1. Refugee Health In Minnesota Carol Berg, RN, MPH Public Health Manager, UCare cberg@ucare.org

2. Presentation Objectives Describe refugee and immigrant populations in Minnesota. Explain the MDH Refugee Health Program. Cite the health needs assessed among new arrivals. Identify strategies to enhance culturally- specific health care services for new arrival populations.

3. U.S.A. U.S. CitizenNon-Citizen Persons fleeing from persecution LPR Immigrant LTR authorized employment Non-Immigrant student tourist refugeeasylee parolee undocumented individual visitor on business 8/03 USCIS Definitions

4. What does it mean to be a refugee? Foreign-born resident who: is not a United States citizen cannot return to his or her country of origin because of a well-founded fear of persecution due to race, religion, nationality, political opinion, or membership in a particular social group Refugee status is generally given: prior to entering the United States by the Bureau of Citizenship & Immigrant Services (USCIS) Eligible for up to 8 months of public assistance.

5. What does it mean to be an immigrant? Foreign-born resident who: is not a United States citizen is defined by U.S. immigration law as a person lawfully admitted for permanent residence in the United States either arrives in the U.S. with an immigrant visa issued abroad, or adjusts their status in the U.S. from temporary to permanent resident may be subjected to a numerical cap

6. What does it mean to be an asylee? Foreign-born resident who: is not a United States citizen cannot return to his or her country of origin because of a well-founded fear of persecution due to race, religion, nationality, political opinion, or membership in a particular social group Asylee status is generally given: after entering the United States by the State Department or USCIS

7. What does it mean to be a parolee? Foreign-born resident who: is not a United States citizen has been given special permission to enter the United States: - under emergency conditions or - when that person's entry into the U.S. is considered to be in the public's interest

8. Migrants to Minnesota Primary Migrants to Minnesota Foreign-born persons whose primary state of resettlement in the U.S. was Minnesota Arrival notification from CDC Secondary Migrants to Minnesota Significant movement of refugees/ immigrants from state of primary arrival Health information requested from primary arrival state If no information is available, baseline health assessment should be done

9. To control communicable disease among, and resulting from, the arrival of new refugees through: health assessment treatment referral Refugee Health Program Goal

10. Functions of MDH Refugee Health Program Coordinate initial health assessments, Educate providers regarding screening protocols, Administer contacts with local health departments for refugee screening, Collect and disseminate health screening data, Collaborate with Volags, MAAs, and other community based organizations, Provide health resources for foreign- born populations and their health care providers.

11. Quarantine Station/CDC MDH Local Health Dept. Screens Forwards to primary provider Forwards to primary provider Primary provider screens Primary provider screens Screening form completed & returned Screening form completed & returned Refugee Health Assessment Information Flow

12. Volags (Volunteer Agencies): Local Organizations or Affiliates Catholic Charities (CC) Lutheran Social Services (LSS) Jewish Family Services or Minneapolis Jewish Family and Children's Services (JFS) MN Council of Churches (MCC) International Institute of Minnesota (IIM) World Relief Minnesota (WRM)

13. Mutual Assistance Associations (MAAs)* Amigos de las Americas Association for the Advancement of Hmong Women in MN Center for Asians and Pacific Islanders CLUES Confederation of Somali in MN Ethiopian Community in MN Hmong American Mutual Assistance Assoc. Hmong American Partnership Intercultural Mutual Assistance Association Islamic Center of MN Lao Assistance Center of MN Lao Family Community Oromo Community of MN SEA Community Council Slavic Community Center Somali Family Services United Cambodian Association of MN Vietnamese Social Services West African Mutual Aide Association *List not comprehensive

14. Refugee Arrivals to MN by Region of World 1979-2010 Refugee Health Program, Minnesota Department of Health

15. Lake Cook Le Sueur Rice Goodhue NoblesRockJacksonMartinFaribaultFreebornMowerFillmoreHouston WinonaOlmstedDodgeSteeleWasecaBlue EarthWatonwan Cottonwood MurrayPipestone Nicollet Wabasha Dakota Scott Wash- ing- ton Chisago Isanti Brown Sibley Carver Hennepin WrightMeeker Kandiyohi Renville Redwood Sherburne LyonLincoln Yellow Medicine Lac Qui Parle Swift Big Stone PopeStevens Traverse Chippewa Stearns Benton Carlton Pine Kanabec Mille Lacs Aitkin Crow Wing Morrison Cass Hubbard Wadena Todd DouglasGrant Ottertail Wilkin Becker Clay Clear Water Mahnomen Norman Red Lake Pennington Polk Beltrami Marshall Itasca Koochiching Lake of the Woods RoseauKittson St. Louis McLeod 71 Anoka Hennepin Number of Refugees Arrival By Initial County Of Resettlement 2010 Primary Refugee Arrival To Minnesota (N=2,320) Ram- sey 0 1- 20 21 - 50 51 - 100 101 - 300 301 – 1,000 1,001 – 2,000

16. Primary Refugee Arrivals, Minnesota 2010 N=2,320 “Other” includes Afghanistan, Cambodia, Cameroon, China (incl. Tibet), Colombia, Cuba, Guinea, Kenya, Liberia, Mali, Mexico, Nigeria, Rwanda, Saudi Arabia, Sierra Leone, Sudan and Togo Refugee Health Program, Minnesota Department of Health *“FSU” includes Armenia, Belarus, Kyrgyzstan, Moldova, Ukraine and Uzbekistan

17. African Refugee Family Reunification Suspended The State Department announced that the U.S. family- reunification program for African refugees has been suspended after DNA testing of applicants revealed widespread fraud. The suspension affects family members seeking to join East Africans, and some Liberians, already in the United States. Minnesota only accepted through the family reunification program (P-3) until June 2008. Source: Voice of America, August 20, 2008

18. “Free Cases” or “Families without U.S. Ties” Def.-: Refugees who do not have family ties or anchors residing in the U.S. or the resettlement state With the change in resettlement policy, Minnesota started accepting “Free Cases” in July 2008: –From July 2008 – Present: 849 (27%) of 3,166 arrivals came as “Free Cases” 2008: 44 (4%) 2009: 178 (14%) 2010: 959 (41%) –Top Countries: Somalia, Burma and Iraq

19. Primary Refugees without U.S. Ties (Free Cases) Minnesota, 2010 Refugee Health Program, Minnesota Department of Health N=959 ‘Other’ includes Cuba and Sudan

20. “New” Refugee Populations 2008 to Present

21. Burma (Myanmar) 1948 - 1974 1974 - 2010 2010 -

22. Background Over 140, 000 refugees along Thai- Burmese border since 1984 (Temporary Protection) oStudents with claims of political persecution versus Ethnic Minorities –U.S.A : Expected to resettle in the US during 10 yrs starting FY2006 –Minnesota: Burmese started arriving in 2003; the KaRen/Burmese starting 2006 To date: 3,372 arrivals Source: Human rights watch and US State Department Fiscal Year US Arrivals 20061,612 200713,986 200818,139 200918,275 201016,693 2011 (Jul)14,089

23. Bhutan

24. Background Over 106, 000 Nepali speaking Bhutanese (Lothsampas) refugees expelled from Southern Bhutan in the early 1990s; currently refugees are living in 7 camps in Nepal Cultural, linguistic expressions denied; Bhutan has denied their right to return to their country U.S.A: At least 60,00 are expected to resettle in the US - special humanitarian concern Minnesota: Bhutanese refugees started arriving in May 2008 To date: 456 arrivals Source: Human Rights Watch and US State Department Fiscal Year US Arrivals 20085,320 200913,317 201012,363 2011 (Jul)10,816

25. IRAQ 1991-200420081963-19912004-2008

26. Background Iraqi refugees (2.2 Million) Syria (~500,000) Jordan (~1.4 million) Other (~360,000) U.S.A: 30,000 referred Minnesota: Iraqi refugees started arriving in April 2008 To date: 445 arrivals Source: Human Rights First and US State Department Fiscal Year US Arrivals 2006202 20071,608 200813,822 200918,838 201018,016 2011 (Jul)7,544

27. Refugee Admissions Ceilings for FY2011 N=80,000 Source: US Department of State

28. Types of Medical Exams  Overseas Visa Medical Examination  U.S. Public Health Service  Domestic Refugee Health Assessment  Minnesota Department of Health  Adjustment of Status Medical Examination  From temporary to permanent resident  Needed to obtain a green card  US Citizenship and Immigration Service

29. Adjustment of Status Exam (Green Card Exam)  Immigrants: exam done by Civil Surgeon required  Refugees: immunizations only (unless arrived with Class A condition); local Public Health can act as Civil Surgeon  Forms are found at www.uscis.govwww.uscis.gov  Call MDH for more guidance

30. Health Status of New Refugees, Minnesota, 2010 ‡ Health status upon arrival No of refugees No(%) with infection screened among screened TB infection* 2,086 (95%) 570 (27%) Hepatitis B infection** 2,160 (98%) 112 (5%) Parasitic Infection*** 2,106 (96%) 471 (22%) Sexually Transmitted 1,765 (80%) 28 (2%) Infections (STIs)**** Malaria Infection 234 (11%) 0 (0%) Lead***** 833 (87%) 16 (2%) Hemoglobin 2,151 (98%) 437 (20%) Refugee Health Program, Minnesota Department of Health ‡ 2010 Preliminary results for arrivals between 01/01/2010 and 12/31/2010 Total screened: N=2,193 (98% of 2,242 eligible refugees) * Persons with LTBI (>= 10mm induration or IGRA+, normal CXR) or suspect/active TB disease ** Positive for Hepatitis B surface antigen (HBsAG) *** Positive for at least one intestinal parasite infection **** Positive for at least one STI *****Children <17 years old (N=954 RHAs)

31. Health Status of New Refugees, Minnesota Immunization Status, 2002-2010 Refugee Health Program, Minnesota Department of Health

32. Health Status of New Refugees Upon Arrival to MN, 2010 *  Screening rate 98% (2,193/2,242)  Immunizations 91% (2,003/2,193) started or continued age-appropriate vaccinations after health screening  Tuberculosis27% (570/2,086) Latent TB infection or suspect/active TB case  Hepatitis B 5% (112/2,160) HBsAg positive *Preliminary Results

33. Health Status of New Refugees Upon Arrival to MN, 2010*, cont’d  Parasitic infection 22% (471/2,106) Tested positive for at least one intestinal parasite (common: Strongyloides, Giardia, Schistosoma, Trichuris, E. histolytica)  Lead level (<17 y.o.) 2% (16/833)  Hemoglobin 20% (437/2,151) less than 12gm/dL  Referrals Primary Care (51%), Pediatrics (43% of <18 yrs), Dental (37%), Public Health Nurse (13%), Vision (8%) *Preliminary results

34. 13/33 201/1,004 N=2,086 screened *Diagnosis of Latent TB infection (N=568) or Suspect/Active TB disease (N=2) Refugee Health Program, Minnesota Department of Health Tuberculosis Infection* Among Refugees By Region Of Origin, Minnesota, 2010 320/803 570/2,086 32/221 4/25 *Preliminary results

35. Hepatitis B infection Among Refugees by Region of Origin, Minnesota, 2010 Refugee Health Program, Minnesota Department of Health N=2,160 screened 112/2,160 37/834 74/1,039 0/32 0/227 1/28 *Preliminary results

36. Intestinal Parasitic Infection* Among Refugees by Region of Origin, Minnesota, 2010 * At least one stool parasite found (including nonpathogenic) Refugee Health Program, Minnesota Department of Health 471/2,106 149/812 271/1,025 3/33 *At least one type of pathogenic intestinal parasite N=2,106 screened 15/32 33/204 *Preliminary results

37.  Infectious Disease – TB, parasites, hep B  Nutritional Deficits – poverty, disease  Immunizations – required for school  Mental Health – loss, fear, adjustment  Access to care – how, why, when, where  Interpreters – language/cultural  Costs – insured, under-insured, no insurance Source: MDH Refugee Health Program Health Concerns: Immediate

38.  Chronic Disease – diabetes, hypertension, obesity, work hazards, TB in frail and elderly  Mental Health – family role and self definition adjustment, isolation, lack of support  Access to care – misunderstanding and mistrust of system  Interpreters – language/cultural  Costs – insured, under-insured, no insurance Health Concerns: Long Term

39. Limitations of Domestic Screening Elective on parts of both state and refugee Wide variation in quality and comprehensiveness across states Funding sources may be limited Clinics’ and clinicians’ experience/ expertise in working with newly arrived refugees &/or tropical medicine varies state to state

40. Areas of Need in Resettlement Applying for Social Security number, public assistance, photo ID Education; English language classes Employment services Housing, food, furniture, clothing (www.211unitedway.org) Health care services: physical, mental, spiritual Ethnic-specific support services (MAAs or other community agencies); www.iimn.org (ethnic resource directory)www.iimn.org Legal Assistance

41. Strategies to Enhance Culturally Competent Care Cultural Assessment (incorporate tool, results in medical record) Other considerations: –interpreter services (Interpreting Stakeholder Group) –bilingual/bicultural staff –appropriate education resources (www.health-exchange.net) Appoint staff as cultural resources (www.culturecareconnection.org) PHN and community-based follow-up

42. Interpreting Stakeholder Group ISG works to improve the quality and delivery of spoken language and interpreter services in Minnesota, and to promote the professionalization of the interpreting industry as a whole. http://www.isgmidwest.org

43. Strategies to Enhance Culturally Competent Care Cultural Assessment (incorporate tool, results in medical record) Other considerations: –interpreter services (Interpreting Stakeholder Group) –bilingual/bicultural staff –appropriate education resources (www.health- exchange.net) Appoint staff as cultural resources PHN and community-based follow-up

44. Stratis Health – Culture Care Connection An online learning and resource center aimed at supporting health care providers, staff, and administrators in their ongoing efforts to provide culturally competent care. www.culturecareconnection.org

45. Diversity In Minnesota – Information Sheets Somalis in MinnesotaHmong in Minnesota http://www.culturecareconnection.org/matters/diversity/somali.html

46. Know Your Community: County Profiles County profiles detail pertinent demographic, socioeconomic, and health status data, with information about vulnerable populations. County Profiles offer providers and administrators an in-depth view of the communities they serve. This information can be used in strategic planning to ensure the provision of culturally and linguistically appropriate health services. http://www.culturecareconnection.org/navigating/mncountyprofiles.html http://www.culturecareconnection.org/navigating/mncountyprofiles.html

47. Minnesota Health Literacy Partnership MHLP, a program of the Minnesota Health Literacy Council, was formed to help coordinate health literacy efforts across the state. The partnership is comprised of health care organizations, consumers, and literacy groups, as well as the state’s health and social service agencies, and has worked with a number of local organizations to develop health literacy training, patient education materials, and toolkits. www.healthliteracymn.org

48. Radio shows ESL Ethnic press ECHO TV Global Brown bags (for staff) Metro Refugee Health Task Force Community health forums Etc! Community Health Education

49. L Listen with empathy to the client’s perception of the problem E Explain your perceptions of the problem A Acknowledge and discuss the differences and similarities R Recommend treatment N Negotiate agreement Berlin, E. A. and Fowkes, W.C., 1983 LEARN

50. Improve access to care Data collection and analysis Equitable payment for immigrant health services Develop clinical guidelines Diversify workforce Use trained interpreters Use CHWs Train providers and educate new immigrants. MN Immigrant Health Task Force, MDH, 2004 Immigrant Health Task Force

51. Contact Information - 2011 MDH Refugee Health Staff: 651-201-5414 MDH Refugee Health Program: www.health.state.mn.us/refugee Metro Refugee Health Task Force Sara Chute: sara.chute@state.mn.ussara.chute@state.mn.us