works to improve nutrition and health among children in developing countries. The nonprofit has recently worked in Uganda, a country that hosted more than 1.4 million refugees in 2020, according to the World Bank. 

“The refugee settlements are part of our vision. But we don't go to the refugee centers,” Casillas said. “One reason is because security is an issue. We don't have the capacity to go into war zones or into any kind of dangerous places.

"There's a lot of work to do outside of that, but we can't do that. Right now, anyway, we would work with an NGO that would, that could. Maybe they have security guards that help them, and so forth.”

Another barrier to using health technologies with refugees can be the healthcare resources available in their host country. 

A study published in the Journal of Medical Internet Research used interviews with key informants and providers in Lebanon who cared for the Syrian refugee population. Researchers found many providers didn’t have the time or resources to scale their investment in tech.

“We do not always have the time [to use the HIS],” one nurse told the researchers, referring to health information systems. “We do a hundred things at the same time.”

“What we found is that the challenge is not from the refugees’ side, but mostly from the end of healthcare systems,” Dr. Reem Talhouk, a study author and vice chancellor research fellow at Northumbria University, wrote in an email to MobiHealthNews.

“As we present in our JMIR paper, healthcare systems that refugees access are often resource constrained, and this makes investment in technologies less likely, especially when it is [in] technologies that are designed specifically for refugees and not the larger population that is accessing the healthcare services.”

Participants were also divided on whether refugees had the health and technological literacy needed to use the tools. Some felt it was difficult to implement because refugees were a mobile population in a possibly unstable environment.

“Here we cannot ignore the social and political rhetoric in the countries receiving refugees and how that influences healthcare providers’ perceptions of refugees,” Talhouk wrote.

“Therefore, what we propose is that health technologies should be designed in a manner that creates a space for refugees to practice and demonstrate their agency rather than being passive beneficiaries of the technology. It is within such spaces that refugees can challenge the stereotypes and assumptions being made about their capabilities.”

In some cases, a population’s literacy rate was able to help boost adoption of digital tools. 

“There is a different kind of physiology of the Syrian refugee crisis than the previous refugee crisis we've seen. One is that Syria was a middle income country before the war. So the population is very literate and text savvy,” said Dr. Aral Surmeli, founder of HERA, a digital health platform for refugees.

The literacy gap may pose another challenge for healthcare providers working with Afghan refugees. In 2004, the most recent year available from the World Bank, about 81% of Syrians ages 15 and up were literate. In comparison, in 2018, only 43% of Afghans were literate.

But there are plenty of benefits to using digital health with refugees, even if the implementation is complex.

“Refugees are usually living with relatively low income levels and what our research has shown is that the cost of transportation to and from health clinics can be a big barrier that technology can help overcome,” she wrote. 

“When we piloted community radio shows that connected Syrian refugees to healthcare providers in Lebanon through a mobile app, refugees identified that being able to ask questions to ascertain if they need to go to the clinic is a huge benefit.

"They also valued being able to engage with healthcare providers from the comfort and safety of their own living spaces, especially since they reported having had negative experiences in healthcare clinics where they felt unwelcome.”

What has digital health for refugees looked like?

Despite the challenges, many doctors and entrepreneurs are looking to address the unmet medical needs of refugees with technology. Surmeli, a physician in Turkey, was inspired to create digital health tool HERA after working with Syrian refugees. 

“My experience is in disaster medicine and refugee health. And obviously, with the influx [of Syrian] refugees since the Syrian war kind of pushed us to focus on them a lot. We provided care mainly in Turkey, in Istanbul and the border cities.

"And that's actually when we thought HERA up, because we saw that their primary way of getting information and being connected was their mobile,” Surmeli said. “And luckily, we do have free healthcare for refugees in Turkey. But the issue becomes the demand side. So we need to bring people to the healthcare services available.”

While working in refugee health, Surmeli and his team began to notice a trend. 

“We saw that a lot of [refugees] did not have vaccinations because preventive health kind of loses its priority when you're in a new country. You have to navigate finding a home, finding schooling for your children, finding a job, and then healthcare kind of loses its priority,” Surmeli said. 

This prompted Surmeli and his team to focus on two main areas: vaccinations and maternal health. 

“Basically, what they do is they download the app, and they put [a] very little amount of data for user friendliness and also take concerns like security and privacy. Using the last menstruation date for the pregnant women or the date of birth of the children calculates automatically when they need to go for a pregnancy check or vaccination dates using the Turkish vaccine calendar,” Surmeli said.

The tool was also developed to help displaced individuals find resources in their new country. For example, the app helps refugees figure out how to access emergency services. 

“Syria did not have a centralized ambulance system. So we're used to calling it like 911 when there's an emergency, but they don't actually know that. They see the ambulances, but they don't actually know the number.”

Surmeli and his team are looking to meet the needs of new immigrant groups coming into the country. In the future, he said, the literacy gap could be solved by using a voice assistant. In-person and online workshops could also be a way to help folks who are less tech savvy access the tools. 

But this isn’t the only effort to help refugees get access to care. In a 2019 HIMSSTV interview, Brian de Francesca, CEO of Ver2 Digital Medicine, discussed how his organization used telemedicine to help connect refugees with doctors from their home country. 

“So you have these physicians around the world who want to help their countrymen in the refugee camps. So you have Syrian, Sudanese, Bangladeshi – all these people stuck here, and these doctors here,” de Francesca said. “But there is a gap in the middle. So that is where we come in.

"There is connectivity everywhere. We provide that bridge, so to speak, so that a Syrian doctor in Canada can do a teledermatology consultation with a Syrian girl in [the] Bicall valley in Lebanon.”

De Francesca explained that while there are often barriers to healthcare and education in refugee camps, there is often some kind of cellular connectivity in refugee camps, and a wealth of doctors dispersed around the world. 

“It’s a very elegant solution to a very serious problem. Here we have millions and millions of refugees without access to healthcare, and we literally have hundreds of thousands of doctors willing to work for free,” he said. 

Solutions for Afghan refugees

In light of the recent refugee crisis in Afghanistan and amid the larger global issue, a number of tech companies have stepped up to offer their help. 

As masses of Afghan people flee their homes, Airbnb and its independent nonprofit organization, Airbnb.org, have committed to providing temporary housing to 20,000 Afghan refugees worldwide at no cost. They are working with nonprofits such as the International Rescue Committee, Church World Service and HIAS to help resettle displaced people. 

“Refugees currently leaving Afghanistan are doing so with nearly zero personal possessions and starting a journey in a new, foreign country,” a spokesperson for Airbnb told MobiHealthNews via email. 

“There is no better way to welcome someone to a new community than by welcoming them to a home – and we have an incredible community of generous hosts who have demonstrated time and time again a willingness to open their homes to people in times of need.”

Refugee populations represent some of the most marginalized and vulnerable groups in the world and are at an increased risk for poor health outcomes. As they resettle in new countries, they must figure out a number of factors related to the social determinants of health, including finding employment, continuing their education, building social connections, accessing public services and securing housing. 

Of all these factors, having a safe and adequate place to live is of central importance to good health outcomes, according to a study published in the International Journal of Environmental Research and Public Health. It says that housing is a key indication of a successful integration and includes testimonies from refugees that share just how important a home is to their health. 

“Everybody needs accommodation to feel safe in it, which is very important,” said Mina, a Middle Eastern refugee resettled in Australia. “If you had a place, then you’ve got peace of mind, and that helps to reduce your anxiety.”

Since announcing its support, the Airbnb team has connected more than 300 Afghan refugees and families to temporary housing in the U.S., including in Sacramento, northern Virginia, Cleveland, Atlanta, Dallas, Seattle and New Jersey.

Airbnb received so much response from the public following its announcement, it’s also allowing hosts to open their homes to additional refugees for free or at a discounted price. The company is also accepting donations to help connect people with temporary housing. 

“While Airbnb.org, with Airbnb’s support, has committed to cover the cost of housing 20,000 refugees worldwide, the additional generosity from hosts offering free stays will help connect more refugees to temporary housing,” the spokesperson said. “Existing hosts or anyone with extra room who is interested in supporting these efforts can welcome a refugee and sign up at airbnb.org/refugees.”

Although refugee housing through Airbnb is only temporary, its nonprofit partners are assigning a case manager to each person to support their long-term needs as they settle into a new country.

Inspired by Airbnb’s efforts, the multi-specialty telehealth provider Hims and Hers shared that it will donate 10,000 free primary care and mental health visits to relocated Afghan refugees. 

The announcement was sparse in its details, but said that Hims and Hers will work with “select NGOs and other relevant partners” to spread awareness to refugees that it’s offering free visits. Hims and Hers will cover the cost of the appointments, and it's searching for additional U.S.-licensed providers and translators to help its efforts. 

Across the pond, U.K. tech home care provider Cera is tackling another social determinant of health for refugees: employment. The startup has pledged to recruit, train and employ 500 Afghan refugees as carers. 

Cera uses technology to deploy services such as social care, nursing and repeat prescriptions in people's homes. 

As a part of its initiative, Cera will work with 160 local councils and the government to get some of the 5,000 incoming refugees a job. The move may also boost the U.K.'s workforce in the social care sector, which currently has around 112,000 vacancies.

While these companies were able to quickly respond to the current refugee crisis, others are still working to stand up support systems. 

A spokesperson for the community-based organization referral company NowPow confirmed to MobiHealthNews that the company is in the process of transitioning its existing tools for immigrants to support refugees as well. 

“NowPow has always been committed to improving access to care and health equity for vulnerable populations, and that commitment extends to refugees. We know our country has vital community resources that can aid the resettlement process and strengthen the health and well-being of refugees, but these resources are only as good as a person’s ability to access them,” Rachel Kohler, CEO of NowPow said in a statement. 

“NowPow’s focus on whole person care across whole communities uniquely positions us to identify resources that are highly matched to the unique needs of refugees – and together with our customer and community partners, we are working to foster critical connections so refugees can get the help they need and deserve.”

NowPow’s platform works by connecting health systems, providers and health plans to community resources in their area that they can then refer to patients. 

Its database already includes services for the unique needs of immigrants, many of which will also be applicable to refugees. These include citizenship preparation services, English as a second language (ESL) classes, healthcare, housing and resettlement assistance, advocacy and legal support, as well as translation and interpreter services. NowPow can offer referrals in a variety of modes, including text, email or a printed document in more than 100 languages. 

Users can also filter the platform based on the specific needs of their population, whether they’re documented or undocumented immigrants, refugees or asylum seekers. 

While scores of doctors, digital health companies and NGOs are looking to help, Talhouk said that it’s always important to remember to include the patients in the design. 

“Another challenge is understanding and defining what we are designing the technology for. Is the technology being designed just so that refugees can access healthcare, or are we also designing it to improve the relationship between refugees and the healthcare system? … Once we start designing for relationships and experiences, then the scope of the technology and the interactions it mediates may radically shift.

"We need this shift, but that would require more commitment from the healthcare system both in principle as well in resources.”