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Explaining lead poisoning amorefugeeuee children

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Title:
Explaining lead poisoning amorefugeeuee children the resettlement process
Creator:
Abdulrahmin, Dalia ( author )
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English
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1 electronic file (33 pages). : ;

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Subjects / Keywords:
Refugee children ( lcsh )
Lead poisoning ( lcsh )
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bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

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Abstract:
Lead is particularly harmful to the growing nervous system and soft tissue of small children. Children living in poorly maintained and old houses are at particular risk of lead poisoning. Testing of refugee children showed an increase in blood lead levels after arrival to the US. In this paper, I provide an insider’s view of the resettlement process to explain why refugee children are at higher risk of living in substandard housing. Highlighting the external financial pressures and time constraints to which case workers are subjected, I show how they are forced to function as street-level bureaucrats employing different strategies to handle their workload which ultimately works to inadvertently elevate blood lead levels among refugee children
Thesis:
Thesis (M.A.)--University of Colorado Denver.
Bibliography:
Includes bibliographic references
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System requirements: Adobe Reader.
General Note:
Department of Anthropology
Statement of Responsibility:
by Dalia Abdulrahman.

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Source Institution:
University of Colorado Denver
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Auraria Library
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All applicable rights reserved by the source institution and holding location.
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952035714 ( OCLC )
ocn952035714

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Full Text
EXPLAINING LEAD POISONING AMONG REFUGEE CHILDREN: THE
RESETTLEMENT PROCESS
by
DALIA ABDULRAHMAN
B.I.C, Zuyd University for Applied Sciences, 2011
A thesis submitted to the Faculty of the
Graduate School of the University of Colorado
in partial fulfillment of the requirements for the degree of
Master of Arts
Anthropology Program
2016


This thesis for the Master of Arts degree by
Dalia Abdulrahman
Has been approved for the
Anthropology Program
by
Sarah Horton, chair
Zanetha Thayer
John Brett
Date: 02/05/2015


Abdulrahman, Dalia (M.A., Anthropology)
Explaining Lead Poisoning Among Refugee Children: The Resettlement Process
Thesis directed by Associate professor Sarah Horton
ABSTRACT
Lead is particularly harmful to the growing nervous system and soft tissue of small children.
Children living in poorly maintained and old houses are at particular risk of lead poisoning.
Testing of refugee children showed an increase in blood lead levels after arrival to the US. In this
paper, I provide an insiders view of the resettlement process to explain why refugee children are
at higher risk of living in substandard housing. Highlighting the external financial pressures and
time constraints to which case workers are subjected, I show how they are forced to function as
street-level bureaucrats employing different strategies to handle their workload which ultimately
works to inadvertently elevate blood lead levels among refugee children.
The form and content of this abstract are approved. I recommend its publication.
Approved: Sarah Horton


DEDICATION
This thesis is dedicated to my parents, Hawa and Mohammed, for their unconditional
love and continuous encouragement, to my husband, Mohamed, for tirelessly taking care of our
little one after so many long work days so mummy can study and lastly, to my advisor, Sarah
Horton, without whose excellent mentoring, dedication and guidance, this thesis would not have
seen the light of day.
IV


TABLE OF CONTENTS
CHAPTER
I. INTRODUCTION............................................1
II. METHODS................................................4
III. A CASE MANAGERS JOB..................................7
IV. LOCATING HOUSING......................................13
V. COUNTERACTING GEOGRAPHIES OF BLAME....................24
VI. CONCLUSION............................................26
REFERENCES................................................28
v


CHAPTER I
INTRODUCTION
Lead poisoning is a serious health issue that has great effects on childrens health and
cognitive development. Lead is harmful for the growing nervous system and soft tissue of small
children. To grow, children drink more water, eat more food and breathe in more air than adults.
Childrens growth needs maximize their lead ingestion and consequent poisoning if lead is
present in the environment (CDC 2006). Despite public health campaigns and advances made in
removing lead from gasoline, paint, food canning and drinking water, lead poisoning is still a
persistent threat to the health of children in many American cities (Caron et al., 2013). A report
from the Center of Disease Control and Prevention (CDC) explains that although the federal
government prohibited the use of lead-based paint in 1978, all children living in houses built
prior to that period are at risk of lead poisoning due to the houses poorly maintained condition
and from exposure to dust and soil.1 Yet, the prevalence of elevated blood lead levels in refugee
children is higher than the 2.2% prevalence among U.S. children. These children did not show
high blood levels initially. However, when tested 3 to 6 months after arrival, they showed
elevated lead levels >10pg/dL2 (CDC 2006).
The question addressed in this study is: what makes refugee children in particular more
prone to have elevated blood lead levels? Health professionals and researchers blame refugees
home environments and cultural practices for childrens exposure to lead. In contrast, research
1 Children are at risk of lead poisoning in houses built prior to 1978 if they are poorly
maintained. In such cases, leaks or damage may expose previous layers of walls with paint that
contains lead; moreover, chipped paint containing lead particles may lie within childrens reach.
2 lOpg/dL was the reference level at which CDC recommends public health actions be initiated.
In 2012, the CDC lowered the reference level to 5pg/dL.
1


and monitoring by faith-based organizations that sponsor refugees report that although refugee
children may arrive with already-elevated blood lead levels, they often show even higher levels
of blood lead when tested a few months after arrival (CWS 2005). A study conducted among 693
refugee children in Massachusetts between 1995 and 1999, for example, concluded that elevated
blood lead levels are two times more prevalent in refugee children than in US born children.
Although these children arrived with elevated levels, their blood lead levels increased
significantly after resettlement due to their deteriorating housing (Geltman et al. 2001). Indeed,
in 2000, elevated blood lead levels resulted in the death of a Sudanese refugee toddler who had
been resettled to New Hampshire along with her family. Researchers suggested that the childs
housing circumstances increased the childs exposure to lead; her blood lead levels at the time of
her death were 392 mg/dL a lethal amount (Geltman et al., 2001). The Bureau of Population,
Refugees and Migration (PRM) already mandates a health examination including a lead
screening within 30 days of a refugees resettlement. After this incident, however, the state of
New Hampshire mandated an additional lead screening of refugee children 3-6 months after their
first screening to track their lead exposure (CDC 2006).
In 2004, health professionals in New Hampshire discovered elevated blood lead levels
among 96 of the 242 refugee children in the age range of 6 months to 15 years who were
resettled in that year. Because these children were tested twice, professionals were able to
determine that the bulk of the lead exposure took place after refugees arrival in the US. These
children showed blood lead levels less than 10 mg/dL in their initial PRM-mandated health
screenings but the second screening mandated by the state of New Hampshire revealed levels
higher than that. Investigations by the CDC revealed moderate lead hazards in residences and
some contamination in soil in the play areas frequented by the children (CDC 2006). Thus while
2


cultural practices and folk home remedies might exacerbate childrens lead poisoning,
considering it to be the primary contributor to the problem overlooks environmental factors that
play a bigger role in the issue.
In this paper, I argue that the resettlement process subjects refugees to circumstances of
structural violence that result in lead poisoning among children. I show that time constraints and
limited financial resources force case managers in refugee resettlement agenciesas a variety of
street-level bureaucrats (Lipsky 1983)to accept substandard housing for their clients and to
resort to taking shortcuts to handle their work load. Thus the resettlement process directly
exposes refugee families to health hazards related to substandard housing, such as lead
poisoning. Through interviews with resettlement agency staff, this thesis provides an emic view
of the process of finding appropriate housing for refugees and how this may lead to increased
rates of lead poisoning among refugee children.
3


CHAPTER II
METHODS
I was first confronted with lead poisoning when I worked as a case manager at a refugee
resettlement agency in Denver and found that the children of a number of my clients showed
elevated blood lead levels. One of these cases was the son of an Iraqi refugee; the father came to
my office asking for a note for his employer for him to miss work to take his son to the hospital
for blood work and to meet with a physician. The medical paperwork the father carried indicated
that the child had an elevated level of lead in his blood level that needed to be addressed as soon
as possible. Neither I nor the father had any indication that this might be related to their pre-
resettlement environment. My client came to the US on a special immigrant visa due to his work
with the US army in Iraq, therefore, the family was well-off in Iraq and the likelihood that they
lived in a poorly-maintained home is small. Despite the possibility that the childs home in the
US might have contributed to his elevated lead levels, this client remained living in the same
apartment home until I left my position at the resettlement agency. I also encountered an African
family with two young children who suffered from elevated blood lead levels; the testing was
done after arrival. This family in particular had many health issues requiring continuous medical
attention; therefore, medical and agency staff might have attributed the childs elevated blood
lead level to lead ingestion overseas and not in the US.
I worked at this agency for fourteen months between 2012 and 2013 and my caseload
averaged 80 to 100 pre-existing cases in addition to about 20 new refugee arrivals, single and
family cases, per month. As a native Arabic speaker who myself had been an asylum seeker in
Europe, I primarily served Iraqi and African refugees. Thus I became interested in how refugees
4


poor housing conditions in the U.S., itself the result of the resettlement process, might contribute
to the problem of lead poisoning among refugee children.
I conducted a total of 8 semi-structured interviews with staff in refugee resettlement
agencies: six interviews with case managers, one reception and placement program coordinator
and one program director. The interviews lasted between an hour to an hour-and-a-half.
Participants answered questions about their responsibilities as case managers and housing
coordinators, the process of locating housing, the obstacles they faced when doing their jobs, and
their knowledge about lead poisoning. All interviewees worked at Colorado based refugee
resettlement organizations. Currently, there are two refugee resettlement organizations active in
Colorado: the African Community Center (ACC) and Lutheran Family Services (LFS), which is
the largest refugee resettlement organization in the Rocky Mountains area. A third agency,
Ecumenical Refugee and Immigration Services (ERIS) closed its doors in June of 2015.
I started data collection in April 2015 two months before the closure of ERIS. Between
the end of April and June 2015,1 was able to interview a former ERIS case manager. After the
end of June, case managers and housing coordinators working at ACC and LFS became
increasingly difficult to reach due to the fact that, now, these two organizations had to divvy up
the existing cases that had been under ERISs management, the new cases which were assigned
to ERIS, as well as to each organizations own allotment of newly arriving and existing refugee
cases.
Understandably, due to the increasing case load of case managersand all agency staff
in generalthere was no response to my emails and calls requesting interviews. Due to their
unresponsiveness, I decided to do walk-ins and ask to meet case managers. This strategy was
only successful at ACC; I was able to schedule two interviews with case managers. I also met
5


with ACCs reception and placement services coordinator, who is responsible for finding
housing for arriving refugee families. This strategy was not successful with LFS staff since the
organization has rigid rules regarding walk-ins; it is not possible to meet any staff member
without an appointment.
I was able to get an interview with LFS at Colorado Springs, but only after they accepted
my offer of volunteering for 8 hours. The busyness of LFS of Denver is understandable since the
organization is receiving a record high number of refugees this year. LFS received 140 refugee
cases in September 2015; the number of arriving refugees in one month hasnt been so high since
1999. In contrast, the housing coordinator at LFS of Colorado Springs indicated that their office
will resettle between 130 and 140 refugees this fiscal year. LFS of Greeley and Fort Morgan also
denied requests for interviews due to high numbers of arrivals in the months of August,
September and October.
Ethical approval for this study was obtained from the Colorado Multiple Institution
Review Board at the University of Colorado Denver.
6


CHAPTER III
A CASE MANAGERS JOB
Resettlement agencies, also called voluntary agencies (VOLAGs), contract with the
federal government to manage refugees resettlement and placement; the US refugee program is
collaboratively directed by the U.S. Department of State through the Bureau of Population,
Refugees and Migration (PRM), the U.S. Department of Homeland Security represented by the
U.S. Citizenship and Immigration Services (US CIS) and the U.S. Department of Health and
Human Services represented by the Office of Refugee Resettlement (ORR) (Dwyer 2010). This
contract obliges VOLAGs to provide what is called basic support services upon refugees arrival.
These services include locating housing for refugee families, applying for social security
numbers and public assistance such as, Supplemental Nutritional Assistance Program (SNAP),
Temporary Assistance for Needy Families (TANF), Medicaid, Medicare and Social Security
Income (SSI). Case managers are also responsible for enrolling children in school, providing
home safety and cultural orientations to help refugees navigate and access the social services
system and public schools system. Meanwhile, case managers continue to work with their
previous refugee clients, serving refugees for up to five years after their arrival.
Additionally, case managers manage the finances of refugees; each refugee receives a
one-time transitional grant, also called reception and placement (R&P) money, provided by
ORR. Officially this grant is a flat $1125 per person, but depending on individual agency policy
the amount can be as low as $925. There are also three time-limited cash assistance programs to
which refugees are entitled. My focus will be on the two programs that are provided to families
with children. For example, the federal Matching Grant Program assists refugees whose
educational and occupational backgrounds promise speedy employment. Assistance is limited to
7


3 to 4 months and a great emphasis is placed on attaining employment as quickly as possible and
becoming self-sufficient. Refugees eligible for the Matching Grant receive $400 per month, $40
per child and rental assistance covering the refugees entire rent throughout the duration of the
program. In exchange, refugees are expected to work diligently to secure employment and are
required to accept the first job offered to them by the agencys employment staff.
Other families with children receive TANF, a once-in-a-lifetime 60-month public
assistance program that offers Medicaid and cash assistance based on the number of children in
the family. To be eligible for TANF, adults in the family are federally required to attend English
language classes or engage in work activities outside the home. These additional federal
resources thus supplement the initial R& P money provided by the ORR.
Nevertheless, VOLAG staff interviewed here report that the R&P is based on outdated
facts and figures and that public assistance amounts are not equally inflated to match living
expenses and the rising rent prices in Denver. Case managers say that they often use the entire
allotment of R&P money, on behalf of refugees, to pay rent and expenses associated with their
housing for the first two or three months. Therefore, refugees arrive to find their R&P money
already used up. During program periods, refugees are intensively assisted and trained to find
employment; if employment is secured, they supplement it, partly or wholly, with cash from
their public assistance program to pay their daily expenses.
In addition, refugees often arrive with idealized visions about US largesse based on
media and previous refugees reports. Many arrive with a vague idea about the R&P money,
which they call welcome money and conceive of as money that they can spend at their own
discretion. Therefore, arriving and finding their R&P money or welcome money already spent on
rent causes frustration and uncooperativeness. This only complicates case managers work
8


which is echoed by one of the interviewees, They wind up being aggravated from the start with
us so this can cause some issues with their services because if they postpone getting services by
fighting with us- it just complicates everything. Postponing services means that case managers
will be at risk of missing service provision deadlines established by the federal government.
In her ethnography of Salvadoran and Columbian migrants in Long Island, Sarah Mahler
explains that the information that migrants have about life in the US is distorted by media and by
previous waves of migrants which is another side of. Migrants accounts to their families and
friends are created as an attempt to resist attacks on their social status in the US by enhancing
their image and status in their homelands (Mahler 1995). This dynamic is applicable to refugees
since they also might try to enhance their image and social status among for the people left
behind. In addition, in the case of refugees, illusions about resettlement are also fed by overseas
orientation which refugees receive before departing for the US. This information is inaccurate as
one of the interviewed reception and placement coordinators puts it, Misinformation from
people who have never been to the United States and lack of knowledge of the trainers [who
provide overseas orientations] and the fact that people idealize America to be something that it is
not, that is the problem. The biggest obstacle when they get here is them facing the fact that they
have to work right away and that they have to work a lot because everything is expensive. This
misinformation and preconceived notions about America feed unrealistic expectations in
refugees and lead to increased work burden for case managers because they have to respond to
these expectations.
Time Constraints
In addition to the financial constraints and unrealistic expectations outlined above, case
managers also work under great stress to meet deadlines. The VOL AGs that are contracted with


PRM are federally-obligated to provide two sets of services to refugeesthe basic needs support
and the core services (PRM 2011) within what is called the R&P period, which is the first 30-
90 days after arrival. The fact that most case manager responsibilities are time-sensitive increases
the stress under which they work. For example, refugees are to receive a general cultural
orientation about their rights and responsibilities within 7 days of arrival; in addition, case
managers must apply for refugees social security cards and public benefits within 10 days of
refugees arrival. Case managers reported that the stress of meeting these deadlines while
simultaneously serving previously-arrived refugee clients and receiving new refugee arrivals on
a weekly basis sometimes reached the point where it is nearly unmanageable. As one case
manager explained, Case management was consuming my life. There wasnt enough time in the
day to get everything done. So you get three families coming within a time span of two or three
days, so you have to do everything times three but you still have these five days to do
orientation. You still have to take them to social security within 10 days. There was one time
when I took 17 people to social security [at once]. Thus case managers themselves reported
working endless unpaid hours to accomplish these tasks within the required time-frame, thereby
subsidizing the federal governments resettlement efforts with their own time and resources.
While meeting deadlines and managing a heavy caseload is a source of stress in and of
itself, contradicting government regulations add to this stress by increasing the amount of time
needed to accomplish each task, in turn decreasing the time that case managers can spend on
other tasks. Government systems are not set up to process individuals who lack documentation
and yet are entitled to government services and assistance. For example, refugees arrive without
social security numbers (SSNs), yet they are eligible for SNAP/cash public assistance cards,
which they are able to get without SSNs. However, once case managers obtain SSNs for
10


refugees, they must take their clients to public assistance offices a second time to get a new
SNAP/cash card under their newly-received SSNs. It is the case managers responsibility to
transport refugee clients to and from public assistance offices, using their own vehicles. In
addition, refugees dont pass airport security clearance until 10 days after their arrival, yet case
managers are still required to apply for SSNs before their clients are cleared, which in turn
results in delays and potential additional trips to social security offices to reapply.
On top of providing services for refugees, case managers responsibilities also include
case noting, filing and completing administrative tasks. If it isnt case noted, it didnt happen.
is one of the statements supervisors and managers repeatedly use to highlight the importance of
case notes and filing. Case managers are required to meticulously document their efforts in
meeting multiple agencies requirements and deadlines in order to satisfy VOLAG audits.
Indeed, having dated, complete and accurate case notes is one of the PRM core services for
which case managers are responsible. One case manager interviewed in this study was fired due
to her lack of attention to case noting and filing paperwork. Despite the fact that, in reality, she
met all deadlines and requirements, having incomplete files and missing case notes meant that
she lacked proof, which was considered a significant shortcoming for which she had to be fired
by her managers. Explaining why she got fired, the case manager recalls that case management
duties took so much time that there wasnt enough time left to pay attention to administrative
tasks. She said: Between running around between these appointments and all these home visits
that are required and everything else, you have to make time to come to the office, file
paperwork as proof of the stuff you did and case note it, again, as a proof for the stuff you did;
and all within the timeframes or youll get your head chewed-off, you get threatened with your
11


job. These financial and time constraints, stringent organizational objectives and contradictory
government regulations work together to create more stress for case managers.
12


CHAPTER IV
LOCATING HOUSING
Locating housing is the most important basic support service required by PRM. It is
also the most time-consuming and challenging task for which case managers are responsible. As
soon as case managers receive a clients arrival information, they must begin the search for
apartments. To do this, case managers depend on a pool of landlords with whom agency staff
have already-established relationships and who are known to accept refugees as tenants. This
pool is limited to a handful of landlords (including corporations and private property owners)
who are willing to rent to refugees.
A number of factors conspire to make refugees be perceived as undesirable tenants,
thereby narrowing the housing options available to refugees. All landlords require rental and
credit histories, social security numbers andmost importantlya stable income, all of which
refugees lack. Refugees typically dont receive SSNs until 4-6 weeks after arrival and they must
depend on R&P money and public assistancerather than their income from employmentto
pay their rent. Finally, most refugees spend considerable time attending English language
classes, which in the short term interferes with their potential employment. These facts severely
impact landlords willingness to rent to refugees. Consequently, refugees are funneled into a
small number of properties of sometimes questionable qualityapartments that may not have
been repainted for years. As one case manager says: In the (apartment complexes) on Colfax, I
really dont think they bother at all. They vacuum it and they are like, here you go. I dont think
these people paint.... Yes, they are willing to work with us but at the same time they are going to
do the least possible. And they want somebody in there to get their money.
13


The time constraints case managers face amplify their stresses in finding adequate
housing for their clients and make them more likely to overlook defects in housing quality. In
some cases, case managers are unable to locate housing until the day before the familys arrival.
In these cases, if there is any issue with the apartment, case managers address it later, as
explained by one of the interviewed resettlement staff members. I realize if your client is
coming tomorrow and there is lead chipping, what are you going to do? Theres no other way.
Priority is given to housing the arriving case; concern about the quality of housing and its
sanitation come later. This clearly contradicts PRM and ORR policies and requirements. Case
managers and agency staff do not intend to violate federal policies but the difficulty of locating
adequate housing and the narrow pool of landlords with whom they may work often leave these
professionals with no other options.
Indeed, it is not only refugees lack of documentation and prior rental histories that limit
the pool of landlords available to them; the meager cash that refugees receive through the R&P
money and their public assistance restricts them to certain areas in the city and to a certain
standard of apartments. The Denver area is the second fastest-growing rental market in the nation
(The Denver Post 2015); indeed, case managers and housing coordinators noticed marked rent
increases recently. Given the meager resources available to refuges and their lack of
documentation, case managers must often settle for cheaper housing of possibly substandard
quality in order to fulfill their job responsibilities. Additionally, housing has to be affordable in
the long run because refugees employability varies due to education and health status.
Because case managers are forced to work with a limited pool of landlords, they must
accept extraordinary requirements and conditions in order to preserve their relationships with
landlords. They will need to draw upon this same small group of landlords in order to house
14


future arrivals. Over time, landlords become somewhat acquainted with the structure of
resettlement and learn that housing is among case managers primary and most challenging
responsibilities. This gives landlords the upper hand in negotiating housing with case managers.
Case managers interviewed in this study report exploitative practices through which landlords
exert their power over case managers and consequently, over refugees.
One of the first requirements that landlords set for renting to refugees is signing the lease
as soon as refugees arrive orif time doesnt permitthe very next day. While fulfilling this
requirement cements the case manager-landlord relationship, refugees, on the other hand, are
victimized by it. They do not choose where they are housed and when the lease is signed, they
are still overwhelmed and exhausted by the journey to the U.S. In cases where refugees are
illiterate in their native language, the process of signing the lease is intimidating and confusing;
they are hauled through it by the case manager and the landlord. In addition, landlords are aware
of the fact that case managers are responsible for refugees and that they will receive assistance
from VOLAGs. Thus landlords use this knowledge to pressure case managers so that their clients
sign leases that last as long as possible. This is because they know that if one family moves out
there will be another refugee family or group of singles who will rent the apartment the very next
day. A former case manager explains: Some landlords, most of them would work with us with
six months or eight months leases to coincide with the clients cash assistance and towards the
end they would say, nope, 12 months or nothing else because, again, they knew we had no
choice. They would say, no it is too much cleaning if there is people moving out every six
months. Faced with the risk of having their families evicted and the difficulty of damaging their
relationship with landlords, case managers are forced to accept such conditions.
15


On the other hand, case managers also pressure refugees to maintain good relationships
with landlords. The following account by a program coordinator sheds light on how refugees are
educated to maintain case manager-landlord relationship, We explain [to refugees] that you
dont have a social, you dont have a job and you dont have credit. These are the thing you need
to get an apartment. These people [landlords] are trusting us and you need to do what they say...
we dont want them to ruin it for anyone else. Maintaining relationships with landlords is of
great importance for housing future arrivals. In fact, case managers often pay two or three
months worth of rent in advanceboth to make sure that their clients dont have rental
difficulties and to reassure landlords who perceive themselves as taking a huge risk by renting to
refugees.
The scarcity of landlords who will rent to refugeesand these landlords own difficulty
finding reliable tenants because of their undesirable housingleads to complicities between
landlords and case managers that in turn harm refugees. Once case managers are forced to accept
lower quality housing for their refugee clients, landlords in turn grant case managers particular
allowances. Because rent consumes a large amount of refugees cash assistance, case managers
tend to house multiple refugees in the same apartment under one lease so that each family has a
little bit of spending money left over after paying rent. Landlords, especially private property
owners, often turn a blind eye to this practice. On the other hand, to save the costs of cleaning
and repainting apartments in between tenants, landlords allow case managers to bring in new
refugee tenants as soon as the previous tenant moves out, without changing the lease. A case
manager reports that, They (landlords) will say, when this person has no more money, bring
somebody else in but they continue the same lease, therefore, they dont have to come in and
clean it. Notably, this practice also exempts landlords from having to repaint the apartment.
16


The substandard quality of refugee housing in Denver is not limited to deteriorated paint
or the presence of lead in the environment. All participants in this study mentioned bug
infestations, such as bed bugs and roaches as an environmental hazard that they take more
seriously and know more about than lead poisoning. Bed bugs and roaches strain case manager-
landlord relationships because landlords have to come in to disinfest apartments periodically.
Because the landlord and the case manager have to explain the process in its entirety to the
refugeewho, in most cases, does not speak Englishdisinfestation is a costly and time-
consuming procedure This situation results in mutual blaming between case managers and
landlords in which landlords often blame refugees backgrounds and hygiene standards for bug
infestations; case managers in turn blame landlords old and poorly maintained apartment
buildings.
A Denver based case manager explains how the structure of the resettlement process
exposes refugees to environmental hazards they never experienced while living in absolute
poverty in refugee camps: These apartments were the most disgusting places Ive ever seen.
This family (housed there) had a little boy who is one and a half. The next day they told me,
something is biting him. Bedbugs had bitten him all over. The lady had swept a pile the size of a
tile of bedbugs. And the landlord tried to tell me that they brought it in. I told him, no, theyve
been in you apartment for six hours, they did not bring it in. The case manager moved the
family immediately after this incident but she lost the deposit that was paid from the familys
R&P money. As a result, the case manager ended up placing the family in a shared, overcrowded
apartment with other Somali community members; she also lost the relationship with this
landlord.
17


Case managers are forced to accept substandard housing to fulfill their job
responsibilities; meanwhile, landlords exploit the stress under which case managers work to keep
their apartments rented. When case managers object to the poor quality of housingas in the
case of the bedbug infestation described abovethey risk losing landlords and further narrowing
the limited number with whom they work. As one case manager says, There is always
somebody there looking to make a buck and take advantage of someone else. Unfortunately, as
refugees and refugee case managers running out of options we have to go with them even though
we know they are trying to scam us, we have to go.
Case managers report that their difficulty finding their clients housing in Denver is
caused by their heavy caseloads as well as the steep rents compared to refugees resources. For
example, case managers at Lutheran Family Services (LFS) in Colorado Springs do not share the
same experiences with their counterparts in Denver because of Colorado Springs lower rents
and fewer refugee arrivals; LFS of Colorado Springs receives 120-140 cases per year and the
organization is able to own two emergency condominiums used to house refugees temporarily
until suitable housing is found. In contrast, in Denver, if case managers do not secure housing
before refugees arrival, they instead house them in motels. This emergency practice in turn
quickly drains the R&P money refugees will use to pay rent later on, thereby only compounding
case managers difficulty in finding refugees appropriate housing in Denver. Therefore, the
lower number of arriving refugees, the owned emergency housing and the relatively lower rents
in Colorado Springs prevent the emergence of landlord-case manager codependency and
exploitation.
18


The Role of Refugee Networks: Reinforcing Housing Patterns
To an outsider, it may seem that case managers are deliberately choosing crime and
poverty ridden areas to house refugees because of the low rents. Case managers try hard to
distribute the refugee population evenly over the Denver metro area. However, in addition to the
limited resources, there are a variety of reasons that case managers resettle refugees in particular
areas of the cityareas where rents are low and that are also characterized by unemployment,
crime, and poverty (Carter and Osborne 2009). First, during the first six to eight months post-
arrival, refugees work closely with case managers, employment specialists and other resettlement
staff to secure employment and attain self-sufficiency. This makes housing in the inner-city and
East Colfax area a practical choice since resettlement organizations in Denver are situated there.
Second, for case managers, the presence of a refugee community can lift some tasks off
their shoulders. Refugees who arrived earlier can assist others who have just arrived to adjust to
their new lives by modeling how to use the public transportation system and do grocery
shopping. In addition, since they are all either working or attending language classes, living in
close proximity to other refugees embeds them in the social networks that in many cases turn out
to be beneficial in securing employment or in acquiring help to register for language classes, all
of which are case managers duties. Therefore, case managers benefit from the clustering of
refugees close to each other.
Finally, refugees often prefer living in close proximity to others from their own
community. Therefore, even if case managers go to trouble to house recently-arrived refugees in
areas outside the inner-city, they may find that their clients will request to be moved to housing
in the areas where their co-ethnics live. Thus for these reasons, case managers do not have any
incentives to look for housing in new locations or to build relationships with new landlords.
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Case Managers as Street-Level Bureaucrats: Stereotyping and Taking Short-Cuts
To mitigate the stress of finding housing for new arrivals while managing their pre-
existing caseload, case managers resort to strategies of stereotyping and mass processing of
clients. These strategies are used by frontline service providers whom Michael Lipsky (1980)
calls street-level bureaucrats. As Lipsky describes, street-level bureaucrats work with heavy
caseloads with limited time and resources at their discretion. Their work is also scrutinized by
managers who are not working in the front lines, but whose job entails making sure that the
agencys objectives are met regardless of whether or not this is possible within the available time
and resources. As a result, street-level bureaucrats develop methods and shortcuts that help them
manage stress and responsibilities without necessarily violating the agencys objectives. To meet
deadlines, manage caseload and meet managers expectations, street-level bureaucrats become
policy makers of their own (Lipsky 1980). One of these shortcuts is stereotyping which street-
level bureaucrats use to be able to process their clients in as little time as possible (1980:142).
In all three Colorado VOLAGs, all case managers are former refugees themselves. As a
variant of street-level bureaucrats, these case managers occupy what Marrow (2012) calls
service-oriented roles. Their ability to speak a refugee language and understanding of the refugee
experience makes them service-oriented individuals who feel committed to serving a
disadvantaged group despite the extremely limited resources with which they must discharge
their mission. Yet in addition to addressing the needs of their clients, case managers have to meet
the requirements of managers and supervisors who dont have daily interaction with refugees
and who occupy regulatory-oriented roles implementing PRM and ORR policy. During the
resettlement process from start to end, then, case managers become saddled with the dual task
of being a judge and a server (Van der Leun 2006).
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Sociologists have argued that as they oscillate between their service and regulatory -
oriented roles, front-line service providerssuch as eligibility workers, law enforcement officers
and social workers play an immense role in the incorporation or exclusion of migrants (Marrow
2012; Van der Leun 2006; Weiner et al, 2004). In her study of mental health services provided to
Latina immigrant women, for example, Horton (2006) describes a setting in which healthcare
providers were trapped between meeting the productivity requirement imposed by the hospital
administration and appropriately serving their patients. Similar to case managers, these
cliniciansalso all Latinoevinced a service orientation. They engaged in advocacy and
uncountable billable hours, thereby shouldering a burden that should have been carried by the
clinic (Horton 2006). Yet the administrations emphasis of clinician productivity led providers
to take short-cuts that served some patients while short-changing others. As clinicians adopted
practices to increase productivitysuch as double-booking clients and engaging in group
therapythis decreased the quality of care and ultimately, to denied access to care for the
disadvantaged. Case managers face a double bind much like these clinicians. As their
organizations emphasize adhering to strict deadlines and meeting federal requirements, they too
face challenges to treating their clients with the discretion they deserve as individuals. Having
the dual role of being loyal to clients and accountable to organization managers is another source
of stress that case managers constantly work under.
Much like the mental health clinicians Horton describes, case managers attempt to cope
with their constraints of time and resources by inventing ways in which they can mass process
their clients regardless of their individual preferences or needs: such as developing short-cuts
that allow them to cope with particular refugee populations in predictable patterns. For example,
while I was working at ERIS, it was well known that case managers house particular populations
21


in particular parts of the city. Following informal protocol, I housed most of my Iraqi clients in
parts of Aurora while I placed my African clients on East Colfax. Among the Iraqis a
wealthier and more educated populationColfax has earned itself a reputation of crime, poverty
and prostitution; therefore, placing Iraqis there was a cause of stress because as soon as they met
other members from their community, they would be advised to move as soon as possible. This
was not only so among Iraqis; one staff member mentions that Afghani refugees share the same
idea about living on Colfax. Iraqis and Afghanis and the entire community in Denver at least
they have created this perception of Colfax that horrible place where you get murdered and get
robbed even through many of them have never been over there they just have heard those horror
stories.
On the other hand, Asian refugees from Burma, Nepal and African refugees from
Somalia, Sudan or Congo did not have prejudices about East Colfax; their sole criterion was
living where their community members live. In fact, placing these populations anywhere other
than East Colfax was asking for more stress. Once African refugees met a community member,
they would be advised to move to East Colfax or to break their lease. One reception and
placement coordinator mentioned of African refugees, So it is not like the perception that some
people have that we are just creating a large refugee camp over there or something. They are
choosing it. I cant make them live somewhere they don't want to live. In addition, case
managers use their own discretion in classifying which groups of refugees are likely to stay in
Denver and which are likely leave the state. When refugees are deemed unlikely to stay in
Colorado, they are placed in shared and often-overcrowded apartments so that they do not have
to sign a separate lease. This shortcut was especially applicable to Somali single adults, who
22


were thought to prefer to move to Minnesota to join the bigger Somali community there and to
take advantage of employment opportunities thought to be more abundant.
Case managers are fully aware of the difference in quality between housing in East
Colfax and parts of East Aurora and of Denver (such as Peoria street, Parker road and Leetsdale
Drive.) East Colfax apartments were dirty, poorly maintained and well-known for bug
infestations compared to those in Aurora or Denver. Nevertheless, because case managers
experience taught them that housing African and Asian refugees anywhere other than East
Colfax would lead to short stays or broken leases, they tended to place new arrivals in the
substandard housing of this area. Thus case managers strategies to cope with their heavy
caseloadsstereotyping and mass processing their clients based on nationalityexposes African
and Asian refugee children to more environmental hazards as compared to their Iraqi
counterparts.
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CHAPTER V
COUNTERACTING GEOGRAPHIES OF BLAME
The literature describing the phenomenon of lead poisoning among refugee children is
saturated by what Paul Farmer (1999) described as geographies of blame. Geographies of
blame are discourses that consider Global South the source of unhealthy practices, ignoring any
structural factors that cause illness. Through his work in Haiti, Farmer criticized anthropologists
relativistic view that Haitian culture was to be blamed as a major contributor to the prevalence of
AIDS and their neglect of other social and economic factors that were at play (1999: 9).
Likewise, the idea that refugee children arrive with already-elevated blood lead levels and that
their parents engage in risky cultural practices places blame on refugees countries of origin and
on refugee culture without examining the role of the resettlement process in lead poisoning.
The academic and public health literature in the US rarely attributes refugee childrens
lead ingestion and subsequent poisoning to their housing conditions; instead, it is reported as the
result of deteriorating conditions in countries of origin and the use of folk remedies (Plotinsky et
al., 2008; Ritchey et al. 2009). For example, the CDC reports that cultural practices and the use
of traditional medicines are the primary reason for high rate of lead poisoning among refugee
children. In its report on the issue, it provides a table with a list of food items, condiments,
glazed pottery items, cultural remedies for indigestion in infants and children, and cosmetics
alongside the country of origin of these lead-containing items. These countries include a variety
of African countries, Iraq and Indiaall of which are part of the Global South and whose
populations often arrive in the United States as refugees or asylum seekers escaping the
detrimental effects that neoliberalism had on their local economies (Holmes 2013).
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The CDC report does mention that refugee children are at risk for lead poisoning since
refugee families often settle in high-risk areas. Indeed, while the CDC report places blame on
refugee cultures, birth places and places of residence before arrival as a main cause of elevated
blood lead levels, the example used to illustrate the severity of this phenomenon is of a Sudanese
toddler who died 5 weeks after resettlement and whose blood lead levels reached 392 pg/dL
because of exposure to lead-based paint in the United States. Despite briefly acknowledging the
role of substandard housing in the U.S. in refugee childrens lead poisoning, the CDC report
ignores the fact that refugee families often do not have control over the location of their homes.
Many academic reports implicitly blame refugees themselves for their lack of knowledge
and awareness about the harmful effects of lead. They therefore ignore the fact that refugee
children generally suffer from malnutrition, which in turn facilitates the quick absorption of lead
and results in elevated blood lead levels (Geltman 2001). Therefore, exposure to minute amounts
of lead can increase blood lead levels in malnourished refugee children. Many parents may
remain unaware of their childrens lead poisoning as the symptoms are not directly visible. Even
if refugees do become aware of the risks posed by their environment, their time-limited cash
assistance programs, and difficulties securing employment, make lead poisoning a lesser priority.
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CHAPTER VI
CONCLUSION
Lead poisoning among refugee children is clearly a reason for concern for health
professionals, those who work with refugees and refugees themselves. Time and financial
constraints are the main reasons pushing case managers and refugees to accept substandard
housing. Yet, research puts the responsibility of poisoned refugee children on their parents
claiming that culture and folk home remedies are the source of the problem. These cultural
practices might play a role in the issue, but it is the condition of substandard housing in the U.S.
that is to blame since refugee children report elevated blood lead levels after resettlement.
Furthermore, the lack of knowledge on the part of case managers who are usually
refugees themselvesand are often unaware of leads negative health effects complicates
refugees education about lead. Case managers knowledge and their ideas about lead poisoning,
in and of itself one of the contributors to the problem, is an issue that requires more research and
investigation since case managers work with refugees on a daily basis and are responsible for
securing their housing. Given their primary role in resettlement, they are indispensable to the
process of educating refugees and raising their awareness about lead poisoning. Yet the federal
government is responsible for the resettlement of refugees, and; can play an important role in
raising awareness about lead poisoning and its effects on childrens cognitive health and growth
by making such education law. Refugees are admitted to the U.S. by the federal government and
it is the governments responsibility to ensure their safety by mandating case manager and
refugee education regarding lead poisoning. Following New Hampshires lead, lead screening
for refugee children should be federally mandated during the first 30-90 days after arrival to
detect any elevation in BLLs. Early detection should help in preventing cases of severe
26


poisoning. In addition, the aim of providing refugees with basic cash assistance is to assist them
in covering basic expenses, such as rent and utilities, until self-sufficiency is achieved. However,
the current amounts of R&P money and refugee cash assistance are not nearly enough to meet
these basic needs, nor to ensure they live in housing adequate to ensure their well-being. It is
unreasonable that the government can afford to treat refugee children through Medicaid after
they have been poisoned by lead but at the same time, the government does not grant enough
funds to VOLAGs and refugees to provide adequate housing that would itself obviate the need
for such treatment.
As the numbers of Syrian refugees continues to rise and the US government raises the
annual ceiling of admitted refugees in response to this global crisis, the problem of lead
poisoning among refugee children has to be addressed with more serious and practical steps. If
the ORR does not increase refugee cash assistance amounts to meet the increasing living costs in
the US, it would be irresponsible to admit more refugees. This will not only tie them to an
inhumane life in poverty and constant distress, but it will also expose their children to health
issues that are preventable if funding for the resettlement process is increased.
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REFERENCES
Centers of Disease Control and Prevention. (2006). Lead poisoning prevention program.
http://www.cdc.gov/nech/lead/Publication/RefgueeToolKit/Refugee Tool Kit.htm
Church World Service. (2005). Lead poisoning prevention: a matter of life and death for refugee
children. www.churchworldservice.org/Immigration
Denver becomes 2nd fastest climbing rental market in the nation.
http://www.denverpost.com/ci 28213367/denver-becomes-2nd-fastest-climbing-rental-market-
nation? source=infinite-up
Farmer, P. (1999). Infections and Inequalities: The Modern Plagues. Berkeley: University of
California Press.
Geltman, PL., Brown MJ, Cochran J. (2001). Lead Poisoning Among Refugee Children
Resettled in Massachusetts, 1995 to 1999. Pediatrics 108:158-162.
Horton, S. (2006). The double burden on safety net providers: placing health disparities in the
context of the privatization of health care in the US. Social Science & Medicine, 63(10):2702-
2714.
Lipsky M. (1980). Street-Level Bureaucrats: dilemmas of the individual in public services. New
York: Russell Sage Foundation.
Marrow, J. (2012). Deserving to a point: Unauthorized immigrants in San Franciscos universal
access healthcare model. Social Science & Medicine, 74:846-854.
Plotinsky R, Straetemans M, Wong L. et al. (2008). Risk factors for elevated blood lead levels
among African refugee children in New Hampshire, 2004. Environmental Research 108:404-
412.
Ritchey D, Scalia Sucosky M Jefferies T et al. (2011). Lead poisoning among Burmese refugee
childrenIndiana. 2009. Clinical Pediatirics 50(7):648-656.
Van der Leun, J. (2006). Excluding illegal migrants in the Netherlands: between national policies
and local implementation. West European Politics, 29(2):310-326.
Weiner, S. J., Laporte, M., Abrams, R. I., et al. (2004). Rationing access to care to the medically
uninsured: the role of bureaucratic front-line discretion at large healthcare institutions. Medical
Care, 42(4):306-312.
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Full Text

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i EXPLAINING LEAD POISONING AMONG REFUGEE CHILDREN: THE RESETTLEMENT PROCESS by DALIA ABDULRAHMAN B.I.C, Zuyd Unive rsity for Applied Sciences, 2011 A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Master of Arts Anthropology Program 2016

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ii This thesis for the Master of Arts degree by Dalia Abdulrahman Has been approved for the Anthropology Program by Sarah Horton, chair Zanetha Thayer John Brett Date: 02/05 /2015

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iii Abdulrahman, Dalia (M.A., Anthropology) Explaining Lead Poisoning Among Refugee Children: The Resettlement Process Thesis directed by Associate professor Sarah Horton ABSTRACT Lead is particularly harmful to the growing nervous system and soft tissue of small children. Children living in poorly maintained and old houses are at particular risk of lead poisoning. Testing of refugee children showed an increase in blood lead levels after arrival to the US. In this at higher risk of living in substandard housing. Highlighting the external financial pressures and time constraints to which case workers are subjected, I show how they are forced to function as street level bureaucrats employing different strategies to handle their workload which ultimately works to inadvertently elevate blood lead levels among refugee children. The form and content of this abstract are approved. I recommend its publication. Approved: Sarah Horton

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iv DEDICATION This thesis is dedicated to my parents, Hawa and Mohammed, for their unconditional love and continuous encouragement, to my husband, Mohamed, for tirelessly taking care of our little one after so many long work days so mummy can study and lastly, to my advisor, Sarah Horton, without whose excellent mentoring, dedication and guidance, this thesis would not have seen the light of day.

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v TABLE OF CONTENTS CHAPTER I. INTRODUCTION ................................ ................................ ................................ ................... 1 II. METHODS ................................ ................................ ................................ ............................ 4 III. ................................ ................................ ................................ 7 IV. LOCATING HOUSING ................................ ................................ ................................ ..... 13 V. COUNTERACTING GEOGRAPHIES OF BLAME ................................ ............................ 24 VI. CONCLUSION ................................ ................................ ................................ ................... 26 REFERENCES ................................ ................................ ................................ ......................... 28

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1 CHAPTER I INTRODUCTION health and cognitive development. Lead is harmful for the growing nervous system and soft tissue of small children. To grow, children drink more water, eat more food and breathe in more air than adults. and consequent poisoning if lead is present in the environment (CDC 2006) Despite public health campaigns and advances made in removing lead from gasoline, paint, food canning and drinking water, lead poisoning is still a persistent threat to the health of children in many American cities (Caron et al., 2013) A report from the Center of Disease Control and Prevention (CDC) explains that although the federal government prohibited the use of lead based paint in 1978, all children living in houses built pri or to that period and from exposure to dust and soil. 1 Yet, the prevalence of elevated blood lead levels in refugee children is higher than the 2.2% prevalence among U.S. children These children did not show high blood levels initially. However, when tested 3 to 6 months after arrival, they showed 2 (CDC 2006) The question addressed in this study is : what makes refugee children in particular more prone to have elevated blood lead levels? H In contrast, research 1 Children are at risk of lead poisoning in houses built prior to 1978 if they are poorly maintained. In such cases, leaks or damage may expose previous layers of walls with paint that contains lead; moreover, chipped pain 2 10g/dL was the reference level at which CDC recommends public health actions be initiated. In 2012, the CDC lowered the reference level to 5 g/dL

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2 and monitoring by faith based organizations that sponsor refugees report that although refugee children may arrive with already elevated blood lead levels, they often show even higher levels of blood lead when te sted a few months after arrival (CWS 2005) A study conducted among 693 refugee children in Massachusetts between 1995 and 1999, for example, concluded that elevated blood lead levels are two times more prevalent in refugee children than in US born children. Although these children arrived with elevated levels, their blood lead levels increased significantly after resettlement due to their de teriorating housing (Geltman et al. 2001) Indeed in 2000, elevated blood lead levels resulted in the death of a Sudanese refugee toddler who had been resettled to New Hampshire along with her family. Researchers suggested housing circumstances her death were 392 mg/dL a lethal amount (Geltman et al., 2001 ). The Bureau of Population, Refu gees and Migration (PRM) already mandates a health examination including a lead screening within 30 After this incident, however, the state of New Hampshire mandated an additional lead screening of refugee children 3 6 mon ths after their first screening to track their lead exposure (CDC 2006). In 2004 health professionals in New Hampshire discovered elevated blood lead levels among 96 of the 242 refugee children in the ag e range of 6 months to 15 years who were resettled in that year. Because t hese children were tested twice professionals were able to determine that the bulk of the These children showed blood lea d levels less than 10 mg/dL in their initial PRM mandated health screening s but the second screening mandated by the state of New Hampshire revealed levels higher than that I nvestigations by the CDC revealed moderate lead hazards in residences and some co ntamination in soil in the play areas frequented by the children (CDC 2006). Thus while

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3 c ultural practices and folk home remedies might exacerbat e lead poisoning, considering it to be the primary contributor to the problem overlooks environmental factors that play a bigger role in the issue. In this paper I argue that the resettlement process subjects refugees to circumstances of structural violence that result in lead poisoning among children. I show that time constraints and limited financial resources force case managers in refugee resettlement agencies as a variety of to accept substandard housing for their clients and to resort to handle their work load. Thus th e resettlement process directly exposes refugee families t o health hazards related to substandard housing, such as lead poisoning. Through interviews with resettlement agency staff, this thesis provide s an emic view of the process of finding appropriate ho using for refugees and how this may lead to increased rates of lead poisoning among refugee children.

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4 CHAPTER II METHODS I was first confronted with lead poisoning when I worked as a case manager at a refugee resettlement agency in Denver and found that the children of a number of my clients showed elevated blood lead levels. One of these cases was the son of an Iraqi refugee; the father came to my office asking for a note for his employer for him to miss work to take his son to the hospital for blood wo rk and to meet with a physician. The medical paperwork the father carried indicated that the child had an elevated level of lead in his blood level that needed to be addressed as soon as possible. Neither I nor the father had any indication that this might be related to their pre resettlement environment. My client came to the US on a special immigrant visa due to his work with the US army in Iraq, therefore, the family was well off in Iraq and the likelihood that they lived in a poorly maintained home is s US might have contributed to his elevated lead levels, this client remained living in the same apartment home until I left my position at the resettlement agency. I also encountered an African fami ly with two young children who suffered from elevated blood lead levels; the testing was done after arrival. This family in particular had many health issues requiring continuous medical attention; therefore, medical and agency staff might have attributed lead level to lead ingestion overseas and not in the US. I worked at this agency for fourteen months between 2012 and 2013 and m y caseload averaged 80 to 100 pre existing cases in addition to about 20 new refugee arrivals, single and family cases, per month. As a native Arabic speaker who myself had been an asylum seeker in Europe I primarily served Iraqi and African refugee s. Thus I became

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5 poor housing conditions in the U.S., itself the result of the resettlement process, might contribute to the problem of lead poisoning among refugee children. I conducted a total of 8 semi structured interviews with staff in refugee resettlement agencies: six interviews with case managers, one reception and placement program coordinator and one program director. The interviews lasted between an hour to an hour and a half. Participants answered questions about their responsibilities as case managers and housing coordinators, the process of locating housing, the obstacles they face d when doing their jobs and their knowledge about lead poisoning. All interviewe es work ed at Colorado based refugee resettlement organizations. Currently, there are two refugee resettlement organizations active in Colorado : the African Community Center (ACC) and Lutheran Family Services (LFS) which is the largest refugee resettlement organization in the Rocky Mountains area. A third agency, Ecumenical Refugee and Immigration Services (ERIS) closed its doors in June of 2015. I started data collection in April 2015 two months before the closure of ERIS. Between the end of April and June 2015, I was able to inter view a former ERIS case manager. After the end of June, case managers and housing coordinators working at ACC and LFS became increasingly difficult to reach due to the fact that, now, these two organizations had to divvy up the existing cases that had been the new cases which were assigned to ERIS as well as cases. Understandably, due to the increasing case load of case managers and all agency staff in gen eral there was no response to my emails and calls requesting interviews. Due to th eir unresponsiveness, I decided to do walk ins and ask to meet case managers. This strategy was only successful at ACC ; I was able to schedule two interviews with case manage rs. I also met

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6 who is responsible for finding housing for arriving refugee families. This strategy was not successful with LFS staff since the organization has rigid rules regarding walk ins ; it is not possible to meet any staff member without an appointment. I was able to get an interview with LFS at Colorado Springs but only after they accepted my offer of volunteering for 8 hours. The bus yness of LFS of Denver is understandable since the organization is receiving a record high number of refugees this year LFS received 140 refugee cases in September 2015 ; 1999. In contrast the housing coordinator at LFS of Colorado Spr ings indicated that their office will resettl e between 130 and 140 refugees this fiscal y e ar LFS of Greeley and Fort Morgan also denied requests for interviews due to high numbers of arrivals in the months of August, September and October. Ethical approva l for this study was obtained from the Colorado Multiple Institution Review Board at the University of Colorado Denver.

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7 CHAPTER III Resettlement agencies, also called voluntary agencies (VOLAGs), contract with the federal government ; t he US refugee program is collaboratively directed by the U.S. Department of State through the Bureau of Population, Refugees and Migration (PRM), the U.S. Department of Homeland Security represented by the U.S. Citizenship and Immigration Services (US CIS) and the U.S. Department of Health and Human Services represented by the Office of Refugee Resettlement (ORR) (Dwyer 2010). This contract obliges VOLAGs to provide what is called basic support services upon refugee arrival. These services include locating housing for refugee families, applying for social security numbers and public assistance such as, S upplemental N utritional A ssistance P rogram (SNAP) T emporary A ssistance for N eedy F amilies (TANF) Medicaid, Medicare and S ocial S ecurity I ncome (SSI). Case managers are also responsible for enrolling children in school, providing home safety and cultural orientations to help refugees navigate and access the social services system and public schools system. Meanwhile, case managers continue to work with their previous refugee clients, serving refugees for up to five years after their arrival Additionally, case managers manage the finances of refugees; each refugee receives a one time tr ansitional grant, also called reception and placement (R&P) money, provided by ORR. Officially this grant is a flat $1125 per person, but depending on individual agency policy the amount can be as low as $925. T here are also three time limited c ash assistance programs to which refugees are entitled. My focus will be on the two programs that are provided to families with children. For example, the federal Matching Grant Program assists refugees whose educational and occupational background s promis e speedy employment. Assistance is limited to

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8 3 to 4 months and a great emphasis is placed on attaining employment a s quickly as possible and becoming self sufficient. Refugees eligible for the Matching Grant receive $400 per month, $40 per child and renta l assistance covering the through out the duration of the program. In exchange, refugees are expected to work diligently to secure employment and are Other f amilies with children receive TANF a once in a lifetime 60 month public assistance program that offers Medicaid and cash assistance based on the number of children in the family. To be eligible for TANF, adults in the family are federally required to attend English language classes or engag e in work activities outside the home. These additional federal resources thus supplement the initial R& P money provided by the ORR. Nevertheless, VOLAG staff interviewed here report that the R&P is based on out dated facts and figures and that public assistance amounts are not equally inflated to match living expenses and the rising rent prices in Denver. Case managers say that they often use the entire allotment of R&P money on behalf of refugees, to pay rent and expenses associated with their housing for the first two or three months. Therefore, refugees arrive to find their R&P money already used up. During program periods refugees are intensively assisted and trained to find employment; if empl oyment is secured, they supplement it, partly or wholly, with cash from their public assista nce program to pay their daily expenses In addition, r efugees often arrive with idealiz ed visions about US largesse based on Many arrive with a vague idea about the R&P money which and conceive of as money that they can spend at their own discretion. T herefore, arriving and finding their R&P money or welcome money already spent on rent causes frustration and uncooperativeness. This only complicates work

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9 which is echoed by one of the interviewees us so this can cause some issues with their services because if they postpone getting services by fighting with us will be at risk of miss ing service provision deadlines established by the federal government. In her ethnography of Salvadoran and Columbian migrants in Long Island, Sarah Mahler explains that the information that migrants have about life in the US is distorted by media a nd by previous waves of migrants which is another side of d friends are created as an attempt to resist attacks on their social status in the US by enhancing their image and status in their homelands (Mahler 1995). This dynamic is applicable to refugees since they also might try to enhance their image and social status among for the people left behind. In addition, in the case of refugees, i llusions about resettlement are also fed by overseas orientation which refugees receive before departing for the US. This information is inaccurate as one of the interviewed reception and placement c oordinator s Misinformation from people who have never been to the United States and lack of knowledge of the trainers [who provide overseas orientations] and the fact that people idealize America to be something that it i s not, that is the problem. The biggest obstacle when they get here is them facing the fact that they have to work right away and that they have to work a lot because everything is expensive. misinformation and preconceived notions about America feed unrealistic expectations in refugees and lead to increased work burden for case managers because they have to respond to these expectations. Time Constraints In addition to the financial constraints and unrealistic expectations outlined above, case managers also work under great stress to meet deadlines. The VOLAGs that are contracted with

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10 PRM are federally obligated to provide two sets of services to refugees the basic needs support and the core services (PRM 2011 ) within what is calle d the R&P period which is the first 30 90 days after arrival. The fact that most case manager responsibilities are time sensitive increases the stress under which they work. For example, refugees are to receive a general cultural orientation about their r ights and responsibilities within 7 days of arrival ; in addition, case social security cards and public benefits within 10 days of arrival. Case managers reported that t he stress of meeting these deadlines while simultaneously serving previously arrived refugee clients and receiving new refugee arrival s on a weekly basis sometimes reached the point where it is nearly unmanageable. As o ne case manager explained enough time in the day to get everything done. So you get three families coming with in a time span of two or three days, so you have to do everything times three but you still have these five days to do orientation. You still have to take them to social se curity within 10 days. There was one time when I took 17 people to social security [at once] Thus case managers themselves reported working endless unpaid hours to accomplish these tasks within the required time frame thereby subsidizing the federal gov While meeting deadlines and managing a heavy caseload is a source of stress in and of itself, contradicting government regulations add to this stress by increasing the amount of time needed to accomplish each task in turn decreasing the time that case managers can spend on other tasks. Government systems are not set up to process individuals who lack documentation and yet are entitled to government services and assistance. For example, refugees arrive without social security numbers (SSNs) yet they are eligible for SNAP/cash public assistance cards which they are able to get without SSNs. However, once case managers obtain SSN s for

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11 refugees they must take their clients to public assis tance offices a second time to get a new SNAP/cash card under their newly transport refugee clients to and from public assistance offices using their own vehicles In addition, airport security clearance until 10 days after their arrival, yet case managers are still required to apply for SSN s before their clients are cleared, which in turn results in delays and potential additional trips to social security offices to reapply. On top of providing services for refugees ca case noting, filing and completing administrative tasks. is one of the statements supervisors and managers repeatedly use to highlight the importance of case notes and filing. Case managers are required to meticulously document their efforts in meeting requirements and deadlines in order to satisfy VOLAG audits Indee d having dated, complete and accurate case notes is one of the PRM core services for which case managers are responsible One case manager interviewed in this study was fired due to her lack of attention to case noting and filing paperwork. Despite the fa ct that, in reality, she met all deadlines and requirements, having incomplete files and missing case notes meant that she lacked proof which was considered a significant shortcoming for which she had to be fired by her managers. Explaining why she got fi red, the case manager recalls that case management that are require d and everything else, you have to make time to come to the office, file paperwork as proof of the stuff you did and case note it, again, as a proof for the stuff you did; off, you get threatened with your

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12 These financial and time constraints, stringent organizational objectives and contradictory government regulations work together to create more stress for case managers.

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13 CHAPTER IV LOCATING HOUSING Locating housing is the most important service required by PRM. It is also the most time consuming and challenging task for which case managers are responsible. As soon as arrival information, they must beg in the search for apartments. To do this, case managers depend on a pool of landlords with whom agency staff have already established relationships and who are known to accept refugees as tenants. This pool is limited to a handful of landlords ( including corporations and private property owners) who are willing to rent to refugees A number of factors conspire to make refugees be perceived as undesirable tenants, thereby narrowing the housing options available to refugees All landlords require rental and credit histories, social security numbers and -most importantly -a stable income, all of which 6 weeks after arrival and they must depend on R&P money and public assistance rather than their inc ome from employment to pay their rent. Finally, most refugees spend considerable time attending English language classes, which in the short term interferes with their potential employment. These facts severely gees. Consequently, refugees are funneled into a small number of properties of sometimes questionable quality apartments that may not have In the (apartment complexes) on Colfax, I

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14 Th e time constraints case managers face amplif y their stresses in finding adequate housing for their clients and make them more likely to overlook defects in housing quality In some cases, case managers are unable to locate housing until the day before the In these cases, if there is any issue with the apartment, case managers address it later, as coming tomorrow and there is lead chipping, what are Priority is given to housing the arriving case; concern about the quality of housing and its sanitation come later. This clearly contradicts PRM and ORR policies and requirements Case managers and agency staff do not intend to violate federal policies but the difficulty of locating adequate housing and the narrow pool of landlords with whom they may work often leave these professionals with no other options. Indeed, it is not only lack of documentation and prior rental histories that limit the pool of landlords available to them; the meager cash that refugees receive through the R&P money and their public assistance restricts them to certain areas in the city and to a certain standa rd of apartments. The Denver area is the second fastest growing rental market in the nation (The Denver Post 2015) ; indeed, case managers and housing coordinators noticed marked rent increases recently Given the meager resources available to refuges and t heir lack of documentation, case managers must often settle for cheaper housing of possibl y substandard quality in order to fulfill their job responsibilities Additionally, h ousing has to be affordable i n the long run because refugee employability varies due to education and health status. Because case managers are forced to work with a limited pool of landlords, they must accept extraordinary requirements and conditions in order to preserve their relationships with landl ords They will need to dr aw upon this same small group of landlords in order to hous e

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15 future arrivals. Over t ime, landlords become somewhat acquainted with the structure of resettlement and learn and most challenging responsibilities. This gives landlords the upper hand in negotiating housing with case managers Case managers interviewed in this study report exploitative practices through which landlords exert their power over case managers and consequently, over refugees. One of the first requirements that landlords set for renting to refugees is signing the lease as soon as refugees arrive or -the very next day. While fulfilling this requirement cements the case manager landlord relationship, refugees, on the o ther hand, are victim ized by it. They do not choose where they are housed and when the lease is signed, they are still overwhelmed and exhausted by the journey to the U.S. In cases where refugees are illiterate in their native language, the process of sign ing the lease is intimidating and confusing; they are hauled through it by the case manager and the landlord In addition, landlords are aware of the fact that case managers are responsible for refugees and that they will receive assistance from VOLAGs Th us landlords use this knowledge to pressure case managers so that their clients sign lease s that last as long as possible This is because they know that if one family moves out there will be another refugee family or group of singles who will rent the apa rtment the very next day. A former case manager explains : end they would say, nope, 12 months or nothing else because, again, they knew we had no choice. They would say, no it is too much cleaning if there is people moving out every six Faced with the risk of having their families evicted and the difficulty of damaging their relationship with landlords, case managers are forced to accept such conditions.

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16 O n the other hand, case managers also pressure refugees to maintain good relationships with landlords The following account by a program coordinator sheds light on how refugees are educated to maintain case manager fugees] that you to get an apartment. These people [landlords] are trusting us and you need to do what they say great importance for housing future arrivals. In fact, c ase managers often pay two or three difficulties and to reass ure landlords who perceive themselves as taking a huge risk by renting to refugees. The scarcity of landlords who will rent to refugees finding reliable tenants because of their undesirable housing leads to complicities between landlords and case managers that in turn harm refugees. Once case managers are forced to accept lower quality housing for their refugee clients, landlords in turn grant case managers particular allowances Because rent consumes a large amount of case managers tend to house multiple refugees in the same apartment under one lease so that each family has a little bit of spending money left over after paying rent L andlords, e specially private property owners often turn a b lind eye to this practice On the other hand, to save the costs of cleaning and repainting apartments in between tenants, landlords allow case managers to bring in new refugee tenant s as soon as the previous tenant moves out without changing the lease A case They (landlords) will say, when this person has no more money, bring clean it. Notably this practice also exempts landlords from having to repaint the apartment.

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17 The substandard quality of refugee housing in Denver is not limited to deteriorated paint or the presence of lead in the environment. All participants in this study mentioned bug infestations, such as bed bugs and roaches as an environmental hazard that they take more seriously and know more about than lead poisoning. Bed bugs and roaches strain case manager landlord relationships because landlords have to come in to disinfest apa rtments periodically. Because the landlord and the case manager have to explain the process in its entirety to the refugee who, in most cases, does not speak English disinfestation is a costly and time consuming procedure This situation results in mutual b laming between case managers and buildings. A Denver based case manager e xplains how the structure of the resettlement process exposes refugees to environmental hazards they never experienced while living in absolute This family (housed there) had a little boy who is one and a half. The next day they told me, something is biting him. Bedbugs had bitten him all over. The lady had swept a pile the size of a tile of bedbugs. And the landlord tried to tell me that they brought it in. I told h R&P money. As a result, the case manager ended up p lacing the family in a shared, overcrowded apartment with other Somali community members; she also lost the relationship with this landlord.

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18 C ase managers are forced to accept substandard housing to fulfill their job responsibilities; meanwhile, landlords exploit the stress under which case managers work to keep their apartments rented. When case managers object to the poor quality of housing as in the case of the bedbug infestation described above they risk losing landlords and further narrowing the limited number with whom they work. As one case manager says, somebody there looking to make a buck and take advantage of someone e lse. Unfortunately, as refugees and refugee case managers running out of options we have to go with them even though C ase managers report that their difficulty finding their clients housing in Denver is c aused by their heavy caseloads as well as For example, case managers at Lutheran Family Services (LFS) in Colorado Springs do not share the same experiences with their counterparts in Denver and fewer refugee arrivals; LFS of Colorado Springs r eceives 120 140 cases per year and the organization is able to o wn two emergency condominiums used to house refugees temporarily until suitable housing is found. In contrast, in Denver, if case managers do not secure housing arrival, they instead house them in motels This emergency practice in turn quickly drains the R&P money refugees will use to pay rent later on thereby only compounding case Therefore, the lower number of arriving refugees, the owned emergency housing and the relatively lower rents in Colorado Springs prevent the emergence of landlord case manager codepend ency and exploitation.

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19 The Role of Refugee Networks: Reinforcing Housing Patterns To an outsider, it may seem that case managers are deliberately choosing crime and poverty ridden areas to house refugees because of the low rents. Case managers try hard to distribute the refugee population evenly over the Denver metro area. However, in a ddition to the limited resources, there are a variety of reasons that case managers resettle refugees in particular areas of the city areas where rents are low and that are also characterized by unemployment, crime, and poverty (Carter and Osborne 2009). First, during the first six to eight months post arrival, refugees work closely with case managers, employment specialists and other resettlement staff to secure employment and attain self sufficiency. This makes housing in the inner city and East Colfax a rea a practical choice since resettlement organizations in Denver are situated there. Second, for case managers, the presence of a refugee community can lift some tasks off their shoulders. Refugees who arrived earlier can assist others who have just arri ved to adjust to their new lives by modeling how to use the public transportation system and do grocery shopping. In addition, since they are all either working or attending language classes, living in close proximity to other refugees embeds them in the s ocial networks that in many cases turn out to be beneficial in securing employment or in acquiring help to register for language classes, all refugees close to each other. Finally, refugees often prefer living in close proximity to others from their own community. Therefore, even if case managers go to trouble to house recently arrived refugees in areas outside the inner city, they may find that their clients will r equest to be moved to housing in the areas where their co ethnics live. Thus for these reasons, case managers do not have any incentives to look for housing in new locations or to build relationships with new landlords.

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20 Level Burea Cuts To mitigate the stress of finding housing for new arrivals while managing their pre existing caseload, case managers resort to strategies of stereotyping and mass processing of clients. These strategies are used by frontline service providers whom Michael Lipsky (1980) calls street level bureaucrats. As Lipsky describes, street level bureaucrats work with heavy caseloads with limited time and resources at their discretion. Their work is also scrutinized by manager s who are not working in the front lines, but whose job entails making sure that the and resources. As a result, street level bureaucrats develop methods an d shortcuts that help them level bureaucrats become policy mak ers of their own (Lipsky 1980 ). One of these shortcuts is stereotyping which street level bureaucrats use to be able to process their clients in as little time as possible (1980:142). In all three C olorado VOLAGs, all case managers are former refugees themselves. As a variant of stree t level bureaucrats, these c ase managers occupy wh at Marrow (2012) calls service oriented roles. T heir ability to speak a refugee language and understanding of the refugee experience makes them service oriented individuals who feel committed to serving a disadvantaged group despite the extremely limited resources with which they must discharge their mission Yet i n addition to addressing the needs of t heir clients, case managers have to meet the requirements of managers and supervisors who aily interaction with refugees and who occupy regulatory oriented roles implementing PRM and ORR policy During the resettlement process fr om start to end, then, 2006 ).

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21 Sociologists have argued that as they oscillate between their service and regulatory oriented roles, front line service providers -such as eligibility workers law enforcement officers and social worker s -play an immense role in the incorporation or exclusion of migrants (Marrow 2012; Van der Leun 2006 ; Weiner et al, 2004 ). In her study of mental health services provided to Latina immigrant women, for example, Horton (2006) describes a setting in which heal thcare imposed by the hospital administration and appropriately serving their patients. Similar to case managers, these clinicians also all Latino evinced a service orientation. They eng aged in advocacy and uncountable billable hours, thereby shouldering a burden that should have been carried by the clinic (Horton 2006). to take short cuts that served some patients while short changing others. As clinicians adopted practices to increase productivity -such as double booking clients and engaging in group therapy this decreased the quality of care and ultimately, to denied access to care for the disadvantaged. Case man agers face a double bind much like these clinicians. As their organizations emphasize adhering to strict deadlines and meeting federal requirements they too face challenges to treating their clients with the discretion they deserve as individuals. Having the dual role of being loyal to clients and accountable to organization managers is another source of stress that case managers constantly work under. Much like the mental health clinicians Horton describes, case managers attempt to cope with thei r constraints of time and resources by invent ing ways in which they can mass process their clients regardless of their individual preferences or needs: such as develop ing short cuts that allow them to cope with particular refugee populations in predictabl e patterns. For example, while I was working at ERIS it was well known that case managers house particular populations

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22 in particular parts of the city. Following informal protocol, I housed most of my Iraqi clients in parts of Aurora while I placed my Af rican clients on East Colfax. Among the Iraqis a wealthier and more educated population Colfax has earned itself a reputation of crime, poverty and prostitution; ther efore, placing Iraqis there was a cause of stress because as soon as they met other membe rs from their community, they would be advised to move as soon as possible. This was not only so among Iraqis ; one staff member mentions that Afghani refugees share the same idea about living on Colfax they have created this perception of Colfax that horrible place where you get murdered and get robbed even through many of them have never been over there they just have heard those horror s tories. On the other hand, Asian refugees from Burma, Nepal and African refugees from Somalia Sudan or Congo did not have prejudices about East Colfax; their sole criteri on was living where their community members live. In fact placing these population s anywhere other than East Colfax was asking for more stress. Once African refugees met a community member, they would be advised to move to East Colfax or to break their lease. One reception and placement coordinator mention ed of African refugees So it is not like the perception that some people have that we are just creating a large refugee camp over there or something. T hey are In addition, case managers use their own discretion in classifying which groups of refugees are likely to stay in Denver and which are likely leave the state. When refugees are deemed unlikely to stay in Colorado, they are placed in shared and often overcr owded apartments so that they do not have to sign a separate lease. This shortcut was especially applicable to Somali single adults, who

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23 were thought to prefer to move to Minnesota to join the bigger Somali community there and to take advantage of employme nt opportunities thought to be more abundant. Case managers are fully aware of the difference in quality between housing in East Colfax and parts of East Aurora and of Denver ( such as Peoria street, Parker road and Leetsdale Drive ) East Colfax apartments were dirty, poorly maintained and well known for bug infestations compared to those in Aurora or Denver. experience taught them that housing African and Asian refugees anywhere other than East Co lfax would lead to short stays or broken leases, they tended to place new arrivals in the substandard housing of this area. caseloads stereotyping and mass processing their clients based on nationali ty exposes African and Asian refugee children to more environmental hazards as compared to their Iraqi counterparts.

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24 CHAPTER V COUNTERACTING GEOGRAPHIES OF BLAME The literature describing the phenomenon of lead poisoning among refugee children is s, ignoring any relativistic view that Haitian culture was to be blamed as a major contributor to the prevalence of AIDS and their neglect of other social and economic factors that were at play (1999: 9). Likewise, the idea that refugee children arrive with already elevated blood lead levels and that on refugee culture without examining the role of the resettlement process in lead poisoning. The academic and public health literature in the US lead ingestion and subsequent poisoning to their housing conditions; instead, it is reported as the result of deteriorating conditions in countries of origin and the use of folk remedies (Plotinsky et al., 2008; Ritchey et al. 2009). For example, the CDC reports that cultural practices and the use of traditional medicines are the primary reason for high rate of lead poisoning among refugee children. In its report on the issue, it provides a table with a list of food items, condiments, glazed pottery items, cultural remedies for indigestion in infants and children, and cosmetics alongside the country of origin of these lead containing items. These countries include a variety of African countries, Iraq and India -all of which are part of the Global South and whose populations often arrive i n the United States as refugees or asylum seekers es caping the detrimental effects that neoliberalism had on their local economies (Holmes 2013).

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25 The CDC report does mention that refugee children are at risk for lead poisoning since refugee families often settle in high risk areas. Indeed, while the CDC rep ort places blame on refugee cultures, birth places and places of residence before arrival as a main cause of elevated blood lead levels, the example used to illustrate the severity of this phenomenon is of a Sudanese toddler who died 5 weeks after resettle ment and whose blood lead levels reached 392 g/dL because of exposure to lead b ased paint in the United States Despite briefly acknowledging the ignores the fact that refugee families often do not have control over the location of their homes. Many academic reports implicitly blame refugees themselves for their lack of knowledge and awareness about the harmful effects of lead. They therefore ignore the fact that refugee children generally suffer from malnutrition, which in turn facilitates the quick absorption of lead and results in elevated blood lead levels (Geltman 2001). Therefore, exposure to minute amounts of lead can increase blood lead levels in malnourish ed refugee children. Many parents may if refugees do become aware of the risks posed by their environment, their time limited cash assistance programs, and dif ficulties securing employment, make lead poisoning a lesser priority.

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26 CHAPTER VI CONCLUSION Lead poisoning among refugee children is clearly a reason for concern for health professionals, those who work with refugees and refugees themselves. Time and fi nancial constraints are the main reasons pushing case managers and refugees to accept substandard housing. Yet, research puts the responsibility of poisoned refugee children on their parents claiming that culture and folk home remedies are the source of th e problem. These cultural practices might play a role in the issue, but it is the condition of substandard housing in the U.S. that is to blame since refugee children report elevated blood lead levels after resettlement. Furthermore, the lack of knowledge on the part of case managers who are usually refugees themselves complicates in and of itself one of th e contributors to the problem, is an issue that requires more research and investigation since case managers work with refugees on a daily basis and are responsible for securing their housing. Given their primary role in resettlement, they are indispensabl e to the process of educating refugees and raising their awareness about lead poisoning. Yet the federal government is responsible for the resettlement of refugees, and; can play an important role in raising awareness about lead poisoning and its effects o by making such education law. Refugees are admitted to the U.S. by the federal government and case manager and refugee education regarding le ad poisoning. lead screening for refugee children should be federally mandated during the first 30 90 days after arrival to detect any elevation in BLLs. Early detection should help in preventing cases of severe

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27 poisoning. I n add ition, the aim of providing refugees with basic cash assistance is to assist them in covering basic expenses, such as rent and utilities, until self sufficiency is achieved. However, the current amounts of R&P money and refugee cash assistance are not nearly enough to meet these basic needs, nor to ensure they live in housing adequate to ensure their well being. It is unreasonable that the government can afford to treat refugee children through Medicaid after they have been poisoned by lead but at the same time, the government does not grant enough funds to VOLAGs and refugees to provide adequate housing that would itself obviate the need for such treatment As the numbers of Syrian refugees continues to rise and the US government raises the annual cei ling of admitted refugees in response to this global crisis, the problem of lead poisoning among refugee children has to be addressed with more serious and practical steps. If the ORR does not increase refugee cash assistance amounts to meet the increasing living costs in the US, it would be irresponsible to admit more refugees. This will not only tie them to an inhumane life in poverty and constant distress, but it will also expose their children to health issues that are preventable if funding for the res ettlement process is increased.

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28 REFERENCES Centers of Disease Control and Prevention. ( 2006 ) Lead poisoning prevention program. http://www.cdc.gov/nech/lead/Publication/RefgueeToolKit/Refugee_Tool_Kit.htm Church World Service. (2005). Lead poisoning prevention: a matter of life and death for refugee children. www.churchworldservice.org/Immigration Denver becomes 2 nd fastest climbing rental market in the nation. http://www.denverpost.com/ci_28213367/denver becomes 2nd fastest climbing renta l market nation?source=infinite up Farmer, P. ( 1999 ) Infections and Inequalities: The Modern Plagues. Berkeley: University of California Press. Geltman, PL., Brown MJ, Cochran J. ( 2001 ) Lead Poisoning Among Refugee Children Resettled in Massachusetts, 1995 to 1999. Pediatrics 108:158 162. Horton, S. (2006). The double burden on safety net providers: placing health disparities in the context of the privatization of health care in the US. Social Science & Medicine, 63(10):2702 2714. Lipsky M. ( 1980 ) .Street Level Bureaucrats: dilemmas of the individual in public services. New York: Russe l l Sage Foundation. access healthcare model. Social Science & Medicine, 74:846 854. Plotinsky R, Straetemans M, Wong L. et al. ( 2008 ). Risk factors for elevated blood lead levels among African refugee children in New Hampshire, 2004. Environmental Research 108:404 412. Ritchey D, Scalia Sucosky M Jefferies T et al. ( 2011 ) Lead poisoning among Burmese refugee children Indiana. 2009. Clinical Pediatirics 50(7):648 656. Van der Leun, J. (2006). Excluding illegal migrants in the Netherlands: between national policies and local implementation. West European Politics, 29(2):310 326. Weiner, S. J., Laporte, M., Abrams, R. I., et al. (2004). Rationing access to care to the medically uninsured: the role of bureaucratic front line discretion at large healthcare institutions. Medical Care, 42(4):306 312.