Clinical and Health Affairs
Caring for the Karen: A Newly Arrived Refugee Group
By David V. Power, M.D., M.P.H., Emily Moody, M.H.S., Kristi Trussell, M.D., Ann O'Fallon, R.N., M.A., Sara Chute, M.P.P., Merdin Kyaw, M.B.B.S., James Letts, M.D., and Blain Mamo, M.P.H.
Since 2004, Minnesota has seen an influx of refugees from Burma. Many of these newcomers came from the Karen state and spent time in refugee camps in Thailand before resettling in the United States. To better understand the health needs of this population, the authors of this article conducted chart reviews at a St. Paul family medicine clinic that serves a number of Karen refugees and reviewed formal data from the Minnesota Department of Health’s Refugee Health Program. Here, they briefly describe this community, the cultural issues that could affect health care providers’ ability to care for Karen patients, and the health concerns of these refugees.
In early 2004, physicians at the University of Minnesota Physicians - Bethesda Clinic in St. Paul started noticing a large influx of patients who had recently arrived from Southeast Asia and had names that were quite different from those of their Hmong patients. These newcomers identified themselves as Karen (pronounced kah-REN), and they came from Burma (Myanmar).* Physicians and staff at the clinic had become familiar with the cultural and medical needs of their Hmong patients; however, it soon became apparent that this new group of refugees came from a different country with a different political climate and had their own set of medical needs and concerns. We discovered little published information about Karen refugees in the United States, with the exception of an informative online cultural profile from the University of Washington.1 We also found a helpful 2007 Canadian assessment of newly arrived Karen refugees and a useful review produced by the Cultural Orientation Resource Center.2,3
In an effort to describe this new population in Minnesota, we performed a detailed chart review of all the Karen patients we could identify at our clinic in the summer of 2007. We identified 322, including 98 adult females, 72 adult males, and 152 children. (The chart review was considered exempt from human subjects approval by the University of Minnesota’s Institutional Review Board.) We also reviewed data gathered by the Minnesota Department of Health’s Refugee Health Program (RHP), which coordinates the initial domestic health assessment of refugees within 90 days of their arrival. The health department had gathered data on 1,745 Karen refugees who came to Minnesota from Thai refugee camps between January 1, 2004, and December 31, 2008. Of those individuals, 1,728 (99%) received the domestic health assessment, which includes screening for tuberculosis, hepatitis B, parasitic infections, sexually transmitted diseases, and malaria; assessment of immunization status; and lead screening for children ages 6 years of age and younger along with a general health assessment and appropriate medical referrals.
Here, we present selected findings from our research to describe the Karen population in Minnesota and provide insights that can help health care providers who may see Karen patients in their practices.
The Karen in Minnesota
The Karen in the United States: A Brief History
In Burma, the Karen state runs northwest to southeast, sharing a long border with Thailand. The Karen people are the second largest ethnic group, numbering almost 6 million. However, the Karen comprise many different tribes with distinct languages and traditions. The two largest subgroups are the Pwo (pronounced “poh”) Karen and the Sgaw (pronounced “skaw”) Karen, who together constitute about 70% of the Karen population. Only a third of the Karen reside in the Karen state; the rest are spread throughout Burma.
Burma, which gained independence from Britain in 1948, is the site of one of the longest-running civil wars in the world today, throughout which the Karen and other ethnic minorities have been directly and continuously targeted by the Burmese military. Villages have been raided and burned, forcing the dislocation of hundreds of thousands of Karen who are mostly rural dwellers. There have been reports of mass rape, forced labor, torture, and imprisonment by the Burmese military. Ethnic targeting has been practiced by the Burmese military for more than 20 years, notably during the dry season, which initiates an influx of military activity in the rural states. This cycle of violence has resulted in thousands of Karen fleeing to refugee camps in Thailand as well as the internal displacement of many thousands more.
Thailand, through negotiations with the United States in 2000, agreed to the transfer of thousands of Karen, Burmese, and other refugees from its camps to Western countries. In addition, Thailand has sent many recent arrivals back across the border to their homeland, thus increasing the population of internally displaced people. There are currently nine refugee camps along the Burma-Thailand border, with an official population of more than 150,000. Actual numbers are estimated to be higher, with approximately 250,000 Karen in Thai refugee camps and another 600,000 to 1 million internally displaced. From 2007 to 2009, approximately 24,000 Burmese refugees (many of whom are Karen) were resettled in the United States.
The Office of Refugee Resettlement (www.acf.hhs.gov/programs/orr/) estimates that during the next 10 years, as many as 100,000 more Burmese refugees could be resettled in the United States. As the population increases throughout the country and in Minnesota, it will be critical for health care providers to become familiar with their beliefs and health needs.
Ethnomed’s Karen Home Page (http://ethnomed.org/culture/karen) U.S. Department of Health and Human Services Office of Global Health’s Background on Potential Health Issues for Burmese Refugees (www.globalhealth.gov/refugee/refugees_health_burmese.html)
The first Karen refugees arrived in Minnesota from Thai refugee camps in 1994, and for the next 10 years arrival numbers were very small (between zero and 30 per year). However, between January 2004 and December 2008, nearly 1,750 refugees from Burma were resettled in the state (Figure). An unknown number have relocated here from other states as well. Although people from a number of different Burmese groups (including ethnic Burmese, Chin, and Mon) have settled in the Twin Cities, it is estimated that 75% to 90% of the Burmese population in Minnesota are Karen and that more than 90% of them have resettled in Ramsey County. There also is a growing community in Worthington, where approximately 600 Burmese refugees live, and at least 10 families reside in Albert Lea. Currently, two family medicine clinics in the Twin Cities—the University of Minnesota Physicians - Bethesda Clinic and the HealthEast Roselawn Clinic—provide primary health care to a large proportion of the Minnesota Karen.4
The Karen speak two major and dissimilar languages: Sgaw Karen and Pwo Karen. The Karen in Minnesota predominately speak Sgaw Karen and generally do not understand Pwo Karen. Many older members of Minnesota’s Karen community also speak Burmese fluently (albeit as a second language), while the younger Karen are more likely to speak Thai, as many grew up in Thai refugee camps. Since 2008, a population speaking yet another distinct Karen language, the Karenni (or Red Karen), have been arriving in the United States; however, few members of that group have resettled in Minnesota.
Language appears to have been a major issue for Karen patients seeking health care in Minnesota. Our chart review revealed that most Karen refugees who came to Minnesota in 2004 experienced some sort of language barrier; very few spoke English, and appropriate interpreters often were not available. Often, Burmese was the common language used by patients and interpreters (some interpreters were Burmese and did not know Karen), but misunderstandings appeared to be common. There was frequent documentation in the charts of delays in care attributed to communication difficulties. We also found that some patients had preferred to speak Pidgin English without an interpreter rather than speak Burmese. In one case, a Pwo Karen patient had to speak Burmese because the interpreter only spoke Sgaw Karen and Burmese. In another instance, a young Hmong man and his Karen wife, who had met in a Thai refugee camp, preferred to communicate through a Thai-speaking interpreter.
In the years immediately following the arrival of the Karen, telephone interpreting services repeatedly confused requests for Karen interpreters with those for Korean interpreters. However, with the influx of multilingual refugees during the past three years, access to interpreters has improved considerably and some organizations now have full-time Karen interpreters. Still, language remains an important issue for many Karen.
■ Naming Structure
Traditionally, the Karen have only a given name. As they have moved to countries where surnames are required, they have adopted family names. Confusion about name order has led to problems with medical charting in some cases. In the Karen community, people are usually addressed by their given name and a title indicating their relationship to the speaker such as grandfather, aunt, or elder. Karen names are frequently short and spelled with one of several vowels (eg, Paw, Po, and Myint) or with a silent “h” (eg, Eh and Htoo). Names often include Saw (which is actually Mr.) or Na (Ms.).
■ Beliefs about Medicine
Because many Karen refugees lived for 10 or more years in Thai refugee camps, they are somewhat familiar with the practices of Western medical organizations such as Doctors without Borders. Traditional Karen medicine includes components of both Ayurvedic and traditional Chinese medicine.5 In addition, many Karen hold animistic beliefs—including believing in the existence of spirits and multiple souls—that may affect their health. Persons who lived in remote jungle villages may have known a variety of healing traditions including use of hot and cold as remedies, chewing betel nut, and smoking pipes. Herbalism, which is widely practiced in Burma, is less likely to be used by the Christian Karen than by those who are Buddhists or animists. However, in contrast to the first wave of Hmong refugees who arrived in the United States in the 1970s with strongly held traditional beliefs about health and minimal knowledge or experience with Western medicine, most Karen refugees in the United States are open to and have a better understanding of the practices of Western health care providers.
In our chart review, there was little documentation of use of herbal or traditional Chinese medicine. One patient was noted to have put turmeric powder on his knee, which was swollen from gout; this caused his skin to appear yellow. Turmeric is believed to have healing properties and has also been placed on the skin of Karen newborns.1 There was no mention in any patient charts of marks caused by cupping or coining, important practices in traditional Chinese medicine that are commonly used by other Asian groups to extract illness from the body.
There were, however, several comments related to patients’ poor compliance with medications or limited insight into their condition and the need to use medications appropriately. We also found anecdotal reports about use of over-the-counter medications including antibiotics obtained in Thailand. Many patients, for example, may have developed the habit of taking a few doses of amoxicillin each time they have a cold. U.S. physicians may need to educate patients about the appropriate use of antibiotics and the consequences of their overuse.
Infectious Diseases among Karen Refugees
Our review found that infectious diseases that are common in the developing world affected a number of Karen patients. Physicians should be aware of these when treating Burmese refugees.
■ Parasitic Infections
On their initial domestic health examination, 15% (249/1,675) of refugees from Burma presented with at least one type of pathogenic intestinal parasite. Infection was most common among children, with the infection rate being 24% (48/197) in children younger than 5 years of age, and 27% (113/418) in those between ages 5 and 14 years. Giardia was the most frequently identified parasite, accounting for 76% (207 of 249) of all parasitic infections. In addition, Minnesota Department of Health data for 2009 only show that 69% (49/71) of refugees from Burma tested positive serologically for infection by Strongyloides.
Although virtually all individuals in our chart review were either given prescriptions or referred to primary care providers for treatment following their domestic health screening, 10% (17/171) of adults and 26% (36/136) of children younger than 18 years still tested positive for a parasitic infection. Those patients may still have had infection because of incomplete compliance with initial treatment or they may have become reinfected. Therefore, retesting of previously treated patients should be considered, especially in the presence of symptoms.
Hepatitis B infection is recognized as endemic in many parts of Southeast Asia. Of the 1,722 refugees who were screened for hepatitis B, 173 (10%) were positive for the hepatitis B surface antigen and 1,055 (61%) were positive for hepatitis B surface antibody. In our chart review, 56% of the antibody-positive patients had no documentation of prior hepatitis B vaccination, suggesting that their immunity was acquired from natural exposure to the virus and not through immunization. Additionally, 25% of the surface-antigen-positive patients were considered to have chronic hepatitis (with concomitant elevated liver enzyme levels). These patients, a number of whom were teenagers or young adults, were referred to a liver specialist for further management. Physicians should be aware that hepatitis B infection is a much more significant problem for younger Karen patients than it is for younger American patients. (Refugees are not currently screened for hepatitis C, although positive antibodies were documented in seven [4%] of our adult patients.)
Between 2004 and 2008, the Department of Health’s disease surveillance data showed that 33% (568/1,717) of Karen refugees tested positive for latent tuberculosis (LTBI). Treatment was initiated for 540 of those (95%). Four (<1%) new arrivals were diagnosed with active TB infection. TB and LTBI are very prevalent in Southeast Asia, and all efforts should be made to prevent TB disease among new arrivals.6 Those who have been started on treatment for active TB or LTBI should be closely followed to ensure adherence and be monitored for medication side effects.
Personal Habits and Disease Prevention
Our chart review also gave us insights into the lifestyle of the Karen such as their use of tobacco and alcohol as well as their feelings about immunizations, preventive screenings, use of contraception, and compliance with medical advice.
■ Personal Habits
We noted that 30 (19%) of 162 adults were documented as cigarette smokers; 80% of these were men. Alcohol consumption was reported for 25 (19%) of 134 adults, 60% of whom were men. Those numbers could be lower than actual because of under-recording. One woman was described as being alcohol-dependent and had been treated in an inpatient facility. There was no mention of illegal substance use.
Betel nut is a common stimulant used in many parts of South and Southeast Asia. In Burma, betel nuts are traditionally chewed with lime, a practice that leaves a brown residue in the oral cavity.3 This practice can contribute to tooth decay and has been linked to the development of oral and pharyngeal cancers.7 In the chart review, only four patients were documented as using betel nut; however, this was certainly underassessed because providers were unaware of this habit. Specific questioning about both current and past history of betel nut chewing likely will reveal a much higher prevalence.
■ Immunizations and Preventive Screenings
In our chart review, it appeared that Karen patients were willing to be vaccinated and to undergo recommended health screenings such as Pap smears, mammography, and colonoscopy. The majority of Karen refugees start receiving some recommended immunizations during their overseas medical examinations in Thai refugee camps.5 Between 2004 and 2008, 93% (1,629/1,745) of the patients whose overseas medical records we analyzed had started their vaccine series. Of the 1,728 who completed the domestic health screening, 91% (1,576/1,728) continued with their vaccine series. Primary care clinicians should either obtain the overseas medical or domestic health screening charts for Karen patients or access the Minnesota Immunization Information Connection (www.health.state.mn.us/divs/idepc/immunize/registry/hp/index.html) for their most current immunization records. As for preventive screenings, our review found that 34 of 58 sexually active women (59%) were up to date with Pap smear recommendations.
■ Sexually Transmitted Diseases and Use of Contraception
Of the 58 women identified as being sexually active in our chart review, 22% had undergone tubal ligation and, of the remainder, 60% had received Depo-Provera injections. Two patients were noted to have Norplant implants, which had been inserted in Thailand (the implant is not presently approved for use in the United States). No STD infections were documented in any of our adult male or female patients at the clinic.
■ Chronic Disease Management
In our chart review of 170 adults, 26 were being treated for gastroesophageal reflux (15%), 11 for hypertension (6%), eight for diabetes (4%), 40 for hyperlipidemia (24%), and three for gout (1.7%). As with other recently arrived refugees, we have noticed that many Karen patients are unfamiliar with chronic disease management and have difficulty understanding the reason for taking medication in the absence of symptoms. We have found that repeatedly explaining the need to control blood sugar or cholesterol over multiple visits is effective and that teaching over time can lead to better compliance with medications.
Important Issues for Karen Patients
- Ascertain the preferred language of each patient
- Know hepatitis B status
- Clarify immunization status
- Investigate for mental health problems (over time)
- Consider parasitic infections (especially in children)
- Dental care is probably necessary
Other Health Issues
■ Dental Caries
Tooth decay and gum disease are very common among Karen refugees because of their lack of access to dental care and the common habit of chewing betel nut; 32% (555/1,728) of the individuals who completed the domestic health assessment needed a referral to a dentist. Prevention of dental caries is an important part of Karen well-child care. Initially, many Karen in the United States only used bottled water for their children. They considered it the safest drinking water in the refugee camps. However, bottled water may have insufficient fluoride, increasing the risk of childhood tooth decay. Clinical education about the safety of the local water supply and the importance of fluoride for dental health may be helpful.
■ Lead Poisoning
The domestic health assessment data show that 7% (17/237) of children younger than 7 years of age presented with elevated blood-lead levels (BLL). This prevalence rate is much higher than that of other refugee children or the general population in Minnesota. Additional investigation of BLL in children 6 months to 14 years of age conducted in the Thai refugee camps in June 2009 by the Centers for Disease Control and Prevention found the prevalence of elevated BLL to be 5% and 14% among children younger than 2 years of age.8 Although the source of lead exposure is not known, food, spices, remedies, cookware, and batteries (all common sources of lead) are being investigated. It is recommended that providers consider Karen children a high-risk group for elevated BLL and that they consider screening for lead if prior test results are unavailable.
■ Mental Health Concerns
In our chart review, 15 Karen adults (8.8%) reported at least one mental health diagnosis. These included depressive disorders, anxiety, and post-traumatic stress disorder. It is our observation that, as with other immigrant groups, Karen patients often are reluctant to initially report mental health problems. We have encountered patients who have sought help for significant mental health problems dating back to their time in Asia only after having been seen at the clinic for several years. It is therefore recommended that providers remain patient and re-evaluate for signs of mental health problems over time.
■ Uncommon Case Reports
One male patient in his 50s was incidentally noted to have a small smooth ball attached subcutaneously to the dorsum of his penis; it had been voluntarily inserted many years earlier and did not bother him. Another patient requested treatment for a grossly enlarged penis, which he said had been caused by an injection of a “silicone-like substance” and was the result of torture in Thailand. This voluntary practice of penile enhancement has been reported among young Thai men.9
We have attempted to outline some of the cultural and clinical findings we have noted while caring for Karen patients. Because the Karen population in Minnesota is growing, it is important for physicians and other health care providers to be aware of and sensitive to their customs and health needs. MM
* Two names, Burma and Myanmar, are used variably to refer to the same country. The name Myanmar comes from the Burmese language and has been criticized for reflecting the marginalization of ethnic minorities by the Burmese military junta. In this article, the country is referred to as Burma, the title used by the U.S. government as well as by the majority of the Karen people.
David Power is an associate professor in the department of family medicine and community health at the University of Minnesota. Emily Moody is a University of Minnesota medical student. Kristi Trussell is an emergency medicine resident at Hennepin County Medical Center in Minneapolis. Ann O’Fallon is the director of the Minnesota Department of Health’s Refugee Health Program; Sara Chute is a program consultant and Blain Mamo is an epidemiologist with the program. Merdin Kyaw is an interpreter in Chicago. James Letts is a family physician at the HealthEast Roselawn Clinic in St. Paul.
This project was supported in part by a grant from the UCare Foundation. We would like to acknowledge the assistance of Eh Taw Dwe and the staff of the Refugee Health Program of the Minnesota Department of Health, Paw Wah Toe, Karen interpreter at Healtheast Roselawn clinic, the Karen interpreters employed by the Kim Tong Agency, the Bethesda clinic staff and, in particular, the medical records staff, and Jim Boulger Ph.D., University of Minnesota, Duluth.
1. Neiman A, Soh, E, Sutan, P. Karen Cultural Profile. Ethnomed; 2008. Available at: http://ethnomed.org/culture/karen/karen-cultural-profile. Accessed February 18, 2010.
2. Denberg A, Rashid M, Brophy J, et al. Initial health screening results for Karen refugees: a retrospective review. Can Commun Dis Rep. 2007;33(13):16-23.
3. Barron S, Okell J, Yin SM, et al. Refugees from Burma: Their Backgrounds and Refugee Experience. Washington D.C.: Center for Applied Linguistics Cultural Orientation Resource Center, Center for Applied Linguistics; 2007. Available at: http://www.cal.org/co/pdffiles/refugeesfromburma.pdf. Accessed March 17, 2010.
4. Personal communications with Karen interpreters, Kim Tong Interpreting Service, November 2009.
5. Bodeker G, Neumann C, Lal P, Oo ZM. Traditional medicine use and healthworker training in a refugee setting at the Thai-Burma border. J Refugee Studies. 2005;18(1):76-99.
6. U.S. Committee for Refugees and Immigrants, Karen Refugees in Tham Hin Camp, June 2006.
7. Lee KW, Kuo WR, Tsai SM, et al. Different impact from betel quid, alcohol and cigarette: risk factors for pharyngeal and laryngeal cancer. Int J Cancer. 2005;117(5):831-6.
8. Mitchell T, Jentes E, Ortega L, et al. Elevated Blood Lead Levels among Children in Refugee Camps Mae La, Umpiem, and Nupo Refugee Camps, Tak Province, Thailand June 2-19, 2009. Centers for Disease Control and Prevention; 2009. Available at: www.brycs.org/publications/upload/cdcreportburmeseleadlevels.pdf. Accessed March 11, 2010.
9.Thomson N, Sutcliffe CG, Sirirojn B, et al. Penile modification in young Thai men: risk environments, procedures and widespread implications for HIV and sexually transmitted infections. Sex Transm Inf. 2008;84(3):195-7.