Overview of Refugee Resettlement and the Massachusetts Refugee Health Assessment Program

1. Overview of Refugee Resettlementand the Massachusetts Refugee Health Assessment Program Paul Geltman, MD, MPH Medical Director Refugee and Immigrant Health Program Department of Public Health

2. Immigration Legal Status Refugee Status: • Refugee: any person who “...owing to well-founded fear of being persecuted…, is outside the country of his nationality and is unable or... unwilling... to avail himself of the protection of that country… or return to it.”* • Similarly defined by the U.S. government, based on likelihood of future repatriation; includes other groups such as asylees; reflects U.S. foreign policy *U.N. Convention Relating to the Status of Refugees, 1951

3. Immigration Legal Status 2 • Other categories: • “Documented” Residents: residents with legal visas of various categories; • Legal Permanent Resident = “Green Card” • Most refugees will apply after 1 year in U.S. • “Undocumented” Residents: without proper legal authorization to be residing in the U.S. • Applicants for political asylum can be both: 13,000 cases pending in Massachusetts

4. Immigration Legal Status 3 • Why is legal status so important? • Federal welfare and immigration legislation of 1996 limited access to public benefits and programs, including Medicaid, Food Stamps, and SSI for most immigrant classes • Refugees and asylees are exempt from most exclusions from 5-7 years • Climate of fear; “public charge” issue

5. Refugee Resettlement • Services contracted out by US Dept. of State • Administered by Voluntary Agencies: “VOLAGs” • International Rescue Committee • International Institute of Boston (Lowell/Lawr/NH) • Catholic Charities • Jewish Family and Children’s Services (HAIS) • Lutheran Social Services • Unaccompanied Refugee Minors Program • Entails package of benefits and public supports: • Refugee Cash and Medical Assistance; retain eligibility for many public programs for 5-7 years • Funding to states through single agency: Mass. ORI

6. Refugee Admissions Ceilings for FY 2000

7. Refugee Admissions Ceilings for FY 2006 Total = 70,000

8. Health Screening of Refugees

9. Overseas Screening • To determine if applicant for permanent visa has: • Excludable medical condition (Class A) • Serious physical/mental disorder (Class B) • Often done by International Organization for Migration or “panel physicians” contracted by local consulates/DOS • Includes basic H&P, blood testing for syphilis and HIV, and TB assessment (CXR or PPD) • In general, limited or no testing of children under age 15 years

10. Communicable Diseases ofPublic Health Significance (Class A) • Infectious TB: CXR • HIV: ELISA • STDs: RPR and exam. • Hansen’s Disease: Exam.

12. Limitations of Overseas Exam • Purpose is to screen for and exclude infectious diseases (STDs) and infectious TB: • active (sputum negative) disease cleared for travel • Exam valid for one year • Quality/procedures variable

13. Domestic Health Screening • Varies from state to state • Federal Office of Refugee Resettlement working with CDC to establish better national clinical guidelines

14. Refugee Health Assessment Program Department of Public Health Purpose: • To control communicable diseases among refugees and newly arrived immigrants, and • To improve the general health status of refugee and immigrant populations …thereby eliminating barriers to successful resettlement caused by health problems Screening, treatment, and follow-up

15. The Laws and Regulations • Immigration and Nationality Act, amended by Refugee Act of 1980 (PL 101-649), INA §412, b. • 4.B: Overseas health screening • 4.C: Notification of State/local health officials (MDPH) • 4.D: Monitoring to ensure receipt of appropriate and timely treatment • 45 CFR IV §400.107: a) As part of its refugee medical assistance program, a State may provide a medical screening to a refugee… • Also created Refugee Cash and Medical Assistance funding streams

16. More Laws! • MGL: Part I, Title XVI, Ch. 111, Sec. 5: The Department [of Public Health] shall take cognizance of the interests of life, health, comfort and convenience among the citizens of the commonwealth… • Numerous others relating to communicable disease control and prevention • Refugee health traditionally was part of the quarantine (police) functions of public health agencies • Role of Department in surveillance: 105 CMR §300.190

17. RHAP History • 1987: MDPH issued formal recommendations for refugee health screening • No county or local public health clinics in Massachusetts, so… • “Go see the doctor down the block and ask him/her to do your health screening and fill out this form…” • Reimbursed by Medicaid (when available)

18. More RHAP History • 1995: U.S. Office of Refugee Resettlement approved plan for MDPH to establish a unique competitive procurement process to develop a network of private clinics, mostly federally qualified community health centers. • These clinics would be specially qualified for screening refugees: a “preferred provider network” called the Refugee Health Assessment Program.

19. Refugee Medical Assistance • Federal funding stream that pays for short-term Medicaid for refugees who would not otherwise be eligible • Carve-out funds to MDPH for administering and reimbursing providers for health screening done shortly after arrival in U.S. • Other states may rely on Medicaid reimbursement directly to providers for health screening services

20. RHAP Financial and Administration Structure • Central office at State Laboratory Institute, Bureau of Communicable Disease Control • Regional offices at SLI, Tewksbury State Hospital and Northampton Regional Health Office • ~2 dozen bicultural/bilingual outreach educator staff • Funds from state but mostly federal sources: • RMA (ORR), HRSA, CDC (TB, other) • Use competitive bidding and procurement system to award contracts to “qualified” clinics

21. Benefits of RHAP Structure • Less dependent on funding for public health infrastructure (cuts in recent years) • Many county/local PH clinics are nursing clinics • Integrates variety of available funding streams • Consolidates screening at fewer sites to enhance provider knowledge and expertise in communities in which refugees live • Facilitates program evaluation and monitoring for changing health needs of refugees • Enhances knowledge of refugee health (7 papers)

22. RHAP Protocol • 2 visits, 4 weeks apart • Testing: • Core tests • Targeted (supplemental) tests • Health education • Immunizations: 2 doses possible • Referrals for primary care and follow-up of urgent medical conditions

23. RHAP Clinical Content: • Blood testing: • Hepatitis B virus (HBsAg and Anti-HBs Ab) • Varicella (Chickenpox) (> 7 years of age) • Blood counts for anemia and eosinophilia • Vitamin D level • Blood lead level (< 7 years of age) • Tuberculosis skin testing • Stool testing for parasites, incl. FlAb for Giardia • Urinalysis screen (for glucosuria, Diabetes) • Other targeted testing (ID, EKG, Gluc, TSH, HCG) • Physical exam with assessment of oral health, development, growth, nutrition, vision, hearing, BP, and oral health • Immunization

24. Kakuma Refugee Camp c. 2000

25. LOTS of kids live in refugee camps! 35,000 at Kakuma, 75% of the camp’s population!

28. Growth and Nutritional Issues • Anemia: Iron Deficiency and Other Micronutrient Deficiencies • Acute and Chronic Malnutrition • Iron Deficiency Is Proven To Be a Precursor of Lead Poisoning • MGL: Part I, Title XVI, Ch. 111, Sec. 190-194 created and delineated powers of the MCLPPP • 105 CMR §400.107 requires reporting of lead testing results to MDPH.

30. Infectious Disease Prevention and Control: • Tuberculosis • Parasites • Hepatitis B • Eosinophilia

33. Parasites • Intestinal parasites are associated with: • ANEMIA (low blood counts) • POOR GROWTH • DIARRHEA • STOMACH ACHE • POOR APPETITE • OTHER COMPLICATIONS • Other increasingly common parasites: • Malaria, Schistosomiasis, Strongyloidiasis, etc… • Empiric pre-departure treatment for malaria and helminths

37. Mental Health • >90% of recent refugees experienced major psychological stress or trauma • Not currently feasible or effective to conduct mental health assessment during the RHAP • Difficult to ensure receipt of on-going mental health care • Asymptomatic refugees are not likely to accept psychological interventions • Difficult to predict which refugees should receive care (i.e.: resiliency) • Mental health issues might impact on public health outreach activities • BUT: might be phasing in screening over next year…