Immigrant, Refugee & Migrant Health Stories
CDC Promotes and Improves the Health of Refugees Every Day
June 20th marks World Refugee Day, a day in which the Centers for Disease Control and Prevention (CDC) joins with the rest of the world to honor the courage and resilience of the world’s refugees. Observing World Refugee Day (themed “With Courage, Let Us All Combine”) gives all of us a chance to reflect on the alarming notion that every 4.1 seconds a person is displaced from his or her homeland as a result of war, famine, or natural disaster.
In 2015, close to 60 million people were forced from their homes due to conflict and disasters. According to the United Nations Refugee Agency (UNHCR)External, “An unprecedented 59.5 million people around the world have been forced from home. Among them are nearly 20 million refugees, over half of whom are under the age of 18. There are also 10 million stateless people who have been denied a nationality and access to basic rights such as education, healthcare, employment and freedom of movement.”
CDC works every day to bring hope and comfort to refugees. Two branches that are at the forefront of this effort, the Emergency Response and Recovery Branch (ERRB) and the Immigrant, Refugee and Migrant Health Branch (IRMH), help promote and protect the health of refugees in complex humanitarian disasters and those undergoing resettlement to the United States, respectively.
The Global Response
Today’s global crises require experts who can quickly respond to health emergencies and provide leadership and needed skills. Within the Center for Global Health’s Division of Global Health Protection (DGHP), ERRB is committed to helping countries prepare for, respond to, and recover from global public health issues related to natural disasters, war, and civil strife.
ERRB implements and coordinates CDC’s responses to global humanitarian emergencies, as requested by partners from the U.S. government, United Nations agencies, and non-governmental organizations. From setting up surveillance systems days after a major earthquake, to evaluating feeding programs in post-conflict settings, these emergency response and recovery experts travel the world to work with populations affected by emergencies.
“Our work includes everything from planning immunization campaigns, improving water and sanitation, and caring for pregnant women and their families to detecting outbreaks of communicable diseases,” notes ERRB Branch Chief Mike Gerber. “Our experts help increase the odds that sound decisions are made and public health systems are strengthened.”
ERRB’s dedicated teams of experts include:
- The Global Response Preparedness Team works with international partners and Ministries of Health to develop plans and procedures for handling emergencies. They also help countries develop their own Emergency Operations Centers, where highly trained experts can gather to exchange information and make decisions quickly in a crisis.
- The Humanitarian Health Team provides expertise in critical areas like assessment; emergency risk communication; evaluation; information management; health, injury, and protection; mental health; non-communicable diseases; nutrition; reproductive health; surveillance; statistics, and vaccine-preventable disease.
- The Global WASH Team, which cuts across three centers— the National Center for Emerging and Zoonotic Infectious Diseases, the Center for Global Health and the National Center for Environmental Health—coordinates CDC’s response and collaborates with the Global WASH clusterExternal to help ensure the delivery of water, sanitation, and hygiene assistance during global emergencies and disease outbreaks and in refugee settings. In addition to responding to emergencies, the team also works with partners to provide training and help strengthen WASH systems.
- The Global Rapid Response Team provides staff who can rapidly deploy anywhere in the world to help CDC experts respond more effectively to global public health emergencies.
- The Public Health Systems Recovery Team works with partners to rebuild public health systems after a global disaster. This team was initially established and worked with partners to help strengthen the public health system following the 2010 Haiti earthquake, and has now expanded efforts to work with other countries impacted by public health crises.
As the world’s population of refugees, asylum-seekers, and those displaced from their homes continues to climb, ERRB remains committed to helping those impacted by global conflict and crises.
IRMH works overseas to promote and improve the health of refugees undergoing resettlement to the United States. Housed within the Division of Global Migration and Quarantine (DGMQ), IRMH’s key partner include the UNHCR, the U.S. Department of State’s Bureau of Population, Refugees, and Migration (PRM), and the International Organization for Migration (IOM).
“To promote refugee health, we provide guidelines for disease screening and treatment in the U.S. and overseas, provide instructions for how medical examinations of refugees should be performed, track and report disease in refugee populations, develop refugee health profiles, respond to disease outbreaks in the U.S. and overseas, and in partnership with IOM and PRM [International Organization for Migration and U.S. State Department’s Bureau of Population, Refugees and Migration], provide vaccinations overseas to control vaccine-preventable diseases and medicines to prevent malaria and eliminate intestinal worms,” said IRMH Chief Nina Marano.
Key resources include:
- DGMQ’s Africa Field Program in Kenya
- DGMQ’s Asia Field Program in Thailand
- Technical Instructions for Panel Physicians and Civil Surgeons
- Overseas Interventions
The Domestic Response
What happens to refugees after they arrive in the United States?
To ensure that U.S.-bound refugees and immigrants have continuity of care after their arrival, IRMH’s Domestic Program works closely with the Health and Human Services’ Office of Refugee Resettlement, state health departments, refugee resettlement agencies, and other local partners to monitor the health of refugee populations. IRMH’s primary partner in these endeavors is the Association of Refugee Health Coordinators, an organization representing U.S. jurisdictions that have refugee health programs.
Through additional partnerships, such as cooperative agreements with 10 U.S. state health departments and two Centers of Excellence in Refugee Health, the Domestic Program is able to compile post-arrival refugee health information from many jurisdictions, improving surveillance and informing guidelines for clinicians.
The development of health education strategies and guideline development are integral components of the Domestic Program. Evidenced-based recommendations for routine post-arrival medical screening of refugees assist state public health departments and clinicians who screen refugees and ensure that refugees receive proper care upon their arrival in the United States.
Additionally, the Domestic Program has produced Refugee Health Profiles of specific refugee populations, which provide targeted cultural and health information about these groups. These profiles enable physicians and other caregivers to provide culturally competent care.
IRMH also strives to develop culturally appropriate health education messages for newly arrived refugees.
“Information about prevention and management of seasonal flu, for example, was developed through focus groups and educational sessions conducted with refugees in their native languages,” said Marano. “They are tailored for low literacy populations by using minimal text and visual cues to portray seasonal flu information.”
The current global refugee crisis has created an urgency for building domestic and international capacity to meet the diverse healthcare needs of refugees, as well as raise awareness among healthcare and public health professionals about refugee health. In addition to its recognition of World Refugee Day 2016, CDC, along with its key partner agencies and organizations, will continue collaborating on strategies to promote and improve refugee health.
“CDC and our partners continue to help refugees at home and abroad; at this time, it’s critically important that we work together to protect the health of the world’s most vulnerable populations,” said Marano.
Unlikely Allies Formed During Panel Physician Trainings
Her diminutive stature belies the enormous impact she has had in improving the educational resources and trainings for panel physicians across the world. As a member of the Medical Assessment and Policy (MAP) Team of the Quality Assessment Program (QAP) in the Division of Global Migration and Quarantine’s (DGMQ) Immigrant, Refugee, and Migrant Health Branch; Erika Willacy works to develop a comprehensive training program for panel physicians. Panel physicians are medically trained, licensed, and experienced doctors practicing outside the United States who perform medical examinations for immigrants and refugees seeking to enter the United States. A medical examination is required for all refugees coming to the United States and all applicants for an immigrant visa who live outside the United States. With approximately 700 panel physicians in 150 countries selected by a U.S. Embassy or Consular Section of the United States Department of State (DOS), ensuring all panel physicians receive proper support and training would be a daunting endeavor for the faint of heart; however, Willacy and her colleagues approach the challenge with determination and enthusiasm.
DGMQ develops guidelines, called Technical Instructions (TIs), for the required medical examinations. The TIs cover vaccinations and medical conditions such as tuberculosis, mental health, and sexually transmitted diseases. The tuberculosis Technical Instructions (TB TIs) were updated in 2007 to reflect advances in science and newer, more precise tests. The updated TB TIs are an essential tool to more accurately identify tuberculosis and improve the health of immigrants and refugees through earlier diagnosis and updated methods of treatment. To help ensure a successful implementation, QAP personnel developed a comprehensive training program to provide support, guidance, and technical assistance to panel physicians implementing the revised TB TIs and to help ensure they successfully conduct immigrant and refugee medical examinations.
The Panel Physician Training Summit is an integral component of the MAP Team effort to manage the panel physician program and provide educational opportunities and trainings for them. Since 2008, nine summits have been held in Jordan, Kenya, the Philippines, India, Ghana, the Dominican Republic, Thailand, Peru, and Turkey, with each one improving upon the other. In 2011, the Panel Physician Training Summits in Thailand and Peru, combined, reached over 200 physicians and consular staff from 44 countries. These were followed in 2012 by a summit in Istanbul, Turkey, that was attended by 120 panel physicians and Consular officers. In March, Atlanta, Georgia was the site of the first U.S.-based Intergovernmental Panel Physician Training Summit, with involvement from the Intergovernmental Immigrant and Refugee Health Working Group (IIRHWG; Australia, Canada, New Zealand, the United States, and the United Kingdom) and was sponsored by the International Panel Physicians Association (IPPA). The training summits featured didactic sessions, as well as interactive, case-based learning; panel discussions; videos; and networking for attendees, with the goal of enhancing the knowledge and understanding of the audience and allowing them to turn that knowledge into practice. For the first time, DGMQ hosted workshops that were separate from the formal Summit to allow panel physicians greater in-depth, hands-on time on certain issues. As Willacy states, “DGMQ has an obligation to ensure the successful implementation of the TIs and that panel physicians feel empowered and properly equipped to do so.” Training summit organizers and attendees agreed there was a tremendous value in having a face-to-face training with time dedicated to understanding and asking questions about real scenarios. Drew Posey, MAP Team Leader, believes the “greatest thing about the training summits is being able to bring together panel physicians from around the world. It is invaluable to be able to interact with so many at once and for panel physicians to be able to network and share lessons learned with one another.” His sentiments mirror that of his colleague, Luis Ortega, Asia Regional Field Program Chief, who considers the training summits a “unique opportunity for panel physicians and consular officers from all over the world to exchange experiences from their practices, discuss solutions to common problems, and provide suggestions and ideas to DGMQ on how to collectively make the required pre-immigration medical examination better.”
The Training Summit in Thailand
While the technical aspects of the summit are critical, the importance of the intangible benefits and connections among attendees cannot be overemphasized. For example, while working together on case studies and in small group sessions during a training summit held in Thailand, a group of participants from Pakistan and India bonded over the cricket matches that were in progress. Their shared affinity for the sport was discovered because of the close relationships that develop among panel physicians as a result of the collaborative nature of the summits. Mary Naughton, summit lead for content, believes the summits “provide a welcoming environment for panel physicians to help each other learn how to implement the TIs and give them an opportunity to put into practice what they have learned.” The summits are conducive for sharing ideas, exchanging information, and providing peer support to overcome the challenges panel physicians face in their home countries. The Panel Physician Training Summits are important forums for attendees to work together, share common challenges and solutions, and develop collaborations that likely would not happen without the face-to-face element the summits provide. As one physician from Scandinavia aptly stated, “I have been to many congresses throughout my career and this is by far the best. I have learned so much and made so many valuable connections.”
Looking Ahead to 2014
While the Intergovernmental Panel Physician Training Summit held in Atlanta, Georgia just concluded, planning has begun and excitement is building for the next Panel Physicians Training Summit, which will take place March 2014, in Cape Town, South Africa. Dr. Posey aptly sums up the sentiments of many of those involved: “The panel physicians’ enthusiasm and appreciation for the summit opportunity make me feel fortunate to be a part of the Summits.” The continued work and dedication to hosting the training summits result in successful medical examinations and ultimately healthier immigrants and refugees.
The Long Road to America – One Refugee’s Experience
Each year, close to 50,000 refugees and 500,000 immigrants come to the United States from around the world. Standards of care, access to health care and treatment, and exposure to infectious diseases differ around the world. The U.S. Centers for Disease Control and Prevention’s (CDC) Division of Global Migration and Quarantine (DGMQ) works to keep infectious diseases and other diseases of public health significance from coming into and spreading in the United States. One way DGMQ accomplishes this by focusing on promoting and improving the health of immigrants, U.S. bound refugees, and migrants through domestic and overseas programs.
DGMQ’s Africa Regional Field Program in Kenya primarily works with refugees under consideration for resettlement in the United States. The program collaborates with the UN High Commissioner for Refugees (UNHCR) and other partners to improve the health of refugees. The program also works extensively with the International Organization for Migration (IOM) to oversee the medical screening of U.S.-bound refugees to prevent the spread of communicable diseases.
Today is the Day
It is a chilly morning in Nairobi, Kenya, but adults and children alike are bundled up and waiting patiently with their suitcases. They are shuffled through the line to weigh and tag their luggage – all their worldly possessions – as they anxiously await their chance to board a plane and begin a new life in the United States. These families are used to waiting; most fled their homes in the 1990s and have been waiting year after year for the opportunity to resettle and make a permanent home again.
Many refugees can never return to their homeland; they would face continued persecution if they did. Some are also living in perilous situations or have specific needs that cannot be addressed in the country where they have sought protection. In such situations, they are settled in a third country, but the odds of resettlement are long. Of the 10.5 million refugees around the world, less than 1 percent will be relocated.
Amina, one of several members of this 1 percent at the IOM transit center in Nairobi, was pregnant when she started her long, winding, and arduous journey in October 1991 with her husband and 3-year-old son, Mohamed. She came from a village 30 kilometers outside Mogadishu in Somalia. After making their way to Mogadishu, her family traveled by car for 2 days to Kismayo. It took them another 4 days to cover the distance from Kismayo to Liboi, a town on the Kenyan border, on a road that translates to the “Curse of the Parents.” This stretch of road proved to be a curse twice over, as Amina’s infant son died of measles before they reached the border and her husband, returning along this road to reunite his sick mother with the family, was gunned down by a militia group just months before Kenya opened her borders to Somali refugees. Amina’s daughter, Sundes – born a few months later in the Utanga refugee camp on the coast of Kenya – would never know her father.
Amina moved her children again to another coastal refugee camp, Swaleh Nguru, but in March 1997, the ongoing tension between Kenyan villagers and the Somali refugees escalated. One day, when Amina left her children at the madrassa (a religious school) to go to the market, the locals set fire to the camp. Young Sundes and her older brother smelled smoke and ran 4 kilometers until they found a woman who used to buy goods from their mother and took them in. They were reunited with Amina the same fateful day, but others were not so lucky, as several of their friends were killed in the fires.
The United Nations closed Swaleh Nguru and sent Amina and her family to the Kakuma refugee camp in the north of Kenya. When I asked her daughter, Sundes, what it was like to grow up in Kakuma, she shrugged and said, “I can’t complain – it’s life.” She went on to say that it’s stifling hot most of the year and while the refugees are given basic food staples, her mother always worked to buy extra food for the family. Her brother dropped out of school when he reached grade 7 and worked as a tea seller, loader, and waiter so she could attend a private school and get a better education.
Their lives are about to change drastically as they start yet another long journey – this time aboard an airplane en route to Kansas City. Their aspirations are no different from the immigrants who have for centuries sought a better life in the United States. Sundes would like to go to college and, having volunteered with FilmAid International in Kakuma, continue working in film. Mohamed would like to complete high school and work to support his family, while his mother wishes to learn English. Ultimately, however, “living safely is enough for now. Living in Kakuma, you don’t sleep sound at night. Locals come in at night and sometimes rob and shoot refugees. You wonder if someone will die tonight or the next.”
While Sundes is sorry to leave her friends behind, she is buzzing with excitement. This World Refugee Day she will not be performing in any plays in the camp, as she has for the past few years. She will be stepping off a plane, arm-in-arm with her brother and mother, to set down roots in a place where they hope they can finally find peace.
It is important to DGMQ that refugees such as Amina, Mohamed, and Sundes have access to medical care and preventive health services prior to arrival in the United States. This family will start their new lives in Kansas City healthy and, most importantly, happy.
Improving Health for Kenya’s Refugees by Building Laboratory Capacity
Not far from the Somalia border in Kenya lies the town of Dadaab, home to over 300,000 refugees in what is the largest refugee camp in the world. Refugees travel long distances, often by foot, without adequate food, water, sanitation, or shelter. They are faced with a host of medical problems which are compounded by the overcrowded conditions and limited access to care in the camps where they live. It is easy for infectious diseases to spread quickly in such conditions. In 2010, the U.S. Centers for Disease Control and Prevention (CDC) Division of Global Migration and Quarantine (DGMQ) responded to nine disease outbreaks in the Dadaab Refugee Camp, including cholera, H1N1 flu, measles, meningitis, and pertussis.
Every year, the United States receives about 4,000 refugees from Dadaab and 50,000 refugees globally. CDC’s DGMQ provides guidance and oversees the quality of medical screening for resettling refugees, while the International Organization for Migration (IOM) conducts the medical exam on-site. “We carry out surveillance in the Dadaab camp in addition to providing technical support to IOM for the migration health exam. The program participates in outbreak investigations and provides public health support to our partners as needed,” said Dr. Rachel Eidex, Director for DGMQ’s Africa Regional Field Program.
In 2007, DGMQ, in collaboration with the United Nations High Commissioner for Refugees (UNHCR) and Deutsche Gesellschaft für Technische Zusammenarbeit (GTZ), started respiratory disease surveillance in the Dadaab Refugee Camp. Eidex explained, “There was no way to figure out the leading causes of illness or to detect an outbreak early on, let alone an emerging pathogen. The health system was stretched and we wanted to help address the daily public health challenges.” It wasn’t easy.
Laboratory capacity in Dadaab was extremely limited. Surveillance and diagnostic specimens had to be transported to a lab in Nairobi for testing, and there are only two flights out of Dadaab each week. Results were often not obtained for weeks or even months. Determining the pathogen associated with an outbreak of watery diarrhea or the cause of someone’s pneumonia could take weeks before results were obtained if a viable specimen was received. In most cases, clinicians didn’t bother sending specimens – either the right specimen collection supplies were not available or by the time the result came back the patient would be long gone. The clinician needed to act on the information at hand and the luxury of a diagnosis was not available. The only way to continue conducting disease surveillance and to help clinicians appropriately treat public health issues in Dadaab was to provide the diagnostic capacity on-site.
CDC’s DGMQ and International Emerging Infections Program worked closely with UNHCR, the International Rescue Committee (IRC), and the Kenya Medical Research Institute (KEMRI) to set up a functioning laboratory at a site where access to water, electricity, space, and staff are significant challenges. The goal was to implement respiratory, febrile, and diarrheal disease surveillance – the leading causes of illness and death in the camp – and to put diagnostic tools in the hands of camp clinicians. On September 15, 2010, a new and improved laboratory officially opened at the Hagadera Hospital in Daadab Refugee Camp. This could not have been accomplished without the extraordinary collaboration and commitment across agencies and programs. The lab serves approximately 1,000 people a month from the camp and the surrounding host community, according to Dr. John Burton, the Health Coordinator for the UNHCR. It is the only lab of its kind in the North Eastern Province of Kenya, and can help serve the needs of others in this region and southern Somalia. The IRC runs the lab with CDC and KEMRI staff embedded to assist with specialized testing. “Data are currently shared with clinicians on site, but eventually we hope this information will be shared more broadly with all the partnering agencies to allow them to examine events as they are happening and make informed public health decisions,” said Eidex.
Recently, the first cases of Shigellosis were identified in Dadaab. Previously, the testing capacity was unavailable and the organism is too fragile for transport; however, the updated lab now has the capacity to identify this diarrheal disease. Today, if a mother walks into the hospital with a febrile child, that child can have numerous tests performed to help determine the cause of the fever. Now, the doctor will know how to treat the patient and the agency will know how to respond in order to protect the community. “There’s no more shooting in the dark when it comes to patient management,” noted Eidex.
It has been a long road and there is still a need for test kits and other support, but with strong partnerships and continued dedication, this project will improve the lives of those seeking refuge in Kenya and beyond.