REFUGEE HEALTH IN PHILADELPHIA

Transcription

1 REFUGEE HEALTH IN PHILADELPHIA Marc Altshuler, MD Associate Professor, Department of Family and Community Medicine Director, Jefferson Center for Refugee Health

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9 Objectives Review the history of refugees and how they come to the United States Learn about Refugee Health in Philadelphia and the Jefferson Center for Refugee Health Listen to refugee s stories Find ways to support refugees

10 Following World War II, the United Nations High Commissioner for Refugees (UNHCR) was formed in 1950 to help the millions of Europeans who fled Europe and lost their homes. They were given 3 years to complete their work 67 years later, the UNHCR is still in existence UNHCR

11 UNHCR 2017 Mandated to lead and coordinate international action to protect refugees and resolve refugee problems worldwide. Ensures that everyone can exercise the right to seek asylum and find safe refuge in another State. Today, a staff of some 8,600 people in more than 130 countries continues to help some 33.9 million persons. 11

12 Definition of Refugee Someone who, owing to a well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group, or political opinion, is outside the country of his nationality, and is unable to or, owing to such fear, is unwilling to avail himself of the protection of that country. Source: UN Convention Relating to the Status of Refugees, Article 1A (1951)

13 Other Terms: Immigrant a foreign born resident who is not a US citizen, lawfully admitted for permanent residence Asylee an immigrant who has fled their country for reasons as a refugee, but is already present in the US Internally Displaced Person (IDP) unlike refugees, they are displaced within their own country frequently for some of the same reasons as refugees.

14 Over 50% are children 45,000 per day are forced to flee Top Countries: Syria 4.9 million Afghanistan 2.7 million Somalia 1.1 million Worldwide Statistics

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16 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) is responsible for awarding legal refugee status in the country of asylum. If all efforts to either help refugees return home or settle permanently in the country of asylum have failed, then third country resettlement becomes the option of last resort.

17 Refugees coming to the U.S. fdaaf400369a_video.html?utm_term=.9e5d07c8fcba

18 Refugee Health in US Refugee Act of 1980 Officially, established a domestic refugee resettlement program Outlined the process for the annual admission of refugees The number of refugees who are admitted to the US. is decided by the President, in consultation with Congress. Since 1975, the United States has resettled over 3 million refugees.

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20 Statistics Fiscal Year 2017 FY 2017: 110,000 FY 2016: 85,000 FY 2015: 70,000 Africa ,000 East Asia ,000 Europe and Central Asia.....4,000 Latin America/Caribbean....5,000 Near East/South Asia... 40,000 Unallocated Reserve ,000

21 Upon Arrival Reception Services Airport pickup Pocket money Housing Hot culturally appropriate meal Basic furnishings and household items Culturally appropriate food staples (until food stamp case is opened) Core Services Apply for social security cards (w/in 10 days) Welfare benefits (w/in 10 days) Medical screening (w/in 30 days) Enroll children in school (w/in 30 days) ESL referral (w/in 10 days) Employment referral (w/in 10 days) Home visits (24 hr, 30 and 90 days) Cultural Orientation Role of agency Housing Transportation Hygiene Budgeting and finances Public benefits Safety Travel Loan repayment Selective service registration Change of address

22 Overseas Health Screens Immigration and Nationality Act (INA) requires that medical screening examinations be performed overseas for all USbound immigrants and refugees Focus is to detect inadmissible diseases and exclude Valid for 1 year Testing includes: H&P to evaluate for drug abuse, STDs, mental disorders associated with harmful behavior, and Hansen s disease serology for syphilis (>15 y/o) CXRs (and AFB smear if CXR+) for TB Immunization status history, vaccination records, and/or serology

23 US Refugee Health Screens Encouraged to take place within 30 days Identify infection, TB infection, parasitosis, survivors of torture Overseas screen is good for 1 year potential for new disease since that screen 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 All refugees are eligible for some package (usually at least 8 months of coverage)

24 HIAS and Council Refugee Arrives in Philadelphia Nationalities Service Center Lutheran Children & Family Service Referrals from family and friends Public Health Centers Private Physicians (Screenings Only)

25 Jefferson s Center for Refugee Health

26 Our Clinic at Jefferson Family Medicine (JFMA) Started in July 2007 as partnership between NSC and JFMA Evaluated over new patients, over total visits Provide a Refugee Medical Home Close proximity to NSC Part of residency curriculum Provides complete care

27 Refugee Health Provides unique learning experiences for students and residents Patients become continuity patients for residents Unique illnesses are seen Teaches an appreciation for events unfolding around the world

28 Jefferson s Center for Refugee Health Clinical Research Outreach/ Education Students: RHP, JeffHOPE site, electives, student navigators FM Residents: Clinic, Electives Faculty, Residents, MPH, Students: Database, review articles, case studies, capstone projects, presentations Community: Consultation, Collaborative Residents, students: Community workshops, vaccine Clinic, women s health, nutrition education Future: Fellowships, Interdisciplinary education, Center of Medical Excellence, Funding

29 Countries of Origin All Refugees (2009) Source: UNHCR, 2009 Global Trends

30 Number of Refugees Seen at JFMA by Country of Origin and Year of Initial Screen Bhutan/Nepal (n=397) Iraq (n=392) Burma (n=259) DRC (n=62) Afghanistan (n=40) Eritrea/Ethiopia (n=83) 80 Syria (n=16) /

31 Refugees Seen at JFMA by Language, (N=1,486) 40% 31% 27% 20% 8% 7% 3% 3% 4% 0% Arabic Burmese Chin Karen Kinyarwanda Nepali Tigrinya

32 Population Pyramid of All Refugees Seen at JFMA, Age Range (Years) 80 and over 75 to to to to to to to to to to to to to to 14 5 to 9 Under 5 Male Female Population (%)

33 40% 30% 20% 22% Prevalence of Infectious Disease Diagnoses in Refugees Seen at JFMA by Country of Origin, % 37% 31% 31% 29% 22% 19% U.S. Comparison Overall Afghanistan Bhutan/Nepal Democratic Republic of Congo Ethiopia/Eritrea Iraq Burma through Thailand Burma through Malaysia 10% 0% 4.0% 3.4% 3.4% 2.5% 2.4% 2.7% 1.1% 1% 1.2% 1% 0.5% 0.0% LTBI HIV Syphilis 0.7% National comparisons for LTBI and Syphilis derived from CDC, Prevalence of HIV for adults and adolescents over the age of 13, from Hall, H. I., An, Q., Tang, T., Song, R., Chen, M., Green, T., & Kang, J. (2015). Prevalence of diagnosed and undiagnosed HIV infection United States, MMWR Morb Mortal Wkly Rep, 64(24),

34 80% Prevalence of Chronic Conditions in Refugees Seen at JFMA by Country of Origin including U.S. Comparison, US Comparison 70% 71% 71% Overall Afghanistan 60% Bhutan/Nepal 50% 48% Democratic Republic of Congo Ethiopia/Eritrea 40% 30% 27% 34% 34% 34% Iraq Burma through Thailand Burma through Malaysia 20% 10% 0% Overweight/ Obesity 19% 17% 15% 12% 13% 11% 10% 8% 6% 5% 4% 3% 4% 5% 4% 5% 3% 1% 1% Hypertension Diabetes Asthma COPD Prevalence of chronic conditions among adult refugees over the age of 18 resettled in Philadelphia, including hypertension, type II diabetes mellitus, asthma, and COPD. U.S. Comparison data collected from CDC, 2014, concerning adults over the age of 18 for hypertension, diabetes, asthma, and COPD, and over the age of 20 for overweight/obesity.

35 Ever Screened for Cervical, Breast, or Colon Cancer by Year of Initial Medical Screening 100% 80% Percent Screened 60% 40% 20% 0% Year of Initial Medical Screen Cervical Mammography Colon Cervical U.S. Comparison Mammography U.S. Comparison Colon U.S. Comparison Cervical Healthy People 2020 Goal Mammography Healthy People 2020 Goal Colon Healthy People 2020 Goal

36 25% History of Torture in Adult Refugees Seen at JFMA by Country of Origin, % 20% 15% 15% 15% 10% 9% 6% 6% 5% 0% Overall (n=764) Democratic Republic of Congo (n=60) Eritrea/Ethiopia (n=33) Iraq (n=230) Burma through Thailand (n=52) Burma through Malaysia (n=83)

37 Some of our patients stories...

38 Refugee Arrives in Philadelphia (~ 800 per year) HIAS Pennsylvania Nationalities Service Center Lutheran Children & Family Service Evaluation based on medical needs, geographic location and availability Children s Hospital of Philadelphia (HIAS Coordinated) Penn Center for Primary Care (HIAS Coordinated) Jefferson Family Medicine (NSC Coordinated) Nemours Pediatrics (NSC Coordinated) Drexel Women s Care Center (NSC Coordinated) Fairmount Primary Care Center (NSC Coordinated) Einstein Community Practice (LCFS Coordinated) Einstein Pediatric Clinic (LCFS Coordinated)

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40 What can you do? Continue to learn about refugees Support local and national refugee resettlement agencies Call your congressional representative to let them know you support the US Refugee Resettlement Program Educate others about refugees

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42 Books: Fadiman, Anne. The Spirit Catches You and You Fall Down. Housseini, Khaled. A Thousand Splendid Suns. Beah, Ishmael. A Long Way Gone. Kidder, Tracy. Mountains Beyond Mountains A Strength in What Remains Suggested Reading:

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44 References Adams et el. Healthcare challenges from the developing world: post immigration refugee medicine BMJ 2004;328: (26 June), doi: /bmj Dey AN, Lucas J. Physical and mental health characteristics of USS and foreign born adults: United States, 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: , Keller A. Lhewa D. Rosenfeld B. Sachs E. Aladjem A. Cohen I. Smith H. Porterfield K. Traumatic experiences and psychological distress in an urban refugee population seeking treatment services. Journal of Nervous & Mental Disease. 194(3):188 94, 2006 Mar Minnesota Refugee Health Provider Guide 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 Aug;95(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): Walker, Patricia F., and Barnett, Elizabeth D. Immigrant Medicine. Elsevier, 2007.