DETROIT — Their home is warm and full of richly spiced aromas, a vast improvement from the chaotic tent cities where they lived while fleeing war in Sudan. Refugee advocates have spent months helping them get settled, signing them up for Medicaid and food stamps and dental care.

Maryam Hassan Yahqub is grateful. But she also says this: “We feel lost.”

Her six children and her baby grandson live in a rough stretch of Detroit, next to several boarded-up and burned-out houses. President Trump’s temporary ban on immigration from Sudan and six other predominantly Muslim nations doesn’t enter their conversations. They don’t have time to think about politics.


They are focused on survival: learning how to live in America. And figuring out how to get medical care for the untreated injuries that followed them through the genocide in Darfur, the refugee camps in Chad, and the long journey to Michigan.

Refugees across the US face similar strain as they seek to assimilate into their new homes. In a new effort to quantify the stress, researchers from Wayne State University many of whom are themselves former refugees are conducting psychological evaluations, stress tests, and genetic analyses on hundreds of new arrivals.

The goal: to identify and measure the problems they face, and then to develop low-cost interventions to help. Home visits or phone calls with multilingual social workers, for instance, might ease stress and help the refugees feel less alone.
“We want to provide treatment in a more culturally tailored way,” said Dr. Arash Javanbakht, an assistant professor of psychiatry at Wayne State University.

Sudanese Refugee Family
Maryam Yahqub, her children, and her grandson in their home in Detroit. Rachel Woolf for STAT

Collecting hair, saliva — and stories

There isn’t much research about the impact of sustained trauma on refugees: Most studies focus on the soldiers of war, not the civilian survivors who seek refuge abroad.

Javanbakht’s team has worked with about 400 refugees so far, and found that about half have depression and 30 percent have post-traumatic stress disorder, or PTSD. Their symptoms often manifest as feeling exhausted, scared, and always on alert.

“Immigration is a very highly stressful life event especially when you’re pushed out of your own country,” Javanbakht said. “These people just cannot assimilate well with society if they don’t have support or care.”

One interesting finding: Children’s stress levels strongly reflect how their mothers feel.

“We’ve found that a child’s anxiety directly correlates with a mother’s anxiety, and a mother’s level of trauma,” Javanbakht said. “So when the mother’s distressed, the children are more likely to be distressed.”

The study also found that 81 percent of the children experience separation anxiety.

Helping mothers cope and assimilate to a new country, and overcome their own PTSD, could be a powerful tool in helping refugee children adjust to their new environment.

The study starts with surveying recent refugees about how they’re feeling whether they’re having night sweats, for instance, and what helped them endure both war and migration.

The researchers are also studying the hair and saliva of the refugees, examining their cortisol levels to measure stress. Cortisol, after all, is a stress hormone and if levels are high in saliva, it means a person’s been recently stressed. If it’s high in hair, it means that person has been psychologically stressed for many months.

Javanbakht is also delving into the refugees’ genetics to see if there’s any inherited predisposition that helps or harms people when they’re confronted with trauma.

One problem: Even these simple tests can amplify a refugee’s anxiety. Some are reticent to share samples of hair and saliva, for instance, worrying that this might ultimately be used as a tool to deport them.

Sudanese Refugee Family
Qsma Hassan Yahqub, 12, washes the dishes at her home in Detroit, Mich. Rachel Woolf for STAT

Gratitude, but also profound anxiety

Looking up from his algebra homework, Maryam’s eldest son, Nassaur, speaks of their life in Darfur and the subsequent refugee camps only in broad strokes. It’s tough to speak plainly about the horrors.

“It was a bad life in the camp very tense,” Nassaur, who is 18, said through a translator.

An example: Nearly 10 years ago, Maryam was stabbed by her sister-in-law. The deep gash in her shoulder caused severe nerve damage that contributes to radiating pain down her entire left side. A physician in Detroit told the family that she’ll need surgery to correct the problem but didn’t explain where to get it done, or how to set it up.

Ever since, they’ve been shuffled from doctor to doctor. With the language barrier, it’s difficult to navigate the convoluted US health care system.

Refugees come with a unique set of health problems that many immigrants do not — because they’ve gone largely without good medical care during their years in camps or on the run, said Dr. Zafer Obeid, a primary care doctor who directs a clinic run by the Arab American and Chaldean Council in Detroit. Many have diabetes and high blood pressure, but often they come with untreated war injuries, such as Maryam’s long-wounded shoulder.

Then there’s the disillusionment that refugees often face after coming to America. “These kids won’t die of starvation or bombs in Detroit,” Javanbakht said. So they’re grateful. At the same time, though, the stress can be unrelenting. And in some cases, the refugees end up in dilapidated housing, crawling with bedbugs or in an apartment building crowded with drug dealers.

“When refugees come here, they often don’t feel happier just safer,” he said.

Beyond the language barriers, the isolation, the homesickness, the cold Midwest winters, the difficulty in navigating an unfamiliar bureaucracy, there’s survivor’s guilt: wondering why they were welcomed into the US, leaving so many of their family and friends behind.

Sudanese Refugee Family
Qsma Hassan Yahqub plays with Muntazir Muhajer Yahqub, who is 2 months old. Rachel Woolf for STAT

Maryam’s eldest daughter, Safia, misses her husband, who still lives in Sudan. The rest of the family came here last April. He hoped to follow. Now, with the travel restrictions in place, he has little hope of joining his family in Detroit any time soon.

This lack of a trusted circle exacerbates the symptoms of PTSD and depression that Javanbakht sees in so many refugees.

“All I want is for the kids to learn more English, and get that surgery so I can stand on my feet to take care of my family as best I can,” Maryam said.

Her son also has modest dreams: “All we want is to learn more English,” Nassaur said. “That way, we can help our mother get the operations she needs, so that she can finally feel better.”

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  • We have recently completed one of the largest prospective studies of stress, resilience, mental health and biological reactions in newly arrived refugees as compared to immigrants. In this NIMH/NIH-funded, 5 year study, we were able to demonstrate that most refugees managed tho cope with most forms of war trauma, if conditions in the US were supportive, low stress. However, with conditional stress in the US, e g socioeconomic strain, mental and somatic health worsened, obesity increased as did healthcare utilization. We also noted changes in how genes expressed themselves, especially gens related to regulations the stress system, inflammatory system, and obesity regulation. In work with our WSU colleague Professor Mark Lumley and colleagues, we demonstrated the efficacy of new and briefer forms of therapy to treat post teaumatic stress disorder. Intersting, in this first study with a truely random sample of refugees, the prevalence of PTSD was low as was depression. However, after coming to the US, rates increased especially if exposed to sustained stress. We are now working with many community based organizations, including ACCESS, Samaritas and others to evaluate effective community driven strategies to enhance wellbeing and integration of refugees. We also now know from this study that resilience strategy is a critical tool to manage post displacement challenges and complements the focus on only assessing stress. We now have several community engaged projects planned with research colleagues at MSU and WSU in order to move the refugee research beyond describing recognized problems to focusing on solutions. This is a critical,y important area and it is great to see the growing interest among communities and researchers to determine strategies to optimize post migration health and well being among refugees.
    Bengt Arnetz, MD, PhD

  • My first question is why is someone spending an undisclosed amount of money to quantify the amount of stress refugees are under instead of just acknowledging that IT’S REALLY HIGH and spending that money actually helping? Because I can see grant money being “spent on refugee services” that actually pays doctors and researchers and data crunchers and analysts and front office phone answerers to study refugees, but refugees are like – we’re still stressed. And hungry. And depressed. And suicidal. And some agency just spent $750,000 to look at us and write a bunch of reports and get paid and how did that help us exactly?

    I just have had some bad experiences with federal grants and how money is allocated – enormous sums are awarded for programs and like 20% gets spent on actual direct services, while the other 80% pays for 27 layers of bureaucracy and cost-inflated supplies and equipment to measure and analyze data.

    I mean, I guess a lot of people don’t understand that refugees are stressed. And I guess some people need a fat spiral bound report complete with powerpoint and panel discussion to even entertain the notion that people who have been living in camps and shot at and raped and starved MIGHT HAVE PTSD FOR THE LOVE OF GOD. But seriously? Genetic testing to prove they are depressed and have night sweats and can’t navigate the US medical system? And a “gosh, oh darn” about the vermin-infested living conditions they’re subjected to once they arrive in DETROIT? It boggles my mind that this isn’t obvious to people.

    I hope there is a clear picture of what can be done to help refugees who are undeniably stressed, depressed, anxious, and bewildered by the medical and social services systems. But America’s track record when helping AMERICANS who are experiencing all of the above is pretty atrocious. I would love to see any money given to programs like these spent on direct services, not research or equipment or genetic testing.

    • Dear Stacey,

      I am the principal investigator on this study. I understand your passionate concerns, and here are a few comments:
      – This work is solely on the WSU department of psychiatry internal funds, no funding specific to care of refugees is used.
      – Majority of the staff on this work, are helping selflessly as volunteers.
      – Establishing and determining the “need” is the first step in any form of meaningful intervention. Prevalence range has been very wide in previous studies based on the type of trauma, environment, and the population. If the prevalence of PTSD is 2% in a population of 1000 people, then there would be need for treatment of 20 people. If the prevalence is 30%, then there is need for treatment of 300 people. The amount of resources needed for these scenarios is different. The data produced from this volunteer based work, will provide valuable insight for the authorities, and also helps advocating for seeking resources to help.
      – Medical care of the population is provided by the clinic where they are seen, and is separate in funding from the university research study.
      – The genetic and biological components of the study, are again funded by the WSU, and the results, along with other genetic studies, can help with providing more sophisticated prevention and treatment of such conditions in the future. Like any other area in the medical field, we need a full biological understanding of the disease to be able to improve our treatment methods.
      – Having established the need, we are working on using our funds, and seek external funds to provide interventions for those identified in high need for evidence based treatments for PTSD and depression.

      Once again, thank you for your concern and care.

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