Refugee Health In Minnesota
Carol Berg, RN, MPH
Public Health Manager, UCare
cberg@ucare.org
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 culturallyspecific health care services for new
arrival populations.
USCIS Definitions
U.S.A.
Non-Citizen
U.S. Citizen
Non-Immigrant
Immigrant
LPR
LTR
authorized
employment
undocumented
individual
student
visitor on
business
tourist
Persons fleeing from persecution
refugee
asylee
parolee
8/03
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.
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
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
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
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
Refugee Health Program Goal
• To control communicable disease
among, and resulting from, the arrival
of new refugees through:
• health assessment
• treatment
• referral
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 foreignborn populations and
their health care
providers.
Refugee Health Assessment
Information Flow
Quarantine Station/CDC
Local Health Dept.
Screens
Forwards to
primary provider
Primary provider
screens
Screening form
completed & returned
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)
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
Refugee Arrivals to MN by Region of World
1979-2010
8000
Number of arrivals
7000
6000
5000
4000
3000
2000
Southeast Asia
FSU
Sub-Saharan Africa
Middle East/North Africa
Refugee Health Program, Minnesota Department of Health
Eastern Europe
Other
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
0
1979
1000
Kittson
2010 Primary Refugee Arrival
To Minnesota (N=2,320)
Lake
of the
Woods
Roseau
Koochiching
Marshall
St. Louis
Beltrami
Pennington
Polk
Cook
Clear
Water
Red Lake
Lake
Itasca
Mahnomen
Norman
Hubbard
Cass
Becker
Clay
Aitkin
Wadena
Crow Wing
Number of Refugees Arrival By
Initial County Of Resettlement
Carlton
Ottertail
Wilkin
Pine
Todd
Mille
Lacs
Grant
Douglas
Stevens
Pope
Kanabec
0
Morrison
Benton
Traverse
Stearns
1- 20
Isanti
Big Stone
Sherburne
Swift
21 - 50
Chisago
Kandiyohi
Anoka
Meeker
71
Wright
Chippewa
Hennepin
Hennepin
Lac Qui Parle
McLeod
Renville
51 - 100
WashingRam- ton
sey
101 - 300
Carver
Scott
Yellow Medicine
301 – 1,000
Dakota
Sibley
Lincoln
Lyon
Redwood
Le
Sueur
Nicollet
Rice
1,001 – 2,000
Goodhue
Wabasha
Brown
Pipestone
Murray
Watonwan
Blue Earth
Waseca
Steele
Dodge
Olmsted
Winona
Cottonwood
Rock
Nobles
Jackson
Martin
Faribault
Freeborn
Mower
Fillmore
Houston
Primary Refugee Arrivals, Minnesota
2010
Laos/Hmong
2%
Ethiopia
FSU
2%
4%
Bhutan
Eritrea Congo (DR)
2%
1% Haiti
1%
Other
5%
8%
Iraq
10%
Burma
36%
Somalia
29%
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
*“FSU” includes Armenia, Belarus, Kyrgyzstan, Moldova, Ukraine and Uzbekistan
Refugee Health Program, Minnesota Department of Health
African Refugee Family
Reunification Suspended
The State Department announced that the U.S. familyreunification 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
“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
Primary Refugees without U.S. Ties (Free Cases)
Minnesota, 2010
Congo (DR)
3%
Eritrea
3%
Bhutan
10%
Iraq
12%
Burma
26%
‘Other’ includes Cuba and Sudan
Refugee Health Program, Minnesota Department of Health
Ethiopia
2% Other
1%
Somalia
43%
N=959
“New” Refugee Populations
2008 to Present
Burma (Myanmar)
1948 - 1974
1974 - 2010
2010 -
Background
• Over 140, 000 refugees along ThaiBurmese border since 1984
(Temporary Protection)
o Students 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
2006
1,612
2007
13,986
2008
18,139
2009
18,275
2010
16,693
2011 (Jul)
14,089
Bhutan
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
2008
5,320
2009
13,317
2010
12,363
2011 (Jul)
10,816
IRAQ
1963-1991
1991-2004
2004-2008
2008
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
2006
202
2007
1,608
2008
13,822
2009
18,838
2010
18,016
2011 (Jul)
7,544
Refugee Admissions Ceilings for FY2011
Unallocated
0%
Near East/
South Asia
49%
Africa
15%
East Asia
26%
Latin America/
Caribbean
7%
Europe/
Central Asia
3%
N=80,000
Africa
East Asia
Europe/Central Asia
Latin America/Caribbean
Near East/South Asia
Unallocated
Source: US Department of State
Types of Medical Exams
 Overseas
 U.S.
Visa Medical Examination
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
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.gov
 Call MDH for more guidance
Health Status of New Refugees, Minnesota, 2010‡
Health status upon arrival
TB infection*
No of refugees
screened
2,086 (95%)
Hepatitis B infection**
2,160 (98%)
112 (5%)
Parasitic Infection***
2,106 (96%)
471 (22%)
Sexually Transmitted
Infections (STIs)****
1,765 (80%)
28 (2%)
Malaria Infection
234 (11%)
0 (0%)
Lead*****
833 (87%)
16 (2%)
2,151 (98%)
437 (20%)
Hemoglobin
‡ 2010
No(%) with infection
among screened
570 (27%)
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
Refugee Health Program, Minnesota Department of Health
*****Children <17 years old (N=954 RHAs)
Year
Refugee Health Program, Minnesota Department of Health
2010
2009
2008
2007
2006
2005
2004
Overseas
Domestic
2003
100
90
80
70
60
50
40
30
20
10
0
2002
Percent
Health Status of New Refugees, Minnesota
Immunization Status, 2002-2010
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
 Tuberculosis
27% (570/2,086)
Latent TB infection or suspect/active TB case
 Hepatitis
B
HBsAg positive
5% (112/2,160)
*Preliminary Results
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
less than 12gm/dL

Referrals
Primary Care (51%), Pediatrics (43% of <18 yrs),
Dental (37%), Public Health Nurse (13%), Vision
(8%)
20% (437/2,151)
*Preliminary results
Tuberculosis Infection* Among Refugees
By Region Of Origin, Minnesota, 2010
N=2,086 screened
Overall TB Infection
27%
570/2,086
Sub-Saharan Africa
SE/East Asia
Latin Ame rica/Caribbean
North Africa /Middle East
40%
20%
16%
14%
201/1,004
4/25
32/221
Europe
0%
320/803
39%
10%
20%
*Diagnosis of Latent TB infection (N=568) or Suspect/Active TB disease (N=2)
Refugee Health Program, Minnesota Department of Health
13/33
30%
40%
*Preliminary results
50%
Hepatitis B infection Among Refugees
by Region of Origin, Minnesota, 2010
N=2,160 screened
Overall Hepatitis B
Infection Rate
Sub-Saharan Africa
5%
112/2,160
37/834
4%
7%
SE/East Asia
Latin America/Caribbean
4%
North Africa/Middle East
0% 0/227
Europe
0% 0/32
0%
74/1,039
1/28
2%
Refugee Health Program, Minnesota Department of Health
4%
6%
8%
*Preliminary results
10%
Intestinal Parasitic Infection* Among Refugees
by Region of Origin, Minnesota, 2010
N=2,106 screened
Overall Parasitic
Infection Rate
22%
Sub-Saharan Africa
18%
SE/East Asia
471/2,106
149/812
26%
271/1,025
Latin
America/Caribbean
North Africa/Middle East
Europe
0%
47%
16%
9%
15/32
33/204
3/33
5%
10% 15% 20% 25% 30% 35% 40% 45% 50%
*At least one type of pathogenic intestinal parasite
* At least
one Program,
stool parasite
found
(including
Refugee
Health
Minnesota
Department
of nonpathogenic)
Health
*Preliminary results
Health Concerns: Immediate

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: Long Term

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
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
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)
• Legal Assistance
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
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
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.healthexchange.net)
• Appoint staff as cultural resources
• PHN and community-based follow-up
Stratis Health – Culture Care Connection
www.culturecareconnection.org
An online learning and
resource center aimed
at supporting health
care providers, staff,
and administrators in
their ongoing efforts to
provide culturally
competent care.
Diversity In Minnesota – Information Sheets
http://www.culturecareconnection.org/matters/diversity/somali.html
Somalis in Minnesota
Hmong in Minnesota
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
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
Community Health Education
•
•
•
•
•
•
•
•
Radio shows
ESL
Ethnic press
ECHO TV
Global Brown bags (for staff)
Metro Refugee Health Task Force
Community health forums
Etc!
LEARN
L
Listen with empathy to the client’s perception of the
problem
E
A
Explain your perceptions of the problem
R
N
Recommend treatment
Acknowledge and discuss the differences and
similarities
Negotiate agreement
Berlin, E. A. and Fowkes, W.C., 1983
Immigrant Health Task Force
•
•
•
•
•
•
•
•
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
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.us