Introduction to Refugee Health

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Introduction to Refugee Health

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

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Case A.T., June 2007

• Youre 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. Temp102.2
• Lives with siblings, no known sick contacts
• Recent Karen (Burmese) immigrant from a refugee
  camp in Thailand.
• Does this broaden your typical differential?

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Before we start

• What exactly is a refugee? An asylee? How do
  they differ from other immigrants?
• What are a refugees 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?

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Overview

• Definitions/Statistics
• Process of Becoming a Refugee
• Refugee Health Screens
• Overseas Domestic Components
• Jeffersons Refugee Clinic/Background on
  Countries/Cases
• Immigrant Health Issues/Concluding Remarks

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

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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

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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

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US Annual Refugee Resettlement Ceilings,
1980-2005
- Dept of HHS, ORR
US Department of State, Bureau of Population,
Refugees and Migration
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Statistics Fiscal Year 2007
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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
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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 policiesand administers U.S. refugee
  assistance and admissions programs
• Volunteer Resettlement Agency (Volag)
• National or local non-profits
• Assists with healthcare, employment, schooling,
  and housing

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Overview

• Definitions/Statistics
• Process of Becoming a Refugee
• Refugee Health Screens
• Overseas Domestic Components
• Jeffersons Refugee Clinic/Background on
  Countries/Cases
• Immigrant Health Issues/Concluding Remarks

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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)

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Becoming a Refugee

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

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Refugee Resettlement

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

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

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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.

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The Refugee Process
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Overview

• Definitions/Statistics
• Process of Becoming a Refugee
• Refugee Health Screens
• Overseas Domestic Components
• Jeffersons Refugee Clinic/Background on
  Countries/Cases
• Immigrant Health Issues/Concluding Remarks

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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

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Overseas Health Screens

• Class A
• Communicable diseases of public health
  significance
• Active, infectious TB
• HIV infection
• Infectious Hansens disease
• Certain STDs
• Mental illnesses with violent behavior
• Drug addiction
• Requires approved waivers for US entry and
  immediate follow-up upon arrival

• 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

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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 HP 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)

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Recommendations for Health Screens

• General agreement in literature (but no universal
  guidelines)
• Complete HP
• 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

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Whats 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.
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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

• 36 were children
• 34 had stunting (lt3 height)
• 28 had wasting (lt3 weight)

Denburg, et al.
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Overview

• Definitions/Statistics
• Process of Becoming a Refugee
• Refugee Health Screens
• Overseas Domestic Components
• Jeffersons Refugee Clinic/Background on
  Countries/Cases
• Immigrant Health Issues/Concluding Remarks

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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 3rd year
  resident and usually an intern.
• Interpretation can be difficult
• Refugees accompanied by volunteers from NSC

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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

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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

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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

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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 (n10),
  asthma and allergies (n4, n3), malaria (n3),
  dental caries (n6), and giardia (n3)

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Primary Populations

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

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• Iraqi Refugees Admitted and SIVs Issued in FY08
  to Date

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How are we doing?NSC Needs Assessment
Satisfaction with Health
NSC Needs Assessment, 2008
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Barriers to Health

• Karen/Burmese
• Preference for traditional healers
• Language barriers
• Inability to navigate health system
• Liberians
• Insurance status
• Lack of continuity of care
• Inability to navigate health system
• Meskhetian Turks
• Insurance status
• Inability to navigate health system
• Lack of centralized information

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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

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

• Diagnosed with AIDS (CD430), Bells 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

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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

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Hisham
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• 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

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Overview

• Definitions/Statistics
• Process of Becoming a Refugee
• Refugee Health Screens
• Overseas Domestic Components
• Jeffersons Refugee Clinic/Background on
  Countries/Cases
• Immigrant Health Issues/Concluding Remarks

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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
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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

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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

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Future directions

• Provider education Cultural competency
• Patient education Outreach
• Research
• Advocacy
• Interdisciplinary Collaboration
• Partners in Hope
• Always room for more help!

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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.
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• The language of social justice is increasingly
  absent from public health parlanceIf we lived in
  a utopia, simply practicing medicine would be
  enough. But no matter how you slice it, we live
  in a dystopia. 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
  responsibilityto prevent social inequalities
  from being embodied as bad health outcomes
• We are now faced with a twenty-first century
  decision where will healers stand in the
  struggle for health care as a human right?

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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.

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• 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.

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References

• Adams et el. Healthcare challenges from the
  developing world post-immigration refugee
  medicine BMJ 20043281548-1552 (26 June),
  doi10.1136/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/g
  uide/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
  Aug95(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.

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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

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

• 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.