1. Longitudinal Refugee Care as a Foundation for Global Health Curriculum: the experiences of a community-based family medicine residency Karl A. Kirby, MD CTropMed® Faculty, St. Mark’s Family Medicine Residency

2. 2 Activity Disclaimer ACTIVITY DISCLAIMER It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. Karl Kirby has indicated he has no relevant financial relationships to disclose.

3. Objectives 1)Understand refugee status 2)Identify unique refugee healthcare challenges 3)Appreciate longitudinal refugee care as the basis for global health curriculum 4)Discuss complementary global health experiences 3

4. BACKGROUND ON REFUGEES Longitudinal Refugee Care as a Foundation for Global Health Curriculum 4

5. Who Are Refugees? UN designation well-founded fear of being persecuted outside the country of his nationality unable to be protected by home county http://www.unhcr.org/pages/49c3646c125.html 5

6. Mae La camp for Burmese refugees, Tak, Thailand. Photo by Mikhail Esteves 6

7. The Refugee Problem Worldwide 5 million refugees repatriate, integrate, or resettle United States resettled > 66,000 refugees out of 88,600 worldwide UNHCR Global Trends 2012 7

8. Refugees in Your State Utah resettled 942 refugees in 2012 with the total around 25,000 You can find out resettlement numbers in your state at: http://www.acf.hhs.gov/programs/orr/resource /refugee-arrival-data Office of Refugee Resettlement – US Department of Health and Human Services 8

9. Major Refugee Groups 2012 Bhutan Somalia Iraq Burma Followed by Eritrea, Iran, Sudan and many others 9

10. Refugee Healthcare After Arrival Screening examination (for public health purposes) Most then qualify for Medicaid for at least 8 months and need a PCP 10

11. Role of Resettlement Agencies (Volags) Provide assistance in the resettlement process for up to 2 years Assist clients in finding a medical home 11

12. National Volags Church World Service (CWS) Episcopal Migration Ministries (EMM) Ethiopian Community Development Council (ECDC) Hebrew Immigration Aid Society (HIAS) International Rescue Committee (IRC) Lutheran Immigration and Refugee Service (LIRS) U.S. Conference of Catholic Bishops (USCCB) U.S. Committee for Refugees and Immigrants (USCRI) World Relief Corporation (WR) 12

13. REFUGEE CARE IN A RESIDENCY CONTINUITY CLINIC Longitudinal Refugee Care as a Foundation for Global Health Curriculum 13

14. Refugee Care at the St Mark's Family Medicine Clinic Suburban Utah About 5% of our patients are refugees Of our refugee patients 39% are <20 (nearly double our general patient base) 14

15. Core Competencies SBP: System-based Practice MK: Medical Knowledge PC: Patient Care ICS: Interpersonal and Communication Skills PBLI: Practice-based Learning and Improvement P: Professionalism 15

16. Competencies achieved through Longitudinal Refugee Care Create appropriate treatment plans with refugee patients based on an awareness of individual culture and available resources (PC, SBP, ICS, P) Use interpreters and communicate effectively with patients and families (ICS) Recognize medical problems unique to countries of origin (PC, MK) See AAFP Reprint No. 287. Recommended Curriculum Guidelines for Family Medicine Residents: Global Health. 16

17. Culture/Empathy/Respect Residents benefit from longitudinal interactions with refugee patients/families from various cultures and backgrounds 17

18. Communication Interpreters Live vs phone interpreters Residents learn best practices Requires MORE TIME Resettlement Agencies Requires greater coordination Residents learn local healthcare system and resources 18

19. Communication 19 DoctorPatient

20. Residents Learn About Medical Issues Relevant to Refugees Tropical Diseases Nutritional Issues Mental Health Chronic Diseases 20

21. Presumptive Screening and Treatments TB screening abroad and on arrival Population-based presumptive parasite treatments are done prior to arrival Residents learn to recognize persistent parasite infections Intestinal Parasite Guidelines for Domestic Medical Examination for Newly arrived Refugees. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Emerging and Zoonotic Infectious Diseases, Division of Global Migration and Quarantine. July 17, 2013. 21

22. Infectious Tropical Diseases Seen in Our Practice Active TB Ascariasis Helicobacter Pylori Hepatitis B HIV Hookworm LTBI Malaria Paragonimous westermanii Pinworm Schistosomiasis Strongyloides 22

23. Nutrition and Environment Darfur camp in Chad. Photo by Mark Knobil. 23

24. Nutrition and Environment Malnutrition Iron deficiency B12 deficiency: 30-60% among Bhutanese refugees Vitamin D deficiency Lead poisoning Vitamin B12 Deficiency in Resettled Bhutanese Refugees - United States, 2008—2011. Morbidity and Mortality Weekly Report. March 25, 2011 / 60(11);343-346 24

25. Mental Health Torture: 56% of Iraqi refugees in Utah have experienced torture prior to arrival 1 PTSD Depression and Suicide: Suicide rates among Bhutanese refugees are nearly double that of other Americans 2 1. Willard CL, Rabin M, Lawless M. The Prevalence of Torture and Associated Symptoms in United States Iraqi Refugees. J Immigrant Minority Health. 6 April 2013. DOI 10.1007/s10903-013-9817-5. 2. Suicide and Suicidal Ideation Among Bhutanese Refugees — United States, 2009–2012. Morbidity and Mortality Weekly Report. 5 July 2013 / 62(26);533-536. 25

26. Chronic Diseases Inherited anemias Challenges in diabetes, HTN, CAD, etc.: - culture and health beliefs - communication - limited resources 26

27. Attitudes Empathy for people from various cultures and backgrounds Compassion for refugees and a desire to advocate for them 27

28. Attitudes Patience with communication barriers Awareness of stereotypes and biases Respect for dignity and autonomy 28

29. Knowledge Major tropical diseases specific to populations The impact of food availability, sanitation, water sources, and local disease Presumptive treatments and the impact on refugee populations 29

30. Knowledge The influence of culture on health and healthcare The role of effective interpretation Resources available pre-departure and post-resettlement 30

31. Skills Use an interpreter appropriately Have effective/respectful cross-cultural doctor patient relationships Practice within cultural beliefs specific to refugee populations 31

32. Skills Form relevant and practical plans Communicate effectively with refugee patients Coordinate care with resettlement agencies 32

33. COMPLEMENTARY EDUCATIONAL ACTIVITIES Longitudinal Refugee Care as a Foundation for Global Health Curriculum 33

34. Global Health Rotations Individual elective international rotations Community medicine month with global health focus Group international experiences 34

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38. Didactic Components Incorporate global health topics into noon conference series Including global health topics in annual retreats 38

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40. Other Components Academic activities: research, posters, presentations Others??? 40

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