Journal of Refugee & Global Health

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In this University of Louisville Grand Rounds lecture, Drs. Rahel Bosson and Ruth Carrico give an overview of the real struggle of the refugee population and provide an update of the current state of refugee health in Kentucky.

They also provide an overview of the Global Health Initiative at University of Louisville, which includes the follow programs: HIV/AIDs, Refugee Health and Immunization, Vaccine and International Travel and Global Health Research Support.

The talk concludes looking to the future with a comprehensive Global Health Center composed of improving refugee orientation and EMR, healthcare worker education, developing guidelines, and bettering our surveillance and epidemiology surrounding global health populations.


The author(s) received no specific funding for this work.

Body Text

UofL Dept. of Medicine Grand Rounds: Drs. Rahel Bosson & Ruth Carrico

Published on May 14, 2015

Rahel S. Bosson, M.D., Assistant Professor of Medicine and Director, Refugee Health Program, and Ruth L. Carrico, Ph.D., RN, FSHEA, CIC, Associate Professor of Medicine at The University of Louisville presented "University of Louisville Center of Excellence in Refugee Health" at University of Louisville Department of Medicine Grand Rounds on May 14, 2015. The talk will focus on reviewing the state of health of refugees resettling in the Louisville community, describing the activities currently in place to address the health issues and challenges posed by the diverse refugee community, and the activities planned for the future as part of a Refugee Health Center of Excellence at the University of Louisville. Presented by the UofL Division of Infectious Diseases.

DR. ROMAN: Welcome to the Department of Medicine Grand Rounds. I want to remind everybody that you should have received this at the front desk. It’s a survey that asks you for information and comments and opinions about our internal medicine residency training program. This is crucial. We need to understand what our faculty feels about our training program and how we can get it better, so please fill this out. Number two, I want to remind everybody that this weekend is the Louisville Symposium on Heart Disease and Women. Louisville Symposium on Heart Disease and Women. I don’t know if Lorrel’s here? Dr. Laura? And this is gonna be at the Jewish Hospital Rudd Heart and Lung Center. I will let them know that they don’t have a Lung Center … but it’s on the sixteenth floor on Abraham Flexner Way, okay? So please attend to this; this is gonna be really exciting.

On this day in, back in 1796, was the first time that Edward Jenner administered a vaccine for smallpox in an eight-year-old boy. Within two years he had injected twenty-three people, and he actually recorded that in a publication, and pretty soon Europe and America started vaccinating patients. On this day in 1857 was the birth of Williamina P. Fleming. Now I betcha you don’t know who Williamina P. Fleming was. We probably would have not known about her, not because we’re not interested in astrology - you might be, or astronomy - but because she was a woman and almost didn’t make it. Let me explain: when Williamina Paton Stevens Fleming was a Scottish-American astronomer who pioneered the classification of stellar spectra, and the first to discover stars called white dwarves. She was recruited after she immigrated to Boston at age 21, by Professor Pickering - not recruited to do science; she was asked to work as a maid at the Harvard Observatory. And in 1881, she was asked to be a secretary, and somebody noticed that she was pretty good with math, and did some calculations, and at some point said, “Why don’t you help us out?” Remember that these days we do this with computers; in those days, they couldn’t do that. So, she started doing that and she devised her own system of classifying stars based on their spectra, and within nine years she catalogued over 10,000 stars and she was put in charge of a whole set, dozens of women, just doing small calculations that today are done by computers, to be able to classify stars and so forth, based on their spectra - Williamina P. Fleming.

On this day in 1900, the Yellow Fever Commission was established in Cuba. Okay, remember, this is just one year after the Spanish-American War. Soldiers were in Cuba realizing they were dying all over the place from yellow fever, and they established a Yellow Fever Commission to identify that.

And with that - that’s an infectious disease - I leave you with the head of Infectious Diseases who’s going to introduce our speakers of the day. One final thing, one final thing - Julio, come up here, but one final thing - this institution is proud, and I am proud, too, that we provide services to international students; that we have people who are interested in visiting Peru, and Ghana, and Haiti to do global health, and what you’re gonna hear today is that you can do global health at home. There are many people in this town who have as many needs, who are isolated, who are sick, who don’t have health care. And it’s very nice to spend two or three weeks in Peru. But it’s much more difficult to stick around and do what is needed for the people around you. Think about it.

DR. JULIO RAMIREZ: Well, this is perfect, because this was supposed to be my introduction of the topic! [laughter] And this figure here, because this figure is not any foreign country, this is all happening in Louisville, and as Dr. Roman mentioned that this is global health, local. Then today, the presentations will have two sections. In one section Rahel Bosson, that is a graduate here from the Department of Medicine, that joined the Division of Infectious Diseases, is going to give you an overview of what it means to be a refugee, and what are the programs here in Louisville, and then Ruth Carrico, the associate professor who is also Assistant Director of our global health initiative, is going to give us an overview of what is it we are doing with our refugee health and administration program, in the department, what is it we are doing now and what is it we are planning to do in the future, and then I leave you with Rahel.

DR. RAHEL BOSSON: So, thank you for giving us this opportunity to talk to you about some of the exciting things happening at the University of Louisville in terms of refugee, in terms of being a center for excellence in refugee health. So our objectives are, like Dr. Ramirez said, I’ll give you a quick background and overview of who the refugees are, where do they come from, and what is their process of getting to the United States? And then I’ll talk more specifically about the refugees coming to Kentucky, and their state of health. And then Ruth will tell you about some of the current activities we’re doing as part of the Global Health Initiative, and then she will finally talk to you about the vision of moving towards the Global Health Center.

So none of us have any disclosures to report.

So … sorry about that, I don’t know how that happened [removes stray text from slide].

So let me first begin my case by introducing you to Maria. Maria is a refugee that I recently saw a few months ago in my clinic. She’s a 50-year-old Cuban refugee that recently immigrated here. She’s an insulin-dependent diabetic, she has hypertension, hyperlipidemia, she has a palpable breast mass and a history of breast cancer, she’s got chronic back pain, she’s on multiple medications but she hasn’t brought any of her medications from overseas and she doesn’t really know all of the medications she’s taking. The ones that she does not are not FDA-approved, but she also is taking some herbal remedies. Maria also cannot sleep at night, she’s anxious, she’s depressed, she’s overwhelmed and tearful, she’s on some antidepressant she doesn’t know of, and she’s separated from all her family in her home country. Maria doesn’t have a job, she doesn’t understand the U.S. healthcare system, her insurance is pending, she does not speak English, she has a special needs child, no childcare, she doesn’t even know services that are available to help her. She has no personal transportation and she can’t really navigate the public transportation herself. So here’s Maria. Now, she now comes to you as a new patient, but you can’t even access her recent visit to the U of L ER because her name or date of birth have been entered differently in the system. So with this, I welcome you to the world of refugee health care. [audience murmurs]

So, to give you a little background on refugees … So, who’s a refugee? The definition of refugee was established back around 1950 in the aftermath of World War II. The United Nations assembled together and they formed the United Nations High Commissioner for Refugees, and in that assembly they adopted the definition of a refugee. It’s been adapted since then, but as it stands now today, according to the UNHCR, a refugee is “any person, owing to a well-founded fear of being persecuted for reasons of race, religion, nationality, or being a membership of any particular social group or political opinion, is outside the country of their nationality, are unable to return to that country due to the fears of being persecuted.” There’s about fifteen million refugees as it stands today in the world, and there’s about 33 million internally displaced people. The picture that you see here is a photo taken by the UNHCR of Kosovo refugees fleeing their homeland back in March of 1999. [indicates PowerPoint slide]

So the refugee process goes something like this: There’s violence, some kind of persecution; and then there’s a flight, a move away from that country to settle into refugee camps in a secondary country. And in these refugee camps, refugees have really no rights at all - they’re not able to leave the compound or the camp, and they can live here for decades. I have seen patients in our clinic that have been in refugee camps for over sixty years, they’ve had their children born there and are now in their 20s, and they don’t even know the land that their family left because of the persecution.

Once you’re in the refugee camp, you then apply to the UNHCR, and this is the only governing body that can mandate international refugee status. And only less than 1% of people that apply to the UNHCR actually are able to be resettled to a third country … such as the United States, Canada, Australia, and other European countries.

Now in the United States, the refugees that have been allocated to come to the U.S. then go through what we call Voluntary Agencies, or VOLAGs. These are nonprofit, private agencies that have partnerships with the federal government to resettle refugees that come to the United States. And these VOLAGs have partnerships with local resettlement agencies, and in Louisville, our local resettlement agencies are called Kentucky Refugee Ministries and Catholic Charities.

So as it stands today, the largest source of refugees is Syria. For over thirty-three years, Afghanistan used to hold the largest source of refugees. But as it stands today, right now there’s about 2.8 million Syrians that are refugees in neighboring countries like Jordan, Egypt, Iraq, and Lebanon, and there’s about 6.5 million internally displaced Syrians right now. Other countries with the largest source of refugees include Afghanistan, Somalia, Sudan, and the Democratic Republic of Congo. And in this statistic Cubans are not considered as refugees, because Cubans actually come through a different route. They either cross on boats and come to the United States, or they go through all over Latin America and then walk and cross into the border. The United State has established a program, called the Cuban/Haitian Entrant Program, back in 1980 that allows for resettlement services to be provided for Cubans once they come to the U.S. And so this [chart] does not include them.

So in the United States, the five states with the largest refugee population include Texas, California, New York, Michigan, and Florida. Kentucky is really the 14th largest in the nation among receiving new refugees, but if you look at it among rural states, Kentucky actually has the largest number of refugees. Back in 2014, we had about 2500 refugees arrive into Kentucky, and in the next fiscal year of 2015, the projection is that we’ll have about 3100 refugees coming to Kentucky. And the reason why we’re seeing so many refugees coming to our state is because the whole premise of the resettlement program is based on self-sufficiency and having jobs, and Kentucky has a lot of factories that these refugees can come and start working as soon as they arrive, and because they don’t require a lot of language skills or cultural acculturation, Kentucky becomes a very popular state to resettle newly-arriving refugees.

So before departure, all refugees receive cultural orientation, and all refugees receive an overseas medical exam, and this overseas medical exam is conducted by a panel of physicians that work with the International Organization for Migration, along with the CDC. And the purpose of these overseas medical exams is really to identify Class A and Class B conditions. Now Class A conditions are conditions that are considered inadmissible into the United States. These are diseases of public health significance, such as active tuberculosis, Hansen’s Disease, untreated syphilis; and then Class B conditions are conditions that will allow you to come into the United States but require close follow-up soon after arrival, and those conditions are things like diabetes, hypertension, malignancy, and any other conditions. Also, depending on which country the refugees are departing from, they receive presumptive treatments for parasites, as well as immunizations. So once all of that is cleared, then travel arrangements are made by the Department of Homeland Security.

So all refugees, once they enter into the United States, go into quarantine at the first port of entry. And at each point of entry, there is a CDC quarantine officer who actually clears them for the next flight. And there’s about twenty U.S. port of entries that have quarantine stations, including New York, San Francisco, Miami, and Chicago. Once they’re cleared, then they’re able to go to their final destination state.

So in Kentucky, Kentucky is actually considered a “Wilson Fish” state, which means that the state government has actually opted out of the resettlement process of refugees, and that process is actually now run by a nonprofit organization called Catholic Charities, and under that nonprofit organization, you have the Kentucky Office of Refugees, who gets all their federal money and allocates some to local resettlement agencies. And the three local resettlement agencies that we have here in Kentucky is the Kentucky Refugee Ministries, located in Louisville and Lexington; we also have the Migration and Refugee Services, a part of Catholic Charities, located in Louisville; and then in Bowling Green and Owensboro, we have the International Center.

So these resettlement agencies are basically designated by the U.S. government to provide direct resettlement services. So this really begins before arrival - they set up their apartment, they furnish the apartment, and then they pick them up, because as you can imagine, refugees basically come with nothing, maybe just a bag of belongings. [indicates PowerPoint] So - and this is really a picture that depicts a case worker orienting the refugees on how to use a stove and an oven, because some of them have lived in these camps for thirty years, and don’t really know even how to use something as basic as this. Other resettlement services provided include, like mental health services, ESL classes, and employment assistance as well.

And so all refugees are eligible for all social programs that a U.S. citizen is eligible for. They’re also eligible to work as soon as they arrive. Because the premise of the whole resettlement program is self-sufficiency, some refugees start working within three months after they have arrived here, at some of these factories here in Kentucky. And this program is really provided for them for eight months, and the idea is that after eight months, these refugees are expected to have spoken the language, learned the culture, had a job and be completely self-sufficient and independent on their own, and you can realize how difficult this is to navigate that system. The refugees are also placed on track for citizenship, and one interesting fact is that all refugees have to pay back the cost of their plane ticket, so after six months of arrival, they start getting a bill from the Department of Homeland Security, asking them to pay back the cost of their plane ticket.

So, as part of the resettlement services, all refugees are eligible for a general health assessment within the first ninety days of arrival, and there are six health clinics that provide this initial assessment here in Kentucky - the University of Louisville is part of the Global Health Initiative; Shawnee Christian Health Center; the Family Centers Americana; Home of the Innocents, which is mainly pediatrics; and then the Bluegrass Community Health Center, located in Lexington; and then Green River District Health Department, located in Owensboro. So, this health assessment is really a comprehensive health exam that is based on guidelines provided by the CDC and these exams include, like reviews of overseas medical records, testing for communicable diseases and parasites, evaluation of immunization records and referral to the U of L Health vaccine clinic, as well as screening for mental health issues and referrals to any sub-specialties as needed. And so this initial assessment really serves as a bridge for the refugees until they’re able to plug into primary care.

So, what is then the state of health of the refugees that are coming into Kentucky? So back around 2011, the University of Louisville entered into a partnership with the Kentucky Office of Refugees and the CDC to develop a Refugee Health Surveillance database. And the purpose of this database was really to strengthen surveillance for diseases among newly-arrived immigrants and refugees. And this database basically captures data from all the domestic health screenings that were done throughout the different resettlement sites across Kentucky. And what resulted from this database was the semi-annual comprehensive report entitled “The State of Refugee Health in Kentucky.” So I’m gonna give you a little excerpt from that report:

So in 2014, there’s a total of about 2100 adult and pediatric refugees that were screened in Kentucky. And among the top countries that came to Kentucky last year included Cubans, followed by people from Iraq, Burma/Myanmar, Somalia, Bhutan, Democratic Republic of Congo, and Afghanistan. These were really the top seven nations that were actually resettled in Kentucky last year.

About 51% of them were married, and about 40% of them were single. The most common language spoken was Spanish, followed by Arabic, Somali, Nepali, Karen. And in terms of age group, our largest number of refugees were less than 18 years of age, followed by 25 to 34 years of age.

In terms of top health conditions across all refugees, among their top ten included dental abnormalities - those are cavities, abscesses, tooth decay - along with TB exposure, hypertension, anemia, mental health issues, and hyperlipidemia. If you look at refugees per population, Cubans had, among their top ten health conditions included hypertension, hyperlipidemia, tobacco abuse, and obesity; whereas if you look at the Bhutanese, among their top ten was TB exposure, anemia, myalgias, hearing loss and depression. And the reason why I gave these two different refugee populations as an example is to really show that our refugee health concerns are not the same across the board, but that there really has to be a population-specific approach when dealing with refugee health.

In terms of cardiovascular risk factors, about 53% of the refugees that came in last year were considered to be obese or overweight. And about 46% had low HDL levels, and about 13% had high cholesterol.

So we use a quantiferon gold to screen for tuberculosis, and about 15% of our refugees who came in last year screened positive. And if they screen positive, then we refer them to the health department to get a chest X-ray and treatment for latent tuberculosis. In terms of parasites, there’s about 20 percent that screen positive for parasites, and some of the most common parasites that we found are blastocystis hominis, giardia, and endolimax nana.

About 50% of our refugees were unvaccinated to Hepatitis B and really susceptible to the disease; 34% were immune due to vaccinations, and 12% were immune due to natural infection. And 2% had Hepatitis C.In terms of HIV, 1% of refugees were newly diagnosed with HIV at arrival, and about 2% were found to have syphilis.

In terms of mental health, we use what’s called the Refugee Health Screener-15 - it’s a mental health screening tool that was developed for the refugee population and it’s supposed to screen for depression, anxiety, and post-traumatic stress syndrome. And from this, we find that Afghanistan screened the most, as screened positive 44%, followed by the people from Iraq at 39% and Democratic Republic of Congo.

We also used the experience of torture and the witness of torture as possible risk factors to developing mental health issues in the future, and you can see that the Iraqis experience the most torture, followed by the Congolese and Afghanis. But then in terms of witnessing torture, the Congolese witness the most torture, followed by the Iraqis and then the Somalis.

So you can see that refugee health is complex. And really, health is really more than just the absence of disease, but rather, it’s the elegant cohesion of the physical, the spiritual, the social, and the psychological aspects of a person working together to optimal wellness. And so for this reason, we have to have a unique approach in addressing all the varied components of a person’s health. And this unique approach, we’re calling it the Transformational Model of Refugee Health, and at the center of this model is the patient. And the idea is that in order to have a sustainable solution to address all the components of a person’s health, and transform them from a state of dependence to independence, we have to have a multilateral and interdisciplinary approach, and we have to be able to form partnerships with communities that are stakeholders for the refugees, as well as partnerships across the disciplines and prescience in the university, across both campuses, including the Belknap campus and the Health Sciences Center. And the component of this - there’s four components to this model. The first is Community Health, and the idea is that people don’t exist in a vacuum, and especially refugees are very communal, and so, and the community can also serve as an eye for us to identify gaps in health care that there are in their communities. So this will look at partnerships with people and churches, as well as partnerships with nonprofit organizations, and partnerships with, like the School of Public Health, as well as the School of Nursing.

The second component is Education. Unless you learn, you cannot grow and develop to become good stewards of your health. And so this is where you have partnerships with the School of Education and partnerships with the School of Arts and Sciences.

The third idea is Social Services. This is really identifying resources in the community and government programs that can help refugees as a stepping stone toward success, and this is where we can partner with the Kent School of Social Work, as well as partnershipping with the School of Law.

And then the fourth component is Economic Empowerment. Unless you break the chain of poverty, then these refugees are only leaving one kind of prison to enter into a new kind of prison, and the idea is to help these refugees move from a platform of, move from really a mode of survival to a platform where they can thrive and succeed, and unless we do that, it will be very difficult for us to help them address their health care issues. So this will be where you can see partnerships with the School of Business, and Economics, and as Ruth comes to talk, she will show you how the things that we’re doing currently and the things we plan to do in the future, all are activities that fall under one or more components of this model.

DR. RUTH CARRICO: Well that was a great overview to talk about the complexities that are involved in refugee care, so what I want to do now is focus a bit on what we are doing with refugee health as part of this Global Health Initiative. So, if we look at the total picture for the Global Health Initiative, it includes those activities that represent international diseases and international intervention opportunities. So the HIV program, we know, has long been here and has really been the platform, the foundation, of our international focus, along with tuberculosis and the other infectious diseases that represent challenges internationally. We have the Refugee Health and Immunization Program that we’re talking about today. In addition, the vaccine at International Health and Travel Program, and then the Global Health Research platform that really is integrated throughout every activity that we do. So we’ll continue and just focus on just the Refugee Health component, but I think as we go through, you’ll be able to clearly see how interrelated these activities are, both in terms of the activities that we have, but even more importantly, the opportunities that really cross all of our specialties in the Health Sciences Center and then into not only the Belknap campus, but also our Center for Predictive Medicine.

So I’m going to focus on six main areas of activity that we have right now within the Refugee Health and Immunization program. These involve surveillance and epidemiology, so we understand the population. Secondly, it's looking at and then, as Rahel talked about this Transformational Model, this approach on, how do we actually get to the community and give some additional depth to programs that place the refugee at the center of the activities so that, instead of providing health care TO them, it is the performance of services WITH them. And then what does this mean, then, for health care professionals? As we try to educate, better educate ourselves, what do we need to do, what do we need to know, what needs to be embedded in our curriculum, as well as in our training and education programs, so that we can do this more effectively and increase in our capacity. And of course, everything we do has to be based on the evidence, so how does our interaction then better inform the evidence so it then can better inform our training programs and our refugee activities. We also know the importance of having a refugee health record so we can actually pull up the information that we are making available and then make that relevant and accessible. And then the Civil Surgeon program as Rahel mentioned - how do we make sure, then, that we enable people to move towards citizenship more effectively.

So I want to go through each one of these and kind of give you the current state, and then we’ll talk about the future.

So our current state for the epidemiology for, in surveillance, that at present we’re providing the domestic health screens for about 30% of newly-arriving adults in Louisville. Now, not too many months ago, this was 0%. Now we’re growing very, very quickly and are the second-largest site for the performance of these activities, and I think that it probably won’t be too long until we will be the largest site. We also, then, are recognizing the needs that exist in the other resettlement areas in Kentucky with respect to health care providers, and knowledge about refugees, so we are beginning to provide them then with support through the use of methods like telehealth and offering them what skills and capabilities we have to enable them to perform these exams as well. We at present provide immunization, then, for 90% of all the newly-arriving refugees in the Louisville area. This is greater, a larger percent, than any other resettlement site. We also then found that we were having issues with children - the fact that we could not get children in to be seen by primary care, by the pediatrician, simply because of the length of time it takes to get them enrolled in Medicaid and provide a card for them. Well, as Rahel mentioned, self-sufficiency is the watchword, and so if children can’t go to school, parents can’t go to work and the whole self-sufficiency process falls apart. So we provide, then, immunizations and school physicals, and then that has enabled us to gain some additional information through the surveillance portion that occurs in this and better understanding, then, not only the pediatric population but the family dynamics that are present with the children and their adults. And then all of this continues to be used to better inform, then, the state of refugee health and so this document that just shows where people come from through the arrival process, the many stops they make, and it continues to reinforce that we are truly a small world, getting smaller, and that we have to embrace that idea that we are our brother’s keeper, and that we will then be addressing those health issues when they come, and that they impact us socially, economically, spiritually and in every other method.

The second activity is looking at how we provide a better, or best, orientation process for the refugees, because they do have information from the resettlement agencies, but you know, the caseworkers and the staff at the resettlement agencies, you know, their sphere of activity is a mile wide and an inch thick, and so there have to be connections, then, with all activities and the resources and the capacities that we have here at the University, then, to be more effective and improve, then, the ultimate outcome. So we are really focusing on how we can go to them, and how do we engage them at the point, then, where they feel safe and they feel secure, and then begin to build relationships, so this has worked very quickly as we have done this, because now we actually have refugees - we’ve kind of had a little coup going on, that we have some that are refusing to go anywhere else than here, so everybody wants to wait for Rahel to have another appointment time. They don’t want to go anywhere else because they like the type of service and that they feel safe when they’re here.

We’ve also focused on the provision of health promotion at the refugee site. So again, how do we engage them in preventing disease, instead of waiting until it occurs and then trying to fix it? And in doing this, we have learned a lot about what it means to be culturally competent, culturally relevant, and then having to understand the adjustments that occur, so that we can appropriately engage with this audience, and this really has meant that we have developed inter-professional partnerships to an extent that we never anticipated. We tend to think that our partnerships involve those on the Health Sciences Center, but truly, this care of refugees touches every single college and school within the university, and as we have met, as part of our activities with this initiative, Dr. Ramirez and I have met with every dean from every college and school to go through the activities that are ongoing, and have been met with what really has exceeded my expectation, a great deal of enthusiasm. So the train keeps getting full, and from people that want to be involved, and want to help with these initiatives. And when you look at the refugees, there is such tremendous appreciation. All of us look for that patient that really is appreciative - everybody needs a thousand things, we can do one or two. That level of appreciation and interaction with them is so incredibly positive that it really is uplifting.

All right, the next portion is, what do we need to know as a healthcare discipline, to provide care for refugees? So this really has shown us that it is important for us to think about what needs to be in the individual curricula, so we can have, then, an area of focus so no matter what your specialty is, you have the ability, then, through both immersive opportunities and case conferences and other educational opportunities, tools and resources, to learn about how, what is relevant to you, to your particular practice. So we are working to develop, then, very specific training programs for different disciplines, specifically starting with nurse practitioners because they have been so involved with us in our division and in this development, to say what needs to be as part of their training. But this is relevant to medicine as well as nursing, dentistry, public health, and pharmacy - all these are directly involved in our care of refugees. In addition, those services that we don’t think a lot about of - social services, yes, but law has been very important to us. Business has been important; languages; engineering - helping us with our processes, so new groups are making this actually happen. And it makes it happen, again, at the site of care that is not only in our clinic, but also at the resettlement agencies, so nobody’s got enough space, we’re included, and so we’re trying to optimize in wherever we can find space, so any place will do.

When we do provide these services, then we’re learning more about the differences in the refugee groups - not only their health conditions, but a little bit more depth deeper than that when we talk about some of the social and cultural aspects, so some examples: We’ve learned a lot about Cubans and reproductive health. An example - when women in Cuba, if you miss two periods, you go to the doctor for a “regulation.” So, “regulations” are very common. So, when we’re seeing the Cuban women, we have to start talking about birth control and reproductive health for women, and it’s a head-scratcher sometimes, so, but that is a way, then, that we’ve really had to, had to partner with our OB-GYN counterparts.

With the Iraqis, tremendous mental health issues. These are problems when, you know, when bombs are overhead and you have seen members of your family abducted or you’ve seen killing and torture and so forth, so a lot of mental health issues involved in this population, so we’ve had to then figure out how we’re going to address the mental health needs.

Congolese families - a lot of family dynamics when you are a woman, single head of household, and you have eight children, there is no man in the picture, he is either killed or has been abducted and now part of the army, so these women come here bringing their children and they are learning how to live in society and not a refugee camp. So that is a big enough adjustment, but still, being a mom with a whole passel full of children creates a lot of issues and quite a steep learning curve during that acculturation process.

The Somalis, a lot of TB infection, we’re struggling now with, as public health gets out of the healthcare business and more into the policy business, what’s going to happen to provide treatment for latent TB, so that we’re thinking about this in a public health perspective and you know, preventing, then, a breakdown and active disease and then transmission within our community.

And then our Bhutanese that have pretty intense metabolic and nutrition issues that need to be addressed then, and fortunately we have our endocrinology counterparts that can help us address these. This is just a handful of the problems, but the point here is that every single specialty, has involvement and has a role and has not only care opportunities, but from an academic perspective, there remain tremendous research opportunities to help us figure out how we can do a better job. And part of this, then, is making sure that we have good data - not only good data from the aggregate perspective, but as we see refugees, we have a very limited opportunity to share information. Everything that we do now with our refugees goes into REDCap, our research database - we keep everything there for the eight- or ten- or twelve-thousand refugees now that we have, so we have an opportunity to provide great aggregate data, but our problem is - what happens to the refugee as they move around? We are pretty much confined right now to Allscripts, and we know that doesn’t work for many of us, especially for the refugee where they may seek care outside a place that uses Allscripts. At the present, we’re trying to better understand why refugees access emergency department services, so we can figure out what we can do to prevent that, and then do a little bit more work in primary care and prevention. We’re working with the CDC, as Rahel mentioned, looking at surveillance and how we can look to see - where are automation opportunities? - so we can provide, then, an individual health record of some sort for the refugees.

As we mentioned, then, during that path to citizenship, we are offering the opportunity by, through the provision of the required immunization immigration exams, and immunizations that are required for green card, so we see, at least offer that service now to all refugees, so we have three USCIS-designated civil surgeons - again, we started off seeing zero, and now we see about 120 a month, and this has expanded not only to refugees but into the entire immigrant community. And this has enabled us to really begin the contact with those overseas panel physicians, so we can understand the issues the refugees encounter as they’re being assessed, before they even make it to the U.S. So then we can see that, what are the needs of these panel physicians, how then can we make our specialists available, and then begin to kind of reimagine our activities.

So currently, just as of today, we’ve provided about 22,000 doses of vaccine for the refugees. More than 800 children have been seen to provide their immunizations and school immunization certificates. More than 500 have been provided with school physicals, so they can stay in school, and that, just in a very short period of time, about a year, we’re now seeing about a thousand of the newly-arriving refugees for a domestic health screening. This has allowed us to pull some of our partnerships from Belknap campus, to help us look at efficiencies - how do we do this, and make sure that we have the time and the resources to support these activities. So our collaboration is vital as we continue this growth, because the growth really has been pretty meteoric.

All right, so, taking all this into account, we’ve gained a lot of experience about not only where we are and how we can improve where we are, but it has helped us really create a vision for the future as we think beyond a global health initiative and look more at a global health center. And you know, serendipitously, the CDC just sent out an application for a Center of Excellence in Refugee Health, so they will fund five centers across the U.S., so we are of course submitting what I think will be an extremely competitive submission. So we will hope that one of these - that we are one of those five.

One thing that we have learned is all of these activities, and if you look at this flower [indicates PowerPoint slide], that shows all of the activities that are involved in the research, service, education and outreach, in dealing with global health. We’ve got to have a good pot with a lot of fertilizer, and the fertilizer really are those services that extend beyond our current capabilities, so we have got to then rethink - and we are actively rethinking - who our partners are. And traditionally we have thought very small, and only within our neighborhood, so now we’re thinking much more broadly and recognizing that the University as a whole has a tremendous number of resources available for it - we just have to go after those.

So I want to take these same six areas, because again, as luck would have it, the CDC mentioned six areas that are almost identical to the six areas that we have identified as important for our growth: surveillance and epidemiology, refugee orientation, healthcare education, guideline development, refugee electronic health record, and then clinical consultation.

So, what we hope to do, and what we I would say hope to do, but what we will do, in the future, is that we will be working, then, to expand our current refugee surveillance network, so that it is not only addressing the issues with the refugees resettling in Kentucky, but also our partners in our border states. So we’re looking, then, much more regionally instead of just statewide. And as we do this, then, we’re using the expertise that we’re developing in our division to add the visualization components of data, so everything then is real-time, so we have much more of a “what is happening now?” instead of “what happened last year?” or even last month, so much more of a real-time reporting process using this surveillance data, so as Dr. Kelley and Dr. Wiemken have helped us then develop this larger surveillance system that takes in the overseas medical information of the initiation health screening and then vaccine, and then help us then enable others across the region to do this same thing into this existing research database, I’ll tell you a little bit about electronic health record in a moment.

For guideline development, of course, we have to look at “what is the surveillance showing us?” So helping us then develop a population-specific, so “what do we need to do specifically about Cuban women and reproductive health?” - how do we then put that into a guideline format, so it is not only available for our use, but available for others who will see the population also, and then use our surveillance findings and then make sure that it’s accessible, so putting those then in electronic and mobile formats, so being more broad in terms of our dissemination of this new knowledge.

With refugee orientation, again focusing on orientation that goes to the community level, and encouraging not only work at the, at the individual community level, but enabling, then, groups in a community to better assimilate into society. We’ve seen a number of cases, most recently some of the elderly Nepalis, who have been here for seven years, and they are allowed then seven years, they need to achieve citizenship; if they do not achieve citizenship, then they are not eligible for some of the social systems, so Medicare, specifically, so we have some 66-year-old Nepalis who have never ventured out of their own community so they have never learned the language, so they will never be able to answer those 120 questions on the citizenship exam, so they’re in a situation now where they have no family, they’re here by themselves, their seven years are up, they risk deportation. So how do we prevent this from happening and recognizing that all of these social determinants of health are important and can’t be just singularly pulled away and ignored?

So as we develop these programs, then we want to make sure, then, that they are readily available, and we know that some refugees take to technology very quickly, we know that some of the MCOs - specifically, Passport - are providing cell phones now to some of their members just to make sure that they have connections, so how can we do simple things and have an issue like Rahel mentioned - they have such trouble riding the bus. How can we make information that will be easy for them to acquire if they have a cell phone? Can we make some of those things available to them?

Also we have new opportunities on the horizon in developing relationships with the airport - the airport has been a specific anchor point that the CDC and the Office of Refugee Resettlement have asked us to consider in working with the community to say, well, what happens if we have a refugee that arrives that has a complex medical condition or develops an infectious disease that is identified during their long plane trip, and that unfortunately has happened in our area, so helping us then address these issues and then focusing again on new relationships that certainly need to be developed.

The fourth is developing health education - now this is not only to and for health care providers, but also for those voluntary agencies, or the VOLAGs - how do we then provide education kind of in both directions, both in the more sophisticated and traditional healthcare provider, and then to those agencies that need more understanding about some of these medical issues and how they may be able to place refugees a little bit differently into communities that may have specific areas of expertise. This is where that we will intend to focus efforts on some more intense curriculum development for care of refugees as part of, then, this whole thought of having residency programs dealing with global health and the full spectrum of what we’re learning, making this available through web-based opportunities as well as through training courses that are more immersive, and even looking at perhaps the development of academic credit.

The fifth is the refugee electronic health record and then how do we make sure that information that we have available is mobile, accessible, while still being able to be added to and analyzed, so when I showed them the surveillance system that we have, also we are developing the process of pulling components into a smaller subset of information that would be the refugee electronic health record that would be available for, to both the refugees and any health care provider, and that if we have additional information about them, maybe they’re, someone developed, you know, we’re monitoring their A1C, and we want to add that to this health record, then we would be able to do that, so, taking data from a post-migration surveillance process and then being able to populate the electronic health record, kinda from both ends of this perspective.

The last area is clinical consultation, and we had, Dr. Lederer was with us when we had our first group that said, how do we get people together and think about the specialties that we need to have that can help us then address the wide array of need of this population, so they helped come up with the name, KARMA, the KARMA project, where we pulled together, then, what does our medical community need to know so that we can provide better care, and this is kind of the basis for our thought, that we then can work better with our overseas panel physicians and then pull together specialists, so if we have someone who has a unique or specialty need, then how can we identify someone here that can connect with them, provide consultative approaches, and then help them with medical decision-making. This would then also enable us to add to our existing database, both our surveillance database and then ultimately the refugee electronic health record, so it pulls in the information much more quickly, and we feel like the data and the record then are much richer for that.

So kind of where we are at this point, and you may have seen this picture before, this is our concept of a Global Health Center, the idea - and as we have continued to look at this and develop this, we look at this as the first building. Building One, then the opportunity for Building Two, and maybe even a Building Three - it depends on how things go.

But Building One is where we are focusing our initial efforts and that would be an opportunity to pull all of the clinical services as well as the research services together, because we know, then that they are, as Dr. Ramirez always reminds me, everything we know is this much, everything we need to know is this much, and so how do we then address all the areas of refugee health that we do not know, and that we will only do that by again expanding the richness of the collaborative research opportunities. So if we have, then, our clinical services, the idea is to have clinical services on the first and at least second floor, perhaps some on the third floor, having research on the third floor, on the first floor having an international market. The idea from the city is to have a farmer’s market, perhaps have an international restaurant that enables then to kind of support that idea of learning about nutrition. Having a coffee area, a kind of a coffee shop where people can come, refugees can come and have access to health care providers and medical information. Other researchers on the second floor, again, more clinic space where we would have the international travel clinic, perhaps even a laboratory, third space could be research space, and then the unique approach is, you know, everything we do has to be built on a platform of sustainability, and so our approach is then with this complex to have floors four and five as residential space that provides, then, the maintenance and operation capital that would be needed to make sure that this is a place of no cost, so when you want to collaborate, you don’t have to pay to collaborate, you come together because that’s how we should be doing things.

So it’s making us rethink how we do everything, it’s made us reengineer our approaches to care, but it’s shown us the many opportunities that are available, so we would certainly welcome you, your ideas, and anybody that wants to join with us. So in our last few minutes, I’ll turn it over to questions, or Dr. Ramirez, you may have some comments, no? All right, great.





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