1. Health Care and Immigrant Populations in the U.S. James A. Litch MD, DTMH Centers for Disease Control and Prevention; WA Department of Health, Epidemiology Office; University of Washington School of Medicine

2. Presentation Overview Health issues facing new immigrant populations in the U.S. One Example: The Tibetan Refugee Resettlement Project Lessons learned: steps for providers interested in delivering health care to immigrant populations

3. High Degree of Vulnerability Disease/Illness Mental illness Isolation Crime Violence (domestic and community) Underemployment Poverty

4. Health Issues: Immediate Tuberculosis Chronic viral hepatitis infection Intestinal parasites Nutritional deficiencies Lack of immunization Depression and other psychiatric illness

5. Health Issues: Urgent Establish primary care and emergency services Identify chronic medical conditions and treatment alternatives Language barriers may be persistent

6. Health Issues: Ongoing New behavioral limits may require rapid change: –Old practices may be dangerous or illegal –The new environment has different risk factors –Awareness of specific cultural practices yields returns

7. Delivering Health Care Health conditions may not be the dominant problem patients face Health care services alone are unlikely to be sufficient This leads to many challenges that require creative linking of resources

8. Tibetan Refugee Resettlement Project Between 1992 and 1993, the first group of Tibetan refugees entered the US 1000 visas were issued for immigration, but a unique stipulation was made that prevented the use of federal resources for support This mobilized a nationwide effort in 21 cities

9. Tibetan Refugee Resettlement Project Refugees from India, Tibet and Nepal Came as individuals, with family members to follow in 3-6 years Seattle received 36 individuals, followed by 150 family members Tibetan community advocates identified and empowered early after arrival

10. Tibetan Refugee Resettlement Project Immigrants were not eligible for public assistance for 1 year Arrived with a prearranged job offer and household sponsor waiting Medical screening and care at a Seattle family medicine residency clinic Structured language, safety/health education, legal support, and acculturation classes Weekly peer support group

11. Key outcome indicator: First group to transition into leadership roles The program was re-incorporated as a new non-profit organization in 1996 to settle the next larger wave of immigrants Tibetan Community Program Tibetan Resettlement Project

12. Lessons Learned for Health Care Providers Specialty or focused clinics for a particular immigrant group are lacking Travel effort to receive care needs to be appreciated Language interpreters are NOT optional Screening is straightforward, but just a starting point

13. Lessons Learned for Health Care Providers: Cont’d Recognize the need for critical referrals: –English as a second language (ESL) –Counseling/Psychiatric care –Housing –Employment –Establishing residence –Peer support

14. Steps for Health Care Providers Commitment is needed from clinic staff, not just the care provider Training: –Family practice residency training –Diploma in Tropical Medicine and Hygiene –Short-term overseas clinical work –Rotate at a regional international clinics Get connected in your local community

15. Conclusion Mainstream, don’t marginalize Treat the individual, and the patient Identify and act to employ outside resources for critical needs