Introduction to Refugee Health

By Jeff Panzer, MD Department of Family & Community Medicine Grand Rounds October 1, 2008

Case – A.T., June 2007

 You’re an intern, working in the ER  18-year-old male with no PMH presents with fevers x 7 days – intermittent, worse at night. Also with malaise, body aches. No N/V/D. Temp=102.2

 Lives with siblings, no known sick contacts  Recent Karen (Burmese) immigrant from a refugee camp in Thailand.

 Does this broaden your typical differential?

Before we start…

 What exactly is a refugee? An asylee? How do they differ from other immigrants?  What are a refugee’s health risks?

 Do refugees need health screenings? If so, what elements should be included in this screening?

 What are the major organizations involved in refugee placement?

 Where do we, as family physicians, fit in? Should we get involved? Why?

Overview

 Definitions/Statistics  Process of Becoming a Refugee  Refugee Health Screens  Overseas & Domestic Components  Jefferson’s Refugee Clinic/Background on Countries/Cases  Immigrant Health Issues/Concluding Remarks

Definitions:



Immigrant –

a foreign-born resident who is not a US citizen, lawfully admitted for permanent residence  

Refugee -

a person who has fled his or her country of origin because of a past

persecution

or a

well founded fear of persecution

nationality, political opinion, membership in a particular social group based upon race, religion,

Asylee –

an immigrant who has fled their country for reasons listed above, but is already present in the US 

Internally Displaced Person (IDP) –

displaced within their own country www.uscis.gov

Worldwide Statistics

 Worldwide, combined # of refugees, returned refugees, and internally displaced persons =

32 million

 12 million refugees/asylees   Afghanistan 2,191,100 Palestine 2,971,600  20 million Internally Displaced Persons

U.S. Statistics

 28 million foreign-born persons live in the US (approx 12% in 2004)  Approx 400,000 documented immigrants annually  In 2003,   Refugees 28,306 ( 10% ) Immigrants 358,411 (90%)  In 1997, 70% from

Europe

and

Central Asia

 In 2004, almost 55% from

Africa

Refugee Health in US Refugee Act of 1980

 Established a domestic refugee resettlement program  Defined the legal term

refugee

 Established the Office of Refugee Resettlement (ORR) in the Dept of HHS  Annually, the President provides Congress with proposed admission numbers

US Annual Refugee Resettlement Ceilings, 1980-2005

Since 1975… -the U.S. has resettled over 2.6 million refugees -a high of 207,000 in 1980 -a low of 27,110 in 2002 -average since 1980 is 98,000 .

- Dept of HHS, ORR US Department of State, Bureau of Population, Refugees and Migration

Statistics Fiscal Year 2007

Refugee Arrivals 2007 - total 48,281

7000 6000 5000 4000 3000 2000 1000 0 CA MS VT PA

States

MN TX

Statistics Fiscal Year 2008

 80,000  8000 each month for the remainder of FY  Regional breakdown Africa . . . . . . . . . . . . . . . . .16,000 East Asia . . . . . . . . . . . . . .20,000 Europe and Central Asia . . 3,000 Latin America/Caribbean . . 3,000 Near East/South Asia . . . .28,000 Unallocated Reserve . . . . 10,000

Important Organizations

 UN High Commissioner for Refugees ( UNHCR )  In refugee camps, provides protection, health care, referral for resettlement  Intergovernmental Organization for Migration ( IOM )  Arranges refugee travel and travel loan  US Citizenship and Immigration Service ( USCIS )  Formerly the Immigration and Naturalization Services (INS)  Overseas federal immigration and naturalization laws  Office of Refugee Resettlement ( ORR )  Plans, develops, and directs implementation of comprehensive program for domestic refugee resettlement  Bureau of Population, Refugees, and Migration ( PRM )  “formulates policies…and administers U.S. refugee assistance and admissions programs”  Volunteer Resettlement Agency ( Volag )   National or local non-profits Assists with healthcare, employment, schooling, and housing

Overview

 Definitions/Statistics  Process of Becoming a Refugee  Refugee Health Screens  Overseas & Domestic Components  Jefferson’s Refugee Clinic/Background on Countries/Cases  Immigrant Health Issues/Concluding Remarks

Becoming a Refugee

 Refugee flees his/her home and community in order to escape war and persecution.

 The office of the United Nations High Commissioner for Refugees (UNHCR) awards legal refugee status in the country of asylum.

 Refugees either…  return home   settle in the country of asylum undergo

third country resettlement

(the option of last resort)

Becoming a Refugee

 UNHCR refers only about 1% of all refugees for resettlement in a third country

 The following countries have resettlement programs:       Australia Canada Denmark Finland Netherlands Norway     Sweden New Zealand Switzerland United States

Refugee Resettlement

 US is largest resettlement country in the world (but not per capita)

Seeking Admission to the US

 Refugees referred by the UNHCR or the U.S. embassy  Refugees who meet the criteria are interviewed by an USCIS officer  USCIS officer decides whether the applicant is a refugee  If approved, the refugee is matched with an American resettlement organization.

The Refugee Process

Refugee arrives in the U.S.

Resettlement Services Months 1 - 6 Refugee Welfare benefits Apply for Green Card Months 1 – 8 After 1 yr Apply for U.S. Citizenship After 5 years Refugees Integrated

Overview

 Definitions/Statistics  Process of Becoming a Refugee  Refugee Health Screens  Overseas & Domestic Components  Jefferson’s Refugee Clinic/Background on Countries/Cases  Immigrant Health Issues/Concluding Remarks

Overseas Health Screens



Immigration and Nationality Act (INA)

requires that medical screening examinations be performed overseas for all US-bound immigrants and refugees   Focus is to detect

inadmissible

diseases – and

exclude

Valid for 1 year   Testing includes:  Screening for mental disorders, drug abuse, and leprosy  HIV, RPR  Chest x-rays Vaccinations

Overseas Health Screens

Class A

 Communicable diseases of public health significance  Active, infectious TB    HIV infection Infectious Hansen’s disease Certain STDs   Mental illnesses with violent behavior Drug addiction

Requires approved entry and immediate follow-up upon arrival waivers for US Class B

 “Physical or mental abnormalities, diseases, or disabilities amounting to a substantial departure from normal well being”

Require close follow-up after arrival in the US

US Refugee Health Screens

 Encouraged to take place within 30 days  Screens vary widely by state  Sign a form and place PPD vs.

 Viewed as comprehensive H&P with lab work and orientation to the health care system  Funding   Federal Refugee Medical Assistance (RMA), State Medicaid funds, ORR grants, State and local governments All refugees are eligible for some package (usually at least 8 months of coverage)

Recommendations for Health Screens

General agreement in literature (but no universal guidelines)  Complete H&P    Pre-refugee & path to host country Infectious Diseases  Trauma Screening labs    CBC with diff, Hepatitis B, RPR, HIV Stool ova & parasite exam Lead screening in children    Tuberculosis testing Immunizations Other: dental, hearing and vision, mental health screening

What’s the data?

Minnesota 1999 study 2545 refugees  49% had +PPDs  7% Hep B SAg +  22% intestinal parasites  1/3 of the world infected with M. tuberculosis  2 millions deaths annually Lifson, Alan, et al.

 36 were children  34% had stunting (<3% height)  28% had wasting (<3% weight)

Canadian Study, 2006

 68 Karen Refugees, screened in Toronto  28% latent TB  13% Hep B SAg +  40% susc. to Hep B  48% with at least one nematode  2 with Malaria Denburg, et al.

Overview

 Definitions/Statistics  Process of Becoming a Refugee  Refugee Health Screens  Overseas & Domestic Components  Jefferson’s Refugee Clinic/Background on Countries/Cases  Immigrant Health Issues/Concluding Remarks

Refugee Clinic at JFMA

  Wednesday afternoon (with prior visit on Monday) Screen at least 5 new patients/week + follow-up    Minnesota screening protocols Dr. Altshuler is main preceptor. One 3 rd year resident and usually an intern.

Interpretation can be difficult  Refugees accompanied by volunteers from NSC

American Resettlement Organizations or VOLAGs

 Provide reception and placement services for refugees coming to the US; determine where in the US the refugee will be resettled  9 private, nonprofit 

national

VOLAGs Hebrew Immigrant Aid Society   Lutheran Immigrant and Refugee Services US Committee for Refugees and Immigrants  Local (3 in Philadelphia)  e.g. Nationalities Services Center

NSC

    Non-profit Founded in 1921 Provides legal, social and educational services to immigrants, refugees, limited and/or non-English speakers NSC provides extensive services & support to the refugee clinic including     Interpreters Case Managers Social Workers Student interns

Our Clinic at Jefferson Family Medicine (JFMA)

 In July 2007, JFMA met with the NSC to discuss new partnership: in Sept 2007, we began providing refugee health screens  Provide NSC clients with coordinated health screens and continuity practice  Ability to provide newborn, pediatric, Ob/Gyn, adult and geriatric medicine  Practice located in academic medical center four blocks from the NSC

The JFMA / NSC Pilot Project

 Between July 07 and January 08, 75 refugees served .

   14 hospitalized (renal failure, heart failure, staph infections, malaria, pregnancy) 100% required follow up visits Other findings included hepatitis B (n=10), asthma and allergies (n=4, n=3), malaria (n=3), dental caries (n=6), and giardia (n=3)

Primary Populations

     Karen (from Burma) Iraqi Liberian / W. Africans Vietnamese Former Soviets   Bhutanese from Nepal New African groups

Iraqi Refugees Admitted and SIVs Issued in FY08 to Date *

How are we doing?

NSC Needs Assessment

Satisfaction with Health NSC Needs Assessment, 2008

Barriers to Health

Karen/Burmese

1.

Preference for traditional healers

2.

3.

Language barriers

Inability to navigate health system

Liberians

1.

Insurance status 2.

3.

Lack of continuity of care Inability to navigate health system

Meskhetian Turks

 Insurance status   Inability to navigate health system Lack of centralized information

Case: M.B.

  33 yo F from Liberia, Africa War from 1989-1996 claimed over 200,000 lives   MB fled after rebels raped her and murdered her parents in her presence Fled to Sierra Leone with her daughter and gave birth to her son in refugee camp there  Awarded refugee status in 2007  Found to be HIV+ on overseas health screen

Case: M.B., after U.S. arrival



Diagnosed with AIDS (CD4=30), Bell’s palsy, VIN II, PTSD



Her 2 children had malaria and were hospitalized



Became pregnant



Had gestational diabetes



Son had needle stick, put on 3 HIV prophylaxis meds



Had C-section, newborn on AZT

Refugees and War



Since WWII

 127 wars (all but 2 in developing countries )  21.8 million war-related deaths 

Modern wars

 9/10 casualties are civilians  6/10 are children

Hisham



“Hisham is like an angel. He loves life & loves people, he also loves every thing good & beautiful in our life. He's really like an angel, as there are angels in the heavens there are also angels on the earth; Hisham is really one of them.”



www.hishamstory.4t.com

Overview

 Definitions/Statistics  Process of Becoming a Refugee  Refugee Health Screens  Overseas & Domestic Components  Jefferson’s Refugee Clinic/Background on Countries/Cases  Immigrant Health Issues/Concluding Remarks

Immigrants – A Drain on our System?

 Do immigrants cost more to our health care system than US-born residents?

  According to one study: No!

18,398 US born and 2843 immigrants, in 1998.

 Healthcare expenditures for US immigrants were about

55% less

than US-born residents.  $2546 vs. $1139  Immigrant children had 74% lower per capita health care expenditures than US-born children. However, ED expenditures were 3x greater.

Mohanty SA, Woolhandler S, Himmelstein DU, 2005

The Healthy Migrant Phenomenon

 Immigrants (to the US, Canada, Australia, and Western Europe) are often

healthier

than native-born residents  Higher rates of infectious diseases  Lower levels of obesity, hypertension, diabetes, cardiovascular disease, serious psychological distress, and overall mortality.

 Immigrants had better health outcomes on measures of smoking, alcohol, and drug abuse – each of these worsened with increased time in the US.

1 Dey, et al.

2 Singh, et al. 2001 3 Kandula et al. 2004

Where do we fit in, as a family medicine residency?

 Preventive medicine!

 Public Health opportunities   Educating/orienting the refugee population Health care access issues  Continuity of care/Integration into health system  Broad spectrum of ages and diseases  Experience can be applied to other immigrant populations

Future directions



Provider education & Cultural competency



Patient education & Outreach



Research



Advocacy



Interdisciplinary Collaboration



Partners in Hope



Always room for more help!

Why Care for Refugees?

 It benefits us, them, and everyone else!



Refugees

– Receive comprehensive screening in a culturally competent manner 

Providers

– Acquire a global view of health, obtain rare knowledge and experience, meet unique people, contribute to the health of an underserved population 

Society

  Short-term: identifies and ameliorates potential public health concerns Long-term: refugees contribute more to society and are more likely to pursue necessary healthcare themselves and for their families Kennedy et al.

“The language of

dystopia

social justice is increasingly absent from public health parlance…If we lived in a utopia, simply practicing medicine would be enough. But no matter how you slice it, we live in a . Increasingly, inequalities of access and outcome characterize medicine. These inequalities could be the focus of our collective action as morally engaged members of the healing professions. For we have before us an awesome responsibility inequalities from being embodied as bad health outcomes… —to prevent social We are now faced with a twenty-first century decision: where will healers stand in the struggle for health care as a human right?”

Take Home Message

 Refugees are a medically-complex underserved population who have flown from persecution.

 We have the opportunity to ease their transition to their new homes, ensure their health, and prevent the spread of disease.

 From these unique patients, we can learn more about global health/politics and become physician advocates for the refugee community.

Give me your tired, your poor, Your huddled masses yearning to breathe free, The wretched refuse of your teeming shore. Send these, the homeless, tempest-tossed, to me: I lift my lamp beside the golden door.

References

          Adams et el. Healthcare challenges from the developing world: post-immigration refugee medicine BMJ 2004;328:1548-1552 (26 June), doi:10.1136/bmj.328.7455.1548

Denburg A, et al. “Initial health screening results for Karen refugees: a retrospective review.” Canada Communicable Disease Report, Dec 1 2007, Volume 33, Number 13.

Dey AN, Lucas J. Physical and mental health characteristics of USS- and foreign born adults: United States, 1998-2003. Advance Data from Vital Health Statistics, 369.

Kandula NR, Kersey M, Lurie N. Assuring the health of immigrants: what the leading health indicators tell us. Annual Review of Public Health 25: 357-376, 2004.

Kennedy J, et al. “A Comprehensive Refugee Health Screening Program.” Public Health Reports Sept-Oct 1999, Volume 114, 469-477.

Lifson, Alan, et al. “Prevalence of Tuberculosis, Hepatitis B Virus, and Intestinal Parasitic Infections Among Refugees to Minnesota.” Public Health Reports Jan-Feb 2002, Volume 117, 69-77.

“Minnesota Refugee Health Provider Guide.” 2007 http://www.health.state.mn.us/divs/idepc/refugee/guide/index.html

Mohanty SA, Woolhandler S, Himmelstein DU, et al. “Health care expenditures of immigrants in the United States: a nationally representative analysis.” Am J Public Health. 2005 Aug;95(8):1431-8.

Singh GK, Siahpush M. All-cause and cause-specific mortality of immigrants and native born in the United States. Am J Public Health 2001; 91(3):392-399.

Walker, Patricia F., and Barnett, Elizabeth D. Immigrant Medicine. Elsevier, 2007.

Useful Websites

www.unhcr.org

www.refugees.org

www.globalhealth.gov

www.uscis.gov/portal/site/uscis www.cdc.gov/ncidod/dq/refugee www.state.gov/g/prm www.nationalitiesservice.org

www.cdc.gov/vaccines

 If you have any questions, comments, or suggestions, or would like to get involved, please contact me.

 [email protected]

Books:  Beah, Ishmael.

A Long Way Gone.

   Fadiman, Anne.

The Spirit Catches You and You Fall Down.

Farmer, Paul.

Pathologies of Power.

Housseini, Khaled.

A Thousand Splendid Suns.