Research Article
Open access
Published Online: 17 June 2021

Risk Communication and Institutional Racism: The Protective Health Effect of Refugee-Led Community Organizations

Publication: Health security
Volume 19, Issue Number S1


Refugees are marginalized groups of people who have experienced multiple traumas and barriers—some due to their prior experiences and many due to the conditions in their new host country.1 The disproportionate impact of the COVID-19 pandemic on communities of color in the United States further compounds the precarity of refugee communities.2 Existing formal institutional structures often ignore the specific needs faced by refugee communities.3 Refugee-led community organizations (RCOs) play a critical role in reaching refugee communities and helping them in their resettlement process because they are grounded in the volunteer work of resettled refugees themselves.4 Our experience working with RCOs during the pandemic highlighted the indispensable role they play in providing a protective effect during the pandemic by helping refugee communities weather pandemic-related shocks, navigate the public benefits systems, access reliable healthcare information through culturally and linguistically appropriate means, and advocate for health security. We also witnessed the institutional negligence and racism experienced by RCOs while working with health systems to assist their communities during the pandemic. By amplifying RCO voices, our struggling health systems can identify reliable and highly motivated community partners who will make a critical difference in mitigating health risks on the ground. The US healthcare system needs to proactively engage with community-based organizations in refugee communities to respond effectively to public health emergencies like the COVID-19 pandemic.
For over 3 years, we conducted participatory action research with refugee groups in a medium-sized midwestern US city.5 This commentary focuses on what we learned about community resilience and action in response to the pandemic by closely following the work of 3 RCOs: 2 Congolese and 1 Bhutanese.6

Institutional Racism and Refugee Community Organizations

Institutional racism is defined as “the collective failure of an organization to provide an appropriate and professional service to people because of their color, culture or ethnic origin.” 7 As a system, racism establishes institutional public health and healthcare policies, procedures, and practices that privilege the dominant racial and ethnic groups, their language, and places of education, employment, and residence. The lack of elected representatives from refugee groups in government systems who can bring forth institutional changes also hinders these groups from receiving necessary help.
One way to combat racism and create better institutional response is through the advocacy work and engagement of civil society organizations. However, in general, ethnic community-based organizations and migrant civil society groups struggle to gain acceptance in urban and health governance networks.4,8,9 RCOs not only advocate against institutional racism but they also function as service providers, helping mitigate the barriers to healthcare that individuals and families face.
The absence of inclusive local health governance, such as permanent health councils and networks with diverse refugee groups, reflects the institutional racism that became a barrier for refugee representation during the early months of the pandemic. In the places where our research community partners worked, institutional racism prevented health departments from proactively reaching out to refugee communities before the pandemic. There were no established patterns of communication between RCOs and the government at the onset of the pandemic. When the 3 RCOs we observed contacted health offices, long-term local government staff resisted providing the requested tailored assistance to their refugee communities, despite self-reported outbreaks. While attempting to promote health literacy in their communities, RCO leaders subsequently faced barriers within the healthcare system that characterize institutional racism. This commentary describes how institutional racism impacts refugees and RCOs alike, with a focus on refugee health disparities and the work of RCOs to ameliorate them.

Role of RCOs in Risk Communication

Refugee communities experience lower health literacy and limited healthcare navigation skills, both of which diminish the positive health effects of being admitted to the United States with 8-month limited access to public healthcare coverage.10 These communities also use a range of cultural resources to manage healthcare, referred to as “cultural health capital,” which is important to understand when providing healthcare navigation assistance.11 RCOs can easily tap into this knowledge and ease the process of navigating healthcare systems, while also increasing health literacy among refugees by properly communicating risk. Peer health navigators with a refugee background, who are bilingual and bicultural, can also create a community health support network.12 Refugee leaders and their organizations are, therefore, typically well-positioned to communicate health risks.
The 2 Congolese and 1 Bhutanese RCOs we worked with leveraged their limited capacities and social networks to access and analyze health safety information released in English during the COVID-19 pandemic. They quickly translated the materials, such as official COVID-19 county health information, into Nepali, French, and Kinyarwanda dialects and native languages and disseminated them to communities using social media and other modes of communication. In addition, RCO leaders invited healthcare workers from within their communities and public health departments to communicate risk, create awareness, and provide verified safety information to community members. These communication channels also enabled RCO leaders to ask the health department for dedicated testing facilities close to their neighborhoods.
A lack of English proficiency and health literacy negatively influences refugee health, even outside of emergency public health events.13 Resettled refugees also struggle to navigate a fragmented health system and obtain health information.5,12 RCO leaders regularly assist community members by providing translation during doctors' appointments and emergency visits. They also assist with scheduling appointments, procedures, and interpreting billing and treatment options. In this way, RCOs have been helping resettled refugees navigate the US healthcare system.5
Initially during the COVID-19 pandemic, county health departments failed to leverage the strength and reach of RCO networks due to the lack of established communication and information-sharing networks with RCOs and their leaders in prepandemic times. This was a missed opportunity to prepare for future public health emergencies. Ongoing engagement with RCOs and refugee leaders is fundamental for the community's overall health and sets the foundation for prompt risk communication during public health emergencies.

Refugee Health Disparities and COVID-19

Refugee status is granted to individuals who have suffered discrimination and persecution for race, ethnicity, religion, nationality, membership in particular social groups, or political opinion.14 Refugees differ from other immigrants in their general health profiles. Typically, immigrants who arrive in the United States are healthier than their average US-born counterparts. However, immigrants with a refugee background arrive with preexisting health problems, including noncommunicable chronic diseases, at a higher rate than other immigrants.15,16 These preconditions place resettled refugees at higher risk of health complications if they become infected with COVID-19. Refugees may also develop mental health disorders as a result of surviving the trauma of persecution and often war.17,18 Furthermore, acculturation of immigrants to the country of resettlement can generate increased stress and loneliness. Finally, refugees' expectations of care can be misconstrued, contributing to further barriers that can have short- and long-term consequences.10
The COVID-19 pandemic has had a more significant health impact on underrepresented ethnic/racial and vulnerable socioeconomic groups.19,20 While there is an absence of health data by immigration status, most resettled refugees and immigrants, once they arrive in the United States, remain a vulnerable group as they usually are considered people of color.21 Limited race and ethnicity data collected on COVID-19 hospitalization from 12 states suggests overrepresentation of Blacks, Hispanics/Latinos, and Native Americans when compared with their overall population proportion.22 Racial and ethnic disparities in the risk of infection are associated with a higher prevalence of comorbidities, less access to healthcare, lower socioeconomic status, and employment in the service sector.23 These factors, rather than biological or behavioral factors, mainly explain racial health inequalities.24
The specific factors that place resettled refugees at a higher risk of contracting COVID-19 include living in poverty, crowded housing conditions, intergenerational households, jobs in the service sectors, and language barriers.21,25 Limited transportation options during the pandemic may impact access to grocery stores in neighborhoods that are food deserts. Public transportation operating at a limited capacity to contain the spread of COVID-19 was a common practice during the spring and summer months of 2020 and may have reduced the likelihood of families bringing sick children to health clinics.21

Racial Bias and Employment Health Safety

Immigrants and refugees constitute a substantial share of the US labor force in essential sectors including healthcare (16.5%), food supply industries (21.6%), and pharmaceutical manufacturing (24.8%), although they make up only 13.5% of the overall population.26 In the Midwest, resettled refugees hold low-paying jobs in manufacturing and meat and food processing facilities.27,28 These industries were the epicenter of the COVID-19 outbreak across the country and disproportionately impacted refugee communities, especially Bhutanese and Burmese refugees, given their greater representation in this sector.29-31 The Bhutanese RCO leaders we worked with explained that their fellow refugees working in food processing facilities contracted COVID-19 in large numbers during the early months of the pandemic. This mass spread of infection was due to lax labor safety standards, poor availability of personal protective equipment, lack of proper social distancing work arrangements, and most important, the absence of safety guidelines in native languages. RCOs were among the first to alert 3 county health departments in the United States about the spread of COVID-19 in the food processing industry. They also wrote to the federal Office of Refugee Resettlement and contacted local resettlement agencies (RAs). In fact, many RCO leaders work as community liaisons with resettlement RAs.
The federal government classified as essential the sectors of the economy where refugee and immigrant labor is predominant, but without safeguarding protections, such as hazard pay, paid sick leave, access to healthcare, or temporary childcare and housing assistance for emergencies.32 The US Centers for Disease Control and Prevention and the Occupational Safety and Health Administration did not do enough to establish enforceable labor safety standards in these essential industries, citing employer difficulty in compliance during the pandemic in their April 2020 guidelines.32 These guidelines disproportionately hurt the people of color with a refugee background and further promoted systemic racism. Instead of protecting adversely affected communities during the pandemic, the federal government reduced workplace protections in sectors with essential workers of immigrant background and misappropriated the public health emergency to further restrict immigration and refugee admissions.32 The weak federal protections demonstrate a dimension of institutional racism that has adversely impacted refugees.

Protective Health Effect of RCOs Beyond Risk Communication

An essential part of the public health response to COVID-19 is community involvement, especially of vulnerable populations.33 RCOs are perfectly placed to fulfill this protective role by leveraging the cultural health capital of refugee communities and creating community health support networks. In the absence of institutional help, RCOs leveraged and mobilized their limited resources to help refugee communities and ameliorated some of the serious adverse impacts of COVID-19 on the refugee population. RCOs provided a protective effect from the more severe shocks of the COVID-19 pandemic by providing material and transactional help that was culturally and psychologically responsive to the needs of their communities (Figure 1).
Figure 1. The protective effect of refugee-led community-based organizations against COVID-19.
Abbreviations: PPE, personal protective equipment.
In addition to health risk communication and workplace health safety, RCOs performed several other activities.34 When personal protective equipment kits were scarce among vulnerable populations, RCOs obtained these supplies and distributed them to older adults and factory workers in their communities as early as April 2020. When refugee leaders found that several families in their communities were infected, RCOs offered help in 2 ways. First, they provided safety kits and food supplies to the infected households. Second, to boost the morale and confidence of infected community members, RCO leaders hosted several discussions and live chats with other community members who had recovered and were recovering from COVID-19 infection to alleviate stigma and fear.
RCO leaders also provided technical support in accessing web-based applications and setting up remote school connections for many of their families during the pandemic. When schools reopened, RCOs leaders helped families navigate the choice to either let children continue learning remotely or send them back to school in person safely with appropriate safety equipment and school supplies.
Community members faced difficulties related to language and navigation when accessing public assistance benefits, such as unemployment. In the early days of the pandemic, nonessential manufacturing jobs closed and mothers had to quit working for childcare reasons. Refugee leaders reported that submitting applications for unemployment online required skills and attention, even for those familiar with technology and fluent in English. When RCOs called government offices on behalf of refugees, the endeavor required 2 phones: one line between the leader and the fellow refugee and the other line for the refugee leader and the government office. This is another example of how state institutions are not built to serve the most vulnerable.
Hands-on assistance with transportation was also fundamental, as transportation options were reduced during the pandemic. Safely driving community members to hospitals, testing centers, rental listings, and grocery stores therefore became an important task for RCOs. RCOs helped their community members more often with these activities during the pandemic due to the closing of in-person services, reduced public transportation facilities, and rising unemployment.


The US government and its healthcare system demonstrated a reactive rather than proactive engagement with refugee communities at the onset of the COVID-19 pandemic. This tardy response to refugee calls for help resulted in institutional practices of racism where certain communities were left out of governments' purview in their emergency response and service delivery. Such institutional bias, while inherently harmful, is especially dangerous during a public health crisis such as the COVID-19 pandemic. These biases and inequalities have disproportionately impacted communities of color, and refugee communities specifically, due to the intersectionality of multiple layers of institutional racism. As existing health systems struggle to cater even to those people who are relatively visible within the system, it is unsurprising that refugees, who remain largely hard-to-reach populations, fall through the wide chasms in the US healthcare system.
Systemic inefficiencies result in the deprivation of essential services to certain communities whose welfare has already been left to the vagaries of changing government priorities. Instead the responsibility falls to local agencies and institutions, such as RCOs, to recognize, accept, and use the strength of undertapped, nontraditional institutional knowledge, cultural competency, and collective action. It is important to create spaces for exchanging information and preparing for future crises. County health departments must establish regular meetings with refugee representatives. Ideally, refugees and other ethnic minority groups will have decision-making power in existing health governance mechanisms. Alternatively, new channels of dialogue could be established if none exists. Healthcare staff can learn about local refugee communities by reaching out to school boards, while local resettlement RAs can connect them with RCOs and their leaders.
RCOs help communities navigate difficult public institutional settings that are either unaware of or dismissive of refugee concerns and needs. The protective health effect of RCOs during the pandemic has been palpable. RCO leaders are contributing to community well-being by providing support in the areas of transportation, public benefits, schooling, and housing. In addition, RCOs provide risk communication, systems navigation, hands-on assistance, and advocacy for their communities. RCO leaders have provided culturally appropriate health information and will continue to perform this service regardless of whether public health offices decide to include these communities in their outreach efforts. Healthcare systems will therefore benefit from pursuing and strengthening collaborations with RCOs. Epidemic responses that do not explicitly consider refugee populations are a threat not only to health ethics and equity but also to US health security at large.


This study has been made possible by The Michigan Institute for Clinical & Health Research (MICHR), grant UL1TR002240.


1. Sangalang CC, Vang C. Intergenerational trauma in refugee families: a systematic review. J Immigr Minor Health. 2017;19(3):745-754.
2. Fortuna LR, Tolou-Shams M, Robles-Ramamurthy B, Porche MV. Inequity and the disproportionate impact of COVID-19 on communities of color in the United States: the need for a trauma-informed social justice response. Psychol Trauma. 2020;12(5):443-445.
3. Bose PS. Welcome and hope, fear, and loathing: the politics of refugee resettlement in Vermont. Peace Confl. 2018;24(3):320-329.
4. Gonzalez Benson O, Pimentel Walker AP. Grassroots refugee community organizations: in search of participatory urban governance. J Urban Affairs. February 22, 2021.
5. Gonzalez Benson O, Pimentel Walker AP, Yoshihama M, Burnett C, Asadi L. A framework for ancillary health services provided by refugee and immigrant-run CBOs: language assistance, systems navigation, and hands on support. J Community Med Health Educ. 2019;9(5):665.
6. Pimentel Walker AP, Sanga N, Gonzalez Benson O, Yoshihama M, Routte I. Participatory action research in times of COVID-19: adapting approaches with refugee-led community-based organizations. Prog Community Health Partnersh. (In Press).
7. Macpherson W. The Stephen Lawrence Inquiry. Vol 1. London: Home Office; 1999. Accessed May 20, 2021.
8. de Graauw E, Gleeson S, Bloemraad I. Funding immigrant organizations: suburban free riding and local civic presence. Am J Sociol. 2013;119(1):75-130.
9. Gleeson S, Bloemraad I. Assessing the scope of immigrant organizations: official undercounts and actual underrepresentation. Nonprofit Volunt Sect Q. 2013;42(2):346-370.
10. Morris MD, Popper ST, Rodwell TC, Brodine SK, Brouwer KC. Healthcare barriers of refugees post-resettlement. J Community Health. 2009;34(6):529-538.
11. Madden EF. Cultural Health Capital on the margins: cultural resources for navigating healthcare in communities with limited access. Soc Sci Med. 2015;133:145-152.
12. Yun K, Paul P, Subedi P, Kuikel L, Nguyen GT, Barg FK. Help-seeking behavior and health care navigation by Bhutanese refugees. J Community Health. 2016;41(3):526-534.
13. Feinberg I, O'Connor MH, Owen-Smith A, Ogrodnick MM, Rothenberg R. The relationship between refugee health status and language, literacy, and time spent in the United States. Health Lit Res Pract. 2020;4(4):e230-e236.
14. Hamlin R. International law and administrative insulation: a comparison of refugee status determination regimes in the United States, Canada, and Australia: comparing RSD regimes. Law Soc Inq. 2012;37(4):933-968.
15. Yun K, Fuentes-Afflick E, Desai MM. Prevalence of chronic disease and insurance coverage among refugees in the United States. J Immigr Minor Health. 2012;14(6):933-940.
16. Mirza M, Luna R, Mathews B, et al. Barriers to healthcare access among refugees with disabilities and chronic health conditions resettled in the US Midwest. J Immigr Minor Health. 2014;16(4):733-742.
17. Walden J. Refugee mental health: a primary care approach. Am Fam Physician. 2017;96(2):81-84.
18. Mishori R, Aleinikoff S, Davis D. Primary care for refugees: challenges and opportunities. Am Fam Physician. 2017;96(2):112-120.
19. Webb Hooper M, Nápoles AM, Pérez-Stable EJ. COVID-19 and racial/ethnic disparities. JAMA. 2020;323(24):2466-2467.
20. Antwi-Amoabeng D, Beutler BD, Awad M, et al. Sociodemographic predictors of outcomes in COVID-19: examining the impact of ethnic disparities in Northern Nevada. Cureus. 2021;13(2):e13128.
21. Clarke SK, Kumar GS, Sutton J, et al. Potential impact of COVID-19 on recently resettled refugee populations in the United States and Canada: perspectives of refugee healthcare providers. J Immigr Minor Health. 2021;23(1):184-189.
22. Karaca-Mandic P, Georgiou A, Sen S. Assessment of COVID-19 hospitalizations by race/ethnicity in 12 states. JAMA Intern Med. 2021;181(1):131-134.
23. Mahajan UV, Larkins-Pettigrew M. Racial demographics and COVID-19 confirmed cases and deaths: a correlational analysis of 2886 US counties. J Public Health (Oxf). 2020;42(3):445-447.
24. Chowkwanyun M, Reed AL Jr. Racial health disparities and Covid-19 - caution and context. N Engl J Med. 2020;383(3):201-203.
25. Loy C, Griffiths D, Gautam R; Peninsula Refugee Research Working Group. Mind the Gap: An Assessment of Need in the Hampton Roads Bhutanese Refugee Community. White Paper. August 15, 2015.
26. New American Economy Research Fund. Immigration and Covid-19. Published March 26, 2020. Accessed May 18, 2021.
27. Miraftab F. Global Heartland: Displaced Labor, Transnational Lives, and Local Placemaking. Bloomington: Indiana University Press; 2016.
28. Stanley K. Immigrant and refugee workers in the Midwestern meatpacking industry: industrial restructuring and the transformation of rural labor markets. Rev Policy Res. 1992;11(2):106-117.
29. Chadde S. Tracking Covid-19's impact on meatpacking workers and industry. Midwest Center for Investigative Reporting. Published April 16, 2020. Accessed April 6, 2021.
30. Waltenburg MA, Rose CE, Victoroff T, et al. Coronavirus disease among workers in food processing, food manufacturing, and agriculture workplaces. Emerging Infect Dis. 2021;27(1):243-249.
31. Zhang M, Gurung A, Anglewicz P, Yun K. COVID-19 and immigrant essential workers: Bhutanese and Burmese refugees in the United States. Public Health Rep. 2021;136(1):117-123.
32. Kerwin D, Warren R. US foreign-born workers in the global pandemic: essential and marginalized. J Migr Hum Secur. 2020;8(3):282-300.
33. Marston C, Renedo A, Miles S. Community participation is crucial in a pandemic. Lancet. 2020;395(10238):1676-1678.
34. Gonzalez Benson O. Welfare support activities of grassroots refugee-run community organizations: a reframing. J Community Pract. 2020;28(1):1–17.

Information & Authors


Published In

cover image Health Security
Health security
Volume 19Issue Number S1June 2021
Pages: S-89 - S-94
PubMed: 34096802


Published online: 17 June 2021
Published ahead of print: 4 June 2021
Published in print: June 2021


Request permissions for this article.




Ana Paula Pimentel Walker [email protected]
Ana Paula Pimentel Walker, PhD, MURP, MA, JD, is an Assistant Professor and Naganika Sanga, MSc, is a PhD Candidate, Taubman College of Architecture and Urban Planning; Odessa Gonzalez Benson, PhD, MSW, is an Assistant Professor, School of Social Work and Detroit School of Urban Studies; and Mieko Yoshihama, PhD, LMSW, ACSW, is a Professor, School of Social Work; all at the University of Michigan, Ann Arbor, MI.
Naganika Sanga
Ana Paula Pimentel Walker, PhD, MURP, MA, JD, is an Assistant Professor and Naganika Sanga, MSc, is a PhD Candidate, Taubman College of Architecture and Urban Planning; Odessa Gonzalez Benson, PhD, MSW, is an Assistant Professor, School of Social Work and Detroit School of Urban Studies; and Mieko Yoshihama, PhD, LMSW, ACSW, is a Professor, School of Social Work; all at the University of Michigan, Ann Arbor, MI.
Odessa Gonzalez Benson
Ana Paula Pimentel Walker, PhD, MURP, MA, JD, is an Assistant Professor and Naganika Sanga, MSc, is a PhD Candidate, Taubman College of Architecture and Urban Planning; Odessa Gonzalez Benson, PhD, MSW, is an Assistant Professor, School of Social Work and Detroit School of Urban Studies; and Mieko Yoshihama, PhD, LMSW, ACSW, is a Professor, School of Social Work; all at the University of Michigan, Ann Arbor, MI.
Mieko Yoshihama
Ana Paula Pimentel Walker, PhD, MURP, MA, JD, is an Assistant Professor and Naganika Sanga, MSc, is a PhD Candidate, Taubman College of Architecture and Urban Planning; Odessa Gonzalez Benson, PhD, MSW, is an Assistant Professor, School of Social Work and Detroit School of Urban Studies; and Mieko Yoshihama, PhD, LMSW, ACSW, is a Professor, School of Social Work; all at the University of Michigan, Ann Arbor, MI.


Address correspondence to: Ana Paula Pimentel Walker, PhD, MURP, MA, JD, Assistant Professor, Taubman College of Architecture and Urban Planning, University of Michigan, 2000 Bonisteel Blvd, Ann Arbor, MI 48109 [email protected]

Metrics & Citations



Export citation

Select the format you want to export the citations of this publication.

View Options

View options


View PDF/ePub

Get Access

Access content

To read the fulltext, please use one of the options below to sign in or purchase access.

Society Access

If you are a member of a society that has access to this content please log in via your society website and then return to this publication.

Restore your content access

Enter your email address to restore your content access:

Note: This functionality works only for purchases done as a guest. If you already have an account, log in to access the content to which you are entitled.







Copy the content Link

Share on social media

Back to Top