Closer to Home

In late summer of 2021, as the United States' military engagement drew to a tumultuous and traumatic end, tens of thousands of Afghan nationals were airlifted from Kabul and brought, by turns to the United States. Led by the Department of Homeland Security, Operation Allies Welcome was a collaborative mission to receive, process, and coordinate resettlement for those evacuated from a collapsing homeland long afflicted by conflict. Families and individuals were sheltered on military bases ("safe havens") while awaiting placement with under-resourced refugee resettlement agencies across the country. Children accounted for nearly half of the approximately 76,000 Afghan refugees.1Youssef N. Almost Half of Afghan Evacuees at U.S. Bases Are Children, Pentagon Says. Wall Str J. Published online October 20, 2021. Available at: 〈https://www.wsj.com/articles/almost-half-of-afghan-evacuees-at-u-s-bases-are-children-pentagon-says-11634720580〉. Accessed February 5, 2023.Google Scholar To our knowledge, no formal research initiatives were engaged with this population during this process. We see this as a lost opportunity, as much could have been learned about trauma and migration from such a defined pool. Most research on children and armed conflict is conducted outside the United States for obvious reasons. Research conducted in conflict zones or refugee camps is invaluable in helping shape interventions and resource allocation. Similarly, rectifying the paucity of knowledge on the welfare of those families who enter resettlement can clarify their needs, prev ent further harm, and maximize the impact of interventions for similarly impacted children going forward. Many Afghan evacuees had experienced an accretion of trauma, as evidenced in the rates of psychological distress recorded in an Afghan National Mental Health Survey published in 2021.2Kovess-Masfety V. Keyes K. Karam E. et al.A national survey on depressive and anxiety disorders in Afghanistan: a highly traumatized population.BMC Psychiatry. 2021; 21: 314https://doi.org/10.1186/s12888-021-03273-4Crossref PubMed Scopus (40) Google Scholar The majority of the Afghan population had experienced at least one traumatic event. On top of high baseline prevalence of depression, anxiety, post-traumatic stress disorder (PTSD), and suicidality, the evacuated population experienced an acute and often traumatic departure from their homeland. In addition to trauma and mental health concerns, some of the Afghan children came with chronic medical conditions while others developed acute medical issues during the evacuation experience. Any study on the refugee health must have the humility to acknowledge that arriving on US soil does not spare a migrant child from further harm or trauma. We know that chronic and/or traumatic experiences children may experience, called adverse childhood events (ACEs), can have lasting effects on children. For refugee children, these ACEs may occur premigration, during migration, and throughout the resettlement process.3Wood S, Ford K, Hardcastle K, et al. Adverse Childhood Experiences in Child Refugee and Asylum Seeking Populations. Public Health Wales NHS Trust, 44; 2020. Available at: 〈https://research.bangor.ac.uk/portal/files/29132989/ACEs_in_child_refugee_and_asylum_seeking_populations.pdf〉. Accessed 04/01/2023.Google Scholar On arrival, individuals and families were met with the daunting task of starting lives anew. They spent days, weeks, or months in a limbo state before reaching their assigned resettlement cities and towns. For some families, resettlement into locales where there were more government resources had the adverse effect of further isolating vulnerable individuals from friends or culturally congruent communities. The adjustment to this new life was exacerbated by unfamiliarity with laws, a temporary and confusing immigration status, and a ticking clock on financial support toward food and housing. Community organizations filled the gaps where governmental aid fell short. Children have experienced bullying in schools, lives have been lost to suicide, and news from a tortured homeland continue to plague vulnerable families, degrading the psychosocial well-being of the family unit and leaving their mark on children as ACEs. Research that identifies specific sources of distress (ie, language barriers, peer dynamics, pre-existing mental health conditions) as well as resiliency factors would help validate what we have gathered anecdotally. It is important to know if resources and services available to refugee families coincide with the highest priority needs and concerns of the family. Research could also help identify how best to deliver resources such as English language classes, community food banks, or job fairs to families. Additionally, refugees often need crucial and timely information so research can explore how to best communicate with families. Research must be conducted with a wide enough lens to record the experience of the population across the different phases of their journey, including the often-treacherous period of resettlement. Researchers should use a trauma-informed lens when engaging children, approaching interviewing with the same risk-versus-benefit question physicians ask before ordering a radiographic study or ordering a blood test—will the information gleaned provide meaningful direction? Trauma should not be revisited without appropriate psychosocial support in place to mitigate reactions. Interviewers should acquaint themselves with the landscape and dynamics the child has experienced and obtain some cultural context to make for a gentler interaction. Resettlement-phase research should meet children where they are: schools, resettlement agencies, community organizations, and medical homes. This proximity would sharpen the view of the factors impacting the well-being of the children and make the resultant recommendations and directives more relevant to those engaging directly with the children. Knowledge of what children need to acclimate to new schools and bridge language barriers, for example, can feedback into advocacy efforts by resettlement agencies to expand school system resources. We must intentionally decolonize research methodologies to yield more valid and applicable directives. The focus of the research should center the concerns and perspectives of the refugee population. It is important to have humility when approaching research of this high-risk population, to avoid assumptions, inappropriate comparisons, or the application of a western world view. Research should be driven by individuals with true cultural connections and guided by relevant worldviews. Needs, assessments, and surveys should match the population, with input from experts with cultural context. Decolonizing the research methodology and process will help move toward research that promotes community self-determination and allows for recovery, healing, and development. Only systemic change can drive sustainable decolonized research. From funding organizations to academic institutions, to the organizations implementing informed action, all must acknowledge the importance of decolonized research and ensure that the work is not reliant on a network of volunteers. During Operation Allies Welcome, we saw federal agencies calling upon the Afghan American community for immediate and urgent help. In the long term, this is not sustainable and formal relationships would ensure continuous and meaningful involvement. Truly effective treatments, and the research that develops these modalities, must incorporate context and nuance. The generalizability of research can be problematic because data from the research can be context bound, as refugee populations differ in several ways including the types of trauma they have experienced, the length of that experience, cultural contexts, the age of the participant, and resources available at the time. Research should identify ways to incorporate the nuance needed to benefit the at-risk population. Surveys developed for the Afghan refugee population, for example, may not be completely relevant for the Ukrainian population. Research tools should match the relevant population, with input from experts connected to the study subjects. We can still intervene. The Afghans and Ukrainians are still in sensitive stages of resettlement, and we continue to see people arriving in the United States from across the southern border. Through a critical reflection on our successes and failures with the recent Afghan arrivals, we can work toward developing more sensitive and thoughtful research that can benefit others escaping armed conflict and create a gentler landscape for their rebuilding. The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. This article was published as part of a supplement sponsored by the Robert Wood Johnson Foundation.