By Catherine Castillo
If you didn’t catch my first post, my name is Catherine Castillo Castro and I am a rising senior. This summer, I am interning at the Wake County Tuberculosis Program in Raleigh, North Carolina (and also the Duke Division of Infectious Disease). Last time, I summarized the current tuberculosis situation in NC and the USA. I mentioned that while TB is relatively uncommon in the US, there are certain high-risk groups of people where the incidence of TB is concentrated. One of these groups, “foreign-born individuals”, includes refugees.
The health department for Wake County runs a communicable disease clinic that covers TB control, immunizations, travel medicine, and refugee health operations. Last week, I observed the Refugee Liaison Nurse administer a refugee health screening for a family of 5. This screening is required after arrival to the US. When refugees arrive in the country, they are first received by a resettlement agency, which contacts the local health department and schedules them for an appointment.
The purpose of this health assessment is to ensure that any communicable disease of public health concern is promptly identified and treated before they can spread to others, and to ensure that any health problems that could impair the refugee’s capacity to find employment and independence are promptly identified and treated while the person is still eligible for Refugee Medical Assistance. Additionally, at this screening refugee families get updated on all the necessary immunizations that are required in the US. While living in North Carolina, I had not previously been aware of the many refugee populations that resettle into this state, nor did I really know what defines a refugee according to policy: "Refugees are people who have fled persecution their own country to find refuge in another country” “.
In the Wake County area, there are refugees from Burma, Vietnam, Somalia, and Iraq, to my knowledge, and probably other countries as well. I am not aware of the number of refugees in this particular area. There are millions of refugees worldwide. Most seek refuge in neighboring countries of asylum, and a small percentage come to the US. To be admitted, a refugee (who is most likely already living in another country of asylum) applies for entry into the US as a refugee and the US State Department must establish that there is a serious threat of persecution based on religion, race, ethnicity, or political affiliation if that person were to stay or return home. This is considered a special type of immigration and the length of the process varies depending on each political situation as well as the total number of refugees which Congress has established for admission to the US per country of origin. Before a refugee enters the US, they undergo an overseas health exam (administered by the International Organization for Migration and overseen by the CDC) to screen for certain health conditions which by law would not allow people to enter the country unless they obtain a waiver and assurance of follow-up care in the US, or if they receive treatment according to established regulations. These conditions include: active, contagious tuberculosis, chancroid, gonorrhea, granuloma inguinale, lymphogranuloma, syphilis, infectious Hansen’s disease, mental illness with violent behavior, and drug addiction. Until 2009, this list also included HIV infection.
There are also some other conditions which the medical exam screens for, but they only require an assessment to determine if follow-up care is needed after arrival to the US. So what about refugee health in the US? Well, from what I observed last week at the refugee health screening, even this one visit is a complicated and tricky process. Foreign medical records have to be analyzed to get the best idea of a person’s immunization and other medical history for every patient, many questions are asked about symptoms, and many shots are administered, especially to children, depending on how many they previously had received in their country of origin which satisfy the US requirements. In this family’s case, each child received 7 vaccines. In one day! That is a lot of shots! Also, depending on the country of origin, patients may have to return to get a TB skin test read or with a series of stool samples which are used to diagnose parasitic infections such as worms. And yet in addition to all of this lengthy process, there are other obstacles in the process. Before a person even gets to the health screening, it might be difficult to get the resettlement agencies to promptly schedule the appointment, and as of now, there are too many people who need to be seen so the next available appointment is not until August. Then, it might be difficult for a family to get transportation to the clinic for their screening.
If they miss their appointment, they are rescheduled for the next available time slot (August!). Once they get to the clinic, there may be a tremendous language barrier as many refugees are not fluent in English. This problem is partially solved by interpreting services which can be obtained over the phone, but this is an expensive service which the county limits the use of and is still not optimal for a healthcare setting. In some cases, an interpreter comes along with a family, but they are not always trained for the role and much can get lost in translation and assumptions. Once they have been seen, it may be difficult for a family to return to have tests read or to submit stool samples, and if they are diagnosed with something they may have trouble obtaining and completing treatments.
One of the larger problems it seems is the current staffing for the Refugee Health program. Like I mentioned, the clinic is completely booked for appointments for months. There is only one nurse in charge of all the paperwork and examinations for all of the families. Additionally, this nurse is supposedly doing this job and is only funded for it half-time, however, it requires her efforts full-time PLUS the aid of another nurse who is only supposed to work in immunizations. How the county is making these funding and staffing decisions is a question worth looking into after observing the frustrations and potential lack of effectiveness which result from these problems.
