Patricia Walker_NARCH Keynote_June 2016

Refugee Health:
Imagining Our Future
North American Refugee Health Conference
Niagara Falls, New York
June 12, 2016
Patricia F Walker, MD, DTM&H, FASTMH
Professor, Division of Infectious Disease and International Medicine
Dept. of Internal Medicine, University of Minnesota
Medical Director, HealthPartners
Travel and Tropical Medicine Center

Disclosure
I receive royalties for the following
educational products:
o Elsevier Publishing for sales of Immigrant
Medicine
o UpToDate for publication of Guidelines for
Care of Adult Immigrants
o Critical Measures, Inc. for on line cross
cultural case studies

• Introduction
• Two case studies
• International
imaginings
• Domestic
imaginings
Photo Credit:
Albany Daily Star
June 6, 2016

Imagining Our Future/
Khalil Gibran, On Children
“Your children are not your
children...they are the sons
and daughters of Life’s
longing for itself…you may
house their bodies, but not
their souls, for their souls
dwell in the house of
tomorrow, which you
cannot visit, not even in
your dreams”

Imagining Our Future…..June 1, 2016
• BEAM me up,
NASA
• The Bigelow
Expandable
Activity Module

Imagining our future requires
remembering our past
• Modern refugee
protection
movement is less
than 100 years old

• Protection of refugees has
occurred since antiquity
• International protection
began with the League of
Nations (1921-1946)
https://www.icrc.org/eng/assets/files/ot
her/727_738_jaeger.pdf

• Convention on the
International Status of
Refugees - 1933
• First time the principle of
non-refoulment acquired the
status of international treaty
law

• FDR and the Evian
Resolution – 1938
• Help people fleeing the
Third Reich from Germany
and Austria
• First time protection was
extended to would be
refugees inside the country
of potential departure

• International Refugee
Organization (IRO) 1946-
1951
• Established by UN General
Assembly to help resettle
central European refugees
to US, Canada, W Europe,
Australia, Israel and Latin
America
Photo: Wikimedia Commons: Passenger ship, possibly
MS SKAUBRYN, berthed at a wharf (8400394605).jpg

• IRO was meant to complete
it’s work by 30 June 1950
• “As soon became evident, it
was unlikely – to say the
least – that the problem of
refugees would be solved by
that date”
• “A Study of Statelessness”
Photo Credit: Wikimedia
The Palmach - Immigration to Israel

“A Study of Statelessness” :
o International travel
o Right of entry and sojourn
o Personal status
o Family rights
o Rights of exercise of trades or profession
o Education, relief, social security
o Exemption from reciprocity, expulsion,
taxation and military service
Original photo uploaded by Fischerjs/Wikipedia

This study served as the main
elements of the
UN Convention Relating to the
Status of Refugees, 1951

US Refugee Program:
o 1600’s…Americans fleeing persecution
since the Pilgrims
o 1948 -250,000 displaced Europeans
from WWII
o 1940’s-50’s – laws assisting those
fleeing Communism (China, Hungary,
Korea, Poland, Yugoslavia)
o 1960’s- fleeing Cuba
o 1980- US Refugee Act after Vietnam
War

Imagining Our Future/International
• The tragic reality
is that we have
guaranteed job
security in
refugee health….
• Yet that allows us
to imagine a
better future

Case study number 1
• The most difficult
day in my career
as a physician
• Vietnamese
refugee crisis
1988-1989

• A world where we
work for peaceful
resolutions of
international
conflicts (so that we
don’t have
refugees…)
Photo: Arcadia University

• A world where
we honor key
principles of
international
refugee law
Photo Credit:
University of Baltimore
School of Law
April 6,2016

• A world where
governments,
IO’s and NGO’s
are prepared for
high volume, long
term tragedies
such as the
Syrian conflict

• A world which views
refugee situations as
the indescribable
human tragedies
which they are, and
which responds with
generosity and
compassion

• “Refugees are
not the danger
– they are in
danger”
Pope Francis
Vatican City
May 28, 2016

• A world which
denounces anti-
immigrant policies -
and the politicians
and individuals who
espouse them

• A world where long
term warehousing of
refugees is
unacceptable…where
durable solutions
include local
integration, not just
repatriation or
resettlement

• A world where
leading
governments
respond by
increasing refugee
acceptance
numbers
Refugees admitted to the US
1980-2015
www.migrationpolicy.org/programs/data
-hub/us-immigration-trends

• A world where
upstream PH
interventions are
supported, and
assessment and
interventions
occur before
resettlement

Overseas
Medical Exam
Sites
Refugee Camps
Urban Centers
Resettlement
Communities
Mobility: time for health interventions
Prevention, surveillance &
Intervention opportunities
Quarantine
Stations
Slide courtesy of Dr. William Stauffer

• A world in
which medical
providers are
prepared for
humanitarian
crises abroad

Case Study Number 2…
• A Karen Burmese
refugee who didn’t
know how to
access emergency
care
Minnesota Medicine
April 2013

Imagining Our Future/Domestic
• Knowledge
• Attitudes
• Practices
Photo courtesy of
Medicine Box Films:
“American Heart”

Lyudmila Brukhis, CMA

Knowledge
o A world where
transitions of care
are seamless as
refugees move
from country of
first asylum to
resettlement
countries

Knowledge
o A world where we
have fingertip
access to the
knowledge we
need about
diseases seen in
each refugee
group

Knowledge which didn’t exist 35 years ago

Knowledge which didn’t exist 35 years ago….
Domestic screening guidelines
Australia http://www.asid.net.au/documents/item/1225
Canada
http://www.cmaj.ca/content/183/12/E824
United States
http://www.cdc.gov/immigrantrefugeehealth/guidelines/r
efugee-guidelines.html

Knowledge which didn’t exist 35 years ago
Dr. Phyllis Kozarsky, CDC Atlanta
Dr. Jay Keystone, Toronto
• The intersection of
refugee health and
travel medicine
• CDC Yellow Book:
o Chapters since 2010 on
refugee health

Mardiya Jafri, PA student

Knowledge
o A world where
we have the
demographic
data we need to
provide best
care
Vietnam,
1876, 16%
Thailand,
1332, 12%
Nepal,
1144,
10%
Cambodia,
1123, 10%
United States,
1061, 9%
Other, 982, 9%
Somalia, 982,
9%
Ethiopia, 910,
8%
Russia, 798, 7%
Laos, 629, 6%
Unknown, 174,
2%
Mexico, 157, 1%
Eritrea, 152, 1%
Liberia, 25, 0% Kenya, 6, 0%
Center for International Health
Country of Origin
Jan-Oct 2014
Vietnam
Thailand
Nepal
Cambodia
United States
Other
Somalia
Ethiopia
Russia
Laos
Unknown
Mexico
Eritrea
Liberia
Kenya

“Just count something”
Atul Gawande, MD
“Effective data collection is the
linchpin of any comprehensive
strategy to eliminate racial and
ethnic disparities in health.”
Tom Perez
Unequal Treatment
Institute of Medicine,2003

Just count something:
Data Collection at HealthPartners*
• Language 99%
• Interpreter Needed 99%
• Race/ethnicity 98%
• Country of Origin 40-98%
*Integrated care delivery system
(hospitals, medical group with >40 clinics, insurance provider)
in the Upper Midwest, US

86% 86%
73.5% 78.4%
0%
20%
40%
60%
80%
100%
1st Qtr 2007 3rd Qtr 2009
white patients patients of color
Mammography Screening: % of women age 50-75 who have been screened by Mammography in the 18 months prior to
and including their most recent primary care visit.
HPMG – Mammography Screening
Disparity by Race
GAP is 7.3%GAP is 12.4%
76.8%
2009 HEDIS
national 90th
percentile
(commercial)

84.4%
73.9%
77.9%
63 %
60
65
70
75
80
85
90
2Q 09
%up-to-datewithscreening
White Black or African American US Born (Black) Foreign Born (Black)
Disparities in Breast Cancer Screening Rates
HealthPartners

Strategies to Reduce Disparities
The “Pink Ticket”
Program
• Same day
mammograms
• Rides
• Mobile units

Dr. Steven Richmond, Internal medicine intern

Knowledge
o A world where
providers are trained
in the body of
knowledge which
encompasses
refugee health

Fowsia Musse, RN

Knowledge
o A world where
providers
acknowledge
expertise in other
disciplines, and avail
themselves of that
knowledge

What Really Creates Health?
Social and
Economic Factors
40%
Health Behaviors
30%
Clinical Care
10%
Physical
Environment
10%
Genes and
Biology
10%
Determinants of Health
Determinants of Health Model based on frameworks developed by: Tarlov AR. Ann N Y Acad Sci
1999; 896: 281-93; and Kindig D, Asada Y, Booske B. JAMA 2008; 299(17): 2081-2083.

Dr. Darin Ruanpeng, Internal Medicine resident

Kathy Lytle, MSW, Social Worker

Knowledge
o A world where providers
have access to colleagues
and experts which is
timely and easy to access,
and where we leverage
that expertise more
effectively

CDC Refugee Centers of Excellence

Knowledge
and patients have access
to an international data
base of patient education
material tailored to
language and health
literacy of refugees

Knowledge
o A world where
refugee health care
providers do more
science – clinical
research and
publishing

Knowledge
routinely ask “Where were
you born, and where have
you traveled?”… and
know what to do with the
answer
Photo Credit:
IOM via WHO

Knowledge
• “In the field of observation,
chance favors only the mind
which is prepared”
 Louis Pasteur
Maltreatment of Strongyloides:
case series and worldwide survey
of physicians in training
Boulware, Stauffer,
HendelPaterson, Walker et al
AM J Med 2007

Knowledge
o A world where we
remember that migration
is circular – and we
routinely ask “are you
planning to travel back
home?” (the Visiting
Friends and Relatives or
VFR traveler)

Attitudes
• Refugee health providers
are guided by a shared
set of core values, but…..
• What attitudes could we
use a little more of?
o Compassion
o Health Equity
o Humility
o Trust
o Respect
Walker PF, Barnett ED;
Immigrant Medicine;Ch1
Elsevier, 2007.

Mr. Ken Nguyen, Vietnamese interpreter

Attitudes we need more of…
Advocacy/calm outrage
o About anti-immigrant attitudes
o About health disparities
Leading by example:
o Academic excellence
o Mentorship and feedback

Attitudes we need more of…
“These are folks who have
lived through
unimaginable trauma," he
says. "Just from a point of
decency, to cut those
people off from the care
that they need just doesn’t
seem like the Canada that
I know.“
Dr Meb Rashid
CBC News, Canada
May 11,2012

Advocacy actually can make a difference

Domestic Practices
• A world where
refugees have
universal access to a
basic set of health and
social services
https://www.projectworthmore.org/tun-lin-
bus-passes-for-refugees

Dr. Ann Settgast, Internist

Domestic Practices
• A world where refugees
are empowered
o We leverage technology
and social media more
effectively
o Cell phones for new
arrivals
o Portable health records
are the norm

Domestic Practices
• A world where our staff
reflects the communities
we serve
o Identify and mentor
refugees in health careers
early
o Support International
Medical Graduates

Dr. Anteneh Zewde, graduating resident

Domestic Practices
• A world where we
listen more – really
listen – to the voices
of refugees
“To understand the
other as other”
Riche: 15th century
explorer to China

Refugees telling their stories

If We Knew Their Stories…
Documentary filmmaker
Chris Newberry
http://www.medicineboxproject.org/

Domestic Practices
• A world where community
based services are the
norm, not the exception
o Community Health
Workers

Domestic Practices
• A world where “use of
family and friends to
interpret” occurs < 1% of
the time
o In person
o Telephone in every room
o Video interpreting

Shashi Dahal, RN

Domestic Practices
• A world where health
disparities report cards
using granular
demography are routine
(and money flows where it
is needed most)
HealthPartners
Disparities Report Card

Domestic Practices
• A world where
electronic
health records
are used more
effectively
o Smart
sets/check lists

Domestic Practices
o Pop up reminders
(“Global Health
Wizard”)
o Registries (ie
tracking of hepatitis
B carriers
“This patient is from a
country where Hepatitis B
prevalence rates exceed
2%.CDC recommends
screening such patients for
Hepatitis B”

Domestic Practices
• A world where incentives
are aligned:
o Providers aren’t
discouraged financially
from caring for refugees
o Refugees are paid to
complete basic preventive
services

Domestic Practices
• A world where we learn
more quickly – where
feedback loops between
international and domestic
refugee health are fast
and bidirectional
o (Providers- that means we
need to publish more)

Leveraging big data in global health
Kamran Khan, MD,MPH
University of Toronto
• www.bluedot.global
• A social benefit
corporation launched in
2014

Imagining Our Future…..
Take the long view, and be hopeful
o Smallpox eradicated 1980 (work
started in 1967)
o 1986 Carter Center sets goal to
eradicate Guinea worm
(3.5 million cases worldwide)
o This year to date: only two confirmed
cases
“I just want to get rid of the last case of
Guinea worm during my lifetime, that's what I
want to do.
Well, with the number of cases this year,
it's looking very good.
It does look good so far”
NPR June 3, 2016

Imagining Our Future…..
maybe it is not rocket science
Transforming how we think:
“It's not a technical issue, at least not to me.
There are so many amazing ways in which
the risks of epidemics can be minimized with
innovative technologies, but ultimately I think
we need to radically transform the way we
think about pandemics and contagion.
They're less about invasions of foreign
microbes and much more about the way
we live and our shared social
responsibilities”.
Author Sonia Shah
Future of Public Health
Johns Hopkins Bloomberg School of Public health
June 9, 2016

The future is in great hands
New York Times June 3, 2016
‘Symbol of Hope’: Refugee Team Named for
Rio Olympics

The future is in great hands
New York Times June 3, 2016
“You’re an athlete; you don’t
think like you’re Syrian or
from London or from
Germany,” Mardini, 17, said
in a video produced by the
I.O.C. “You will just think
about your race. You have
your lane, your swimming
cap, your swimming lesson.
That’s it.”

My final thoughts…
• Listen more
• Learn more
• Advocate more
• Change the system
more

Thank you…Mahad sanid….. Galatome….Krop khun
kha…..Gracias…..Ameseginale
Special thanks to….
My patients
My parents
My family
My colleagues

Patricia Walker_NARCH Keynote_June 2016

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