Providing Pediatric Care for Newly Resettled Refugee Children and Adolescents in DeKalb County
By Susan. S. Reines, M.D. and Tarissa Mitchell, M.D.
For the past five years, The Southeast Permanente Medical Group’s (TSPMG) Cares Program and DeKalb County Board of Health (DCBOH) have collaborated to provide pediatric services to newly resettled refugee children in DeKalb County.
The Refugee Pediatric Clinic opened its doors on May 5, 2010, to help refugee kids with chronic medical conditions gain access to specialty care providers. Initially providing limited services only one day per week, we now provide comprehensive pediatric care four days per week, offering well child exams and acute and follow-up visits. Same-day and walk-in access are also available. In 2014, we completed more than 2,000 visits for approximately 800 children and teens.
The clinic is staffed by TSPMG physicians and nurse practitioners, and we are lucky to work with volunteer pediatricians from the Centers for Disease Control and Prevention (CDC) and pediatric residents from Emory University. DCBOH provides clinic staff, including an LPN, a public health tech, multilingual reception staff, laboratory staff and a cadre of dedicated and trained onsite medical interpreters who speak approximately eight different languages; language line services provide additional language support when needed.
The national Reach Out and Read program has generously worked with us to help immerse young refugees in the English language and the joys of reading. Collaborations with Emory University and CDC have encouraged ongoing clinical research, which has been presented at national American Academy of Pediatrics meetings.1,2
We were inspired to start this clinic when it appeared that refugee children in our community with significant health problems were having trouble accessing follow-up care after their initial health screening and were “falling through the cracks.” Although they had health insurance (Refugee Medical Assistance), they confronted new obstacles. Language and communication barriers, transportation barriers and a low level of health literacy were only compounded when they encountered our complex healthcare and insurance system.
Our goal was to deliver care in a setting that could effectively address some of these barriers and provide multiple services in one location. DCBOH had the necessary infrastructure for this program, including a well-developed refugee screening clinic with a multilingual staff that already evaluated new refugees. Numerous ancillary services were already in place, including Women, Infants, and Children (WIC); clinics for HIV, other sexually transmitted infections, tuberculosis (TB), latent TB infection and dental care; the Children’s First Program; and programs for mental health and environmental health. We succeeded in establishing a pediatric clinic built on the widely recognized core values of immigrant medicine.3
We strive to:
- Recognize the continued health inequities faced by refugees after resettlement.
- Show respect for our patients’ cultures, religions, experiences and resilience.
- Promote trust by using bilingual staff and not rushing through encounters.
- Demonstrate cultural humility by showing respect, interest and willingness to learn from others.
- Approach newly arrived refugees with compassion.
- Understand the unique health profiles of refugees based on their country of origin.
An understanding of these values helped our perceptive practitioners quickly determine the cause of this baby’s elevated lead level:
Baby S was a 3-month-old exclusively breastfed refugee from Afghanistan. Her labs were significant for a lead level of 22ug/dl (normal less than 5µg/dl). Development was appropriate for age and mother’s lead level was undetectable. The pediatric provider immediately noticed that the infant was wearing eyeliner, or surma, brought from Afghanistan. These products are believed to help eyesight develop and ward off evil spirits, but can also expose children to lead. The Division of Environmental Health at DCBOH made a home visit and tested the surma for lead, finding an extremely high level. The family was counseled about the dangers of this product in children and immediately stopped using it. One month later, the lead level was 19 µg/dl and, thereafter, continued to fall.
Table 1 lists many of the unique medical problems we have treated in children and teens over the past 5 years.
In the next section, we will give an overview of refugee health, providing some global and local statistics, and a description of the refugee medical screening process.
The United Nations High Commissioner for Refugees reported that in 2014 there were 59.5 million forcibly displaced persons worldwide, representing the largest refugee crisis since World War II. This number includes 19.5 million refugees, 38.2 million internally displaced people and 1.8 million asylum seekers.4 About one-third of the world’s refugees originate in Syria and Iraq, but large numbers also come from Afghanistan, Somalia, the Democratic Republic of the Congo (DRC) and Sudan.4
In 2014, 69,986 refugees resettled in the United States, of which 2,694 from 34 countries arrived in Georgia.3 The majority originated from Burma/Myanmar, Bhutan, Somalia, Iraq, DRC and Afghanistan (Table 2). Each year, Georgia receives approximately 3-5 percent of the U.S.-bound refugee population, primarily in DeKalb County, and ranks among the top 10 states (numerically) for refugee resettlement.
Depending on their countries of origin, refugees may have a high burden of infectious diseases, including hepatitis B, TB and parasitic infections. Many children have lived in refugee camps or other settings where malnutrition and micronutrient deficiencies are prevalent. Others have received little or no care for significant congenital anomalies and sequelae of difficult pregnancies and traumatic deliveries. Mental health problems such as post-traumatic stress disorder, depression and anxiety are frequent in those who have been traumatized by war, conflict, persecution and torture.
Refugee Medical Screening
The Overseas Medical Evaluation. Prior to resettlement in the United States, refugees undergo an overseas medical examination conducted by panel physicians selected by the Department of State, with regulatory oversight and technical instructions for the examination provided by the Centers for Disease Control and Prevention (CDC). The purpose of this exam is to identify and prevent (or delay until treatment is complete) travel in those with communicable diseases of public health significance (such as active tuberculosis, leprosy, untreated sexually transmitted infections) and mental health disorders associated with harmful behaviors and drug addiction. Conditions noted at the time of the exam that do not legally preclude travel are documented on the overseas medical record.
Additionally, most refugees bound for the United States are offered a number of Advisory Committee on Immunization Practices (ACIP)-recommended immunizations, as well as pre-departure presumptive treatment for parasitic infections that varies by country of origin. Immunizations and parasitic treatment are not legally required but are strongly recommended to refugees to improve health and prevent resettlement delays that arise during outbreaks of vaccine-preventable disease.
A completed overseas health assessment (DS-2053) form is given to families prior to travel, and they are instructed to bring this form to their domestic health evaluation. This health information is also available on a CDC database (Electronic Disease Notification System) and can be accessed by state and local health departments. CDC guidelines for pre-departure and post-arrival medical screening and treatment can be found on their website.
Domestic Medical Screening. Once refugee families arrive in Georgia, most undergo a comprehensive medical screening within 30 days at the DCBOH Refugee Screening Clinic. Under the supervision and guidance of Drs. Sentayehu Bedane (Manager of Countywide Services) and Alawode Oladele (Lead Physician of Refugee and TB services), the DCBOH screened 2,574 (95 percent) of new refugee arrivals in Georgia in 2014. Table 3 provides a summary of the age-appropriate medical evaluation performed.
All new refugees receive Refugee Medical Assistance (RMA) for the first eight months after resettlement. Following the initial domestic health screen, adults are referred to their primary care provider, and children and adolescents are offered appointments in the Refugee Pediatric Clinic or can be seen by a primary care physician in the community. A family nurse practitioner is available to assist adults with their referrals.
Despite the challenges and sometimes frustrations of providing care to this unique group of patients, the clinic has been a valuable addition to the refugee resettlement process and a rewarding experience for providers and staff. We present a successful model for how multiple health partners (DCBOH, TSPMG, Emory University, CDC) can combine resources to improve healthcare for an often overlooked group in our community. We look forward to many more years of service to the refugees who have demonstrated tremendous courage, strength and resilience in the face of extreme adversity and hardship.
- Shah, A. Y., Suchdev, P. S., Mitchell, T., Shetty, S., Warner, C., Oladele, A., Reines, S. Nutritional Status of Refugee Children Entering DeKalb County, Georgia. Journal of Immigrant & Minority Health. 2014; 16(5):959-967.
- Calhoun, C. Reines, S., Suchdev, P. Oladele, Goodman, A. Adapting an Autism Screening Tool for Use in the DeKalb County Refugee Pediatric Clinic. Poster presentation, AAP National Conference 11/ 2014.
- Walker, P., Barnett, E. Immigrant Medicine. Philadelphia: Elsevier; 2007, p 6.
- UNHCR Global Trends 2014. Available: http://www.unhcr.org/pages/49c3646c4b8.html
- Fiscal Year 2014 arrivals. Available: http://www.acf.hhs.gov/programs/orr/resource/fiscal-year-2014-refugee-arrivals