Feature
Global Health Hot Zone
By Marc Hequet
Minnesota has become a haven for newcomers to this country and a hub for experts in international health.
Shamanism and elders. River blindness and malaria. The exotic has entered the vocabularies of Minnesota physicians as the state has become a haven for refugees and immigrants from around the globe. The arrival of each group of newcomers means health care providers must get a rapid education in tropical diseases, new drugs, and the traditions of peoples coming from countries in Southeast Asia, Africa, Central America, and Eastern Europe.
As cold Minnesota has become home to arrivals from warm climates, it also has become a hot spot for global health: A growing number of physicians and other providers gather periodically at Shriner’s Hospital in Minneapolis to discuss parasites and fevers more common in the Serengeti than St. Paul. A University of Minnesota course just became one of 13 in the world to be accredited by the American Society for Tropical Medicine and Hygiene. The director of that course is the Centers for Disease Control and Prevention’s go-to guy on refugee medicine. A St. Paul clinic is one of 30-some sites conducting global surveillance for emerging travel-related diseases. And the director of that clinic is co-editing a textbook on best practices in migrant medicine.
The Cambodian Connection
Why is Minnesota, deep in the heart of the North American continent, a thriving hub for global health? It stems in great part from the efforts of a few Minnesota health professionals to care for Cambodian refugees in 1979.
One, Neal Holtan, M.D., now medical director for the St. Paul-Ramsey County Department of Public Health, was a volunteer with the American Refugee Committee, a Minneapolis-based organization that sent a dozen medical professionals to help the Cambodian refugees who were pouring into camps in Thailand.
The World Under One Roof
A local clinic is a model for caring for newcomers.
Physicians who treat immigrants and refugees need to understand that they sometimes must adjust their approach to care in the interest of cultural sensitivity. The Center for International Health at Regions Hospital in St. Paul has become a national model for how to do that, and much of the credit goes to its architect, Pat Walker, M.D., the clinic’s medical director.
Walker, who joined the clinic in 1988, says one way of providing the best care for her patients is to sometimes put respect for cultural tradition over professional curiosity. She tells of one young Hmong man on her service in the early 1990s who would lose consciousness, then wake up. He told her it was nothing new—he had been called to be a shaman, a healer in contact with the spirit world.
About 150 young Hmong men in the United States were having such attacks at around the same time. Many died. A nurse called a few months later and told Walker, who was the young man’s primary physician, that after another such episode he, too, had died. His family begged her not to order an autopsy. Autopsies are at odds with Hmong funeral practices. Walker badly wanted to know what had killed him, but she assented to the family’s wishes.
Another way the clinic practices good medicine while honoring the traditions and wishes of the people it serves is by employing bilingual and bicultural staff. It has a Somali-American internist, a Hmong-American physician assistant, a Vietnamese-American psychiatrist, and a Russian-American psychologist and internist among its staff. The nurses are likewise diverse. All must know tropical and other international ailments.
The clinic also has nine professional interpreters who have studied medical terminology. It uses a family member as interpreter in only 4 percent of cases. Family may hide domestic abuse or depression, she says. And an interpreter untrained in medical terminology may mislead or alarm the patient.
Because most refugees have depression, anxiety, or post-traumatic stress disorder, the clinic offers mental-health services on site. It also has staff who arrange for transportation and provide guidance regarding medical bills. Walker says, “All those things are more important to patients than, ‘What’s your blood pressure?’” —M.H.
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The refugees were fleeing Pol Pot, leader of a communist regime under which an estimated 1.5 million Cambodians perished from malnutrition, illness, or overwork. The regime out-and-out executed at least another 200,000.
Holtan had worked with Hmong patients arriving in Minnesota from Southeast Asia in the mid 1970s. An internal medicine physician, he had just started a new job at what then was St. Paul-Ramsey Medical Center when he decided to take a leave and help the refugees.
At a camp in northeastern Thailand, Holtan found mayhem. Hundreds of thousands were without food, shelter, or medical care. Refugees had tuberculosis, malnutrition, malaria, bad teeth, and broken bones that hadn’t been set properly. Some were blind or deaf.
Unable to speak the language, the medical volunteers had to learn to treat people who freely mixed folk remedies and Western pharmaceuticals yet were suspicious of Western medical practices. Some very sick patients, refusing to stay overnight in the hospital, would go home with relatives in the evening and come back in the morning. When a rare cold front moved in from the mountains and little boys’ testicles shrank in the lower temperatures—a normal response—the locals thought the Westerners’ immunizations had sterilized the boys. Some went so far as to harass and intimidate the medical volunteers.
Holtan knew that many camp residents would eventually join their families in Minnesota. So when he returned, he convinced St. Paul-Ramsey Medical Center to open a clinic the following year that could take on the challenge of providing care to the new residents.
In the beginning, the International Clinic at St. Paul-Ramsey, now Regions Hospital, treated only patients from Southeast Asia. Since then, it has treated wave after wave of newcomers from across the globe.
Now called the Center for International Health, the clinic is extraordinary if not unique in terms of the population it sees and the practices it has put in place to serve them. It has become a laboratory for developing practice standards around international health (See “The World Under One Roof,” p. 29). And it is part of a global network called GeoSentinel, a joint effort of the International Society of Travel Medicine and the CDC to track emerging travel-related diseases.
The clinic’s medical director, Patricia Walker, M.D., was a third-year student at Mayo Medical School when the Cambodian refugee crisis broke. She had been born in Taiwan and moved to Bangkok, Thailand, as a child. That made Walker a natural to join the team in Thailand helping the fleeing Cambodians.
Walker returned to Minnesota to finish medical school but later went back to Thailand to work with refugees. Meanwhile, she had a standing offer from Holtan to come to work as medical director at the International Clinic in St. Paul, which she eventually accepted in 1988. Walker has been there ever since. “The thing that actually excites me is that I have the opportunity to take care of people from all over the world,” says Walker, who still sees patients. “They teach me so much about history and culture around the world, and about courage and dignity.”
In addition to seeing patients, she does research and teaches at the University of Minnesota, where she is an assistant professor in the Division of Infectious Disease and International Medicine. Walker’s research often starts with clinical experiences at the Center for International Health. She has published several articles and book chapters based on cases that have come into the clinic and on the clinic’s performance in terms of patient satisfaction and patient outcomes. Walker also speaks internationally on refugee and immigrant health and is co-editing what she believes is the first text on the subject. Immigrant Medicine, scheduled for publication this spring, has more than 100 contributors. It is designed to offer guidance for working with immigrants and refugees to physicians, nurse practitioners, physician assistants, medical and nursing students, public health providers, medical relief workers, and clinic administrators.
Between 2002 and 2004, Walker also chaired Minnesota’s Immigrant Health Task Force, a group of 70 experts who developed guidelines for treating newcomers that are now employed nationally. In 2004, the University of Minnesota Medical School asked her to help define, launch, and direct its Global Health Pathway in the department of internal medicine. Residents who take part in the program do one- to two-month rotations in overseas clinics as part of the curriculum.
William Stauffer, M.D., assistant professor of infectious disease and international medicine at the University of Minnesota, was also instrumental in developing the Global Health Pathway. He has taken a leading role in helping physicians learn more about malaria, tuberculosis, and other diseases common to newcomers. “The world,” he says, “has shrunk very quickly.”
Stauffer, a Salt Lake City native who grew up in Minnesota, became interested in tropical disease while accompanying his birdwatching father to equatorial destinations as a child. He started his medical career in internal medicine and pediatrics, then took tropical medicine training at Johns Hopkins University. In 1999, perceiving a demand for information on international health among members of the local health care community, he organized regular discussions about tropical medicine at Shriner’s Hospital (go to www.tropical.umn.edu for more information). He expected a dozen or so people at the first session. About 60 came.
Such work led to his being designated the main medical technical expert for the CDC and the U.S. Department of Health and Human Services’ Office of Refugee Resettlement in developing domestic medical screening and presumptive treatment guidelines for refugees. Stauffer’s proposed CDC guidelines will be phased in over the next two years. The changes involve tests and/or presumptive treatment for conditions common among arriving refugees such as malaria, TB, and intestinal parasites.
Students of the World
For Walker, Stauffer, and other physicians who work with new arrivals, doing the best for their patients has meant learning to look beyond the obvious and to take clues from the patients themselves. “They often know more about the diseases of their country than you do,” says Stacene Maroushek, M.D., Ph.D., M.P.H., chair of the division of pediatric infectious disease at Hennepin County Medical Center and an assistant professor at the University of Minnesota. She has been working with Africans and other newcomers since the mid 1990s.
Maroushek once cared for a Burundi child who had an itchy bump on her back. Maroushek questioned whether the bump needed to be removed and warned that insurance might not pay, if the insurer deemed removal was for cosmetic reasons. The family was adamant. They knew what it was: a worm that would cause onchocerciasis—“river blindness.” Worldwide, 17.7 million people have the disease, which is spread by the bite of infected black flies: 270,000 victims are blind and another 500,000 have visual impairment, according to the World Health Organization. One symptom is a subcutaneous nodule, a kind of mother worm that releases other parasites. When Maroushek saw the pathology report, it confirmed the family’s hunch.
Maroushek also says doctors sometimes try to go too fast with new arrivals. Physicians want to take care of dental work, untreated heart murmurs, and other conditions newcomers have endured for years. Recent arrivals often have other priorities: finding a place to live, learning how to get around town, enrolling their kids in school.
Those children, however, may be harboring tuberculosis and other maladies that could spread quickly in schools if untreated. The TB rate in the United States has been dropping, but the country still has more than 14,000 cases—and the prevalence of the disease in foreign-born individuals is more than eight times that of individuals born in the United States. Minnesota, with 199 cases in 2005, is one of six states in which more than 70 percent of TB cases were diagnosed in foreign-born individuals, according to the CDC.
Although most physicians are familiar with TB and its symptoms, on malaria and other tropical illnesses, U.S. doctors have some catching up to do. Plasmodium falciparum, a particularly virulent strain of malaria now prevalent in sub-Saharan Africa, can kill within hours of the onset of symptoms—but U.S. physicians who rarely, if ever, see malaria might take days to diagnose it, Stauffer says.
“The global is local in health care,” HealthPartners’ Walker says. “When you have immigrant patients, you have to think about the whole broad spectrum of disease. If you think only of Western diseases, you might make a mistake and miss the diagnosis.”
She recalls a Southeast Asian patient who had seen another doctor but was still suffering from weight loss and fever when he arrived in her clinic. The first doctor had found a lesion and sent the patient to an oncologist for a biopsy. That, says Walker, is an entirely reasonable response on the part of a Western physician. But the oncologist found no cancer.
Walker, however, quickly suspected tuberculosis that had spread beyond the lungs, creating the lesions. She was right.
Give and Take
Tuberculosis is curable if patients take their drugs. But getting them to comply can further complicate an already challenging situation. “You can’t demand it,” says Holtan, who mainly sees TB patients. “It has to be presented and mutually agreed upon.” And that may mean getting clan elders involved in a patient’s care.
Indeed, more give and take than physicians are accustomed to is often the way to go with international patients. “If your big thing is pain in your shoulder and you also have TB,” Holtan says, “I would definitely pay attention to treating that shoulder pain and making it equally important. In return, insist that the patient take the TB meds.”
Immigrants also may not understand how their new home affects their health. Douglas Pryce, M.D., a staff physician at Hennepin County Medical Center, tries to get modest Somali women to spend an hour a day in the sun with bare arms and legs in order to get enough Vitamin D. The melanin in their dark skin and the fact that they are swathed from head to foot in colorful, billowing dress puts them at risk of osteomalacia—softening of the bones from vitamin D deficiency. “They don’t live in a sun-drenched country anymore,” Pryce says. He urges them to get out on the balcony of their high-rise or to another private place to catch some of Minnesota’s limited sunshine during the winter.
Pryce’s experience illustrates the difficulty physicians face in convincing newcomers of the importance of preventative care. Somalis and other Africans are accustomed to seeing a doctor only when they’re sick. They may not at first understand the need to take medication for hypertension, for example, when they feel fine. And, notes Walker, if a pill gives them a headache—they may just stop taking their meds entirely.
For More Information
• Providers guide to quality and culture (http://erc.msh.org)
• Resources for cross cultural health care (www.diversityrx.org)
• Kaiser health disparities report (kaisernetwork.org/Daily_reports/
rep_disparities.cfm)
• The Center for Cross Cultural Health (www.crosshealth.com)
• Cross Cultural Health Care (www.xculture.org)
• National Center for Cultural Competence (www.cultural@georgetown.edu)
• Health Advocates (www.healthadvocates.info)
• Immigrant profiles (www.ethnomed.org)
• Hablamos Juntos Resource Center (www.hablamosjuntos.org)
• National Alliance for Hispanic Health (www.hispanichealth.org)
• Hmong Health (www.hmonghealth.org)
• Islamic Health and Human Services (www.hammoude.com/Ihhs.html) |
Ready is Relative
Physicians will continue to face such challenges as more and more internationals continue arriving in Minnesota. Since 2004, the Minnesota Department of Health says the state has gained 18,000 new refugees, many of whom live in the Minneapolis and St. Paul metropolitan area. Refugees escaping political strife and, in some cases, religious persecution numbered more than 7,000 in 2004. In 2005, more than 5,000 refugees arrived—including nearly 2,300 Somalis and more than 1,700 Hmong. In 2006, the count was about the same: more than 5,000 refugees, including 3,600 from Somalia. Even more people immigrated here for less dire reasons.
This year, Minnesota anticipates a wave of Burmese refugees who will join a small community already in Ramsey County. The Department of Health does not yet know how many are coming, but will work with the Burmese community to educate health care providers about the newcomers’ cultural traditions and health concerns.
The influx of new arrivals may never end, given that we live in a world wracked by war and disease. People somewhere will always be looking for someplace better. Minnesota may be it—particularly now that its medical community has a better understanding of their needs. MM
Marc Hequet is a St. Paul freelance writer.