Sheila M. Pickwell
Nursing Experiences With Indochinese Refugee Families
INTRODUCTION The history of the Indochinese in America parallels
the evolution of the neighborhood where I have worked for 22 years, the community of Linda Vista in San Diego, CA. This community of 20,000 is only five miles from downtown but is geographically isolated by free- ways and canyons. Spring of 1975 brought the first major influx of refugees into California. The availabil- ity of low cost housing prompted the resettlement of many families into our area. During the intervening six years the complexion of the community has changed from multiracial American to 50% Indochinese refugee. This change has resulted in both conflict and adaptation for the established residents, the refugees and the health, education and welfare professionals.
The Linda Vista community was developed in the 1940s by the federal government. Multistoried apart- ments were built to house defense plant workers and military dependents. A shopping center was constructed in 1942 and dedicated by Eleanor Roosevelt. Gradually, the apartments were purchased by individuals and rented to low-income transient families. Duplexes and single-family dwellings were built around the periphery.
Many of the homes continue to be occupied by long- time residents, but 55% of the housing consists of rental units. Three elementary schools, one junior high school and one senior high school serve the area. When the refugees arrived the population was fairly evenly divided between black, white and hispanic ethnic groups.
Each refugee family moving into the community has replaced a former resident, causing ill will and resent- ment in the American population. Landlords favor the Indochinese because they are clean, responsible, uncom- plaining and willing to pool financial resources to pay high rents for substandard housing. Social agencies, refugee resettlement agencies and community clinic and school personnel have acted as mediators in disputes and have attempted to allay conflict and fears among all groups.
What has occurred in our schools and community will likely be repeated many times across the country as the current Indochinese population of half of a million in- creases by the continuing entry of 4,000 refugees monthly. Secondary migration also is occurring as fami- lies and individuals leave their original settlement site to join friends and family established in other parts of the country.
86 THE JOURNAL OF SCHOOL HEALTH FEBRUARY 1983
COMMUNITY HEALTH CARE Since its inception Linda Vista has been medically
underserved. Some residents receive Medicare or Medi- caid benefits, but a large proportion have no resources to finance health or dental care. Medical attention has traditionally been sought on an episodic basis in the emergency room of a nearby hospital. The elementary schools are staffed by school nurse practitioners who do as many physical examinations as their full schedules permit. The Department of Public Health has one Well- Child clinic monthly and offers public health nursing (PHN) services. It was as a PHN that I first became involved in Linda Vista in 1960.
Community volunteers in 1972 surveyed the residents to determine health care needs. They rented and re- furbished a building and established the Linda Vista Health Care Center. The center offered a full range of services including pediatric and general medicine, womens health care, psychosocial counseling and an extensive home visiting program. The clinic staff responded to the need for accessible culturally relevant health care. Now, in 1983, the patient population is 70% refugee. This has prompted the community resi- dents to feel they have lost the primary care facility they worked so hard to establish just a decade ago.
THE REFUGEES It would be desirable if communities could be for-
warned and health departments, medical and education- al facilities prepared for the influx of refugees. How- ever, this has not been the pattern established by our government. Most of your experiences will likely be similar to ours. One day, perhaps unexpectedly, an Indochinese child will register at your school or a family come to your facility for care.
The first priority for the health provider is to deter- mine the ethnicity of the refugee. Currently, there are approximately 423,000 Vietnamese, 75,000 ethnic Lao, 65,000 Laotian Hmong and 63,000 Cambodians in America. The families are each sponsored by one of the voluntary agencies charged by the government with re- settlement. The federal government channels resettle- ment monies through the Indochinese Refugee Assist- ance Program (IRAP) to the voluntary agencies for direct dispersion to the families for rent, food and clothing. Additional money is allocated to the states for job training, English language classes, general relief and Medicaid. Financial aid to both the refugees and the helping agencies is being drastically reduced by the present administration.
Prior to admission to the country, the refugees have spent months to years in camps in southeast Asia. It is from these camps that they are screened and selected for transport to the U.S. The U.S. priority at this time is family reunification.
My personal experience with the refugees began in May 1975, while coordinating home care services to the patient population of the Health Care Center. As refugee families became part of our clientele, home visits were extended to them as well. Of course, language barriers were frequent obstacles to good com- munication. In 1975 many refugees spoke at least some English or had friends or relatives w h o could translate. As our population increased we were able to hire our own translators and train them in history taking and selected health education principles. Home visits were invaluable to the refugee families as well as to us. We gained insight into their family relationships and child rearing practices as well as indicating to them our con- cern for their health and adjustment problems.
Looking back over six years of home visits I am amazed at the many changes the refugees have made to adapt to our way of life. Many of the early arrivals, particularly the Vietnamese, were highly sophisticated and cultured people, very much in concert with American mores and customs. The Hmong who arrived in I975 appeared to us to be primitive and alien. The Hmong are mountain tribespeople from Laos who were marked for extinction by the invading Vietnamese forces because they had worked directly for the Ameri- can CIA, fighting against the Pathet Lao and building airstrips in the highlands for use by the U.S. aircraft.
The Hmong arriving in San Diego wore their tradi- tional dress and headcoverings. They wore no under- wear and the children urinated on the floors and the adults in the streets. Many dried fly-covered meat on clotheslines in their backyards. Their diet contained liberal doses of garlic and homes smelled of boiling chicken livers, garlic and urine.
Now, six years later, refugee homes have taken on the appearance of typical American homes. Furniture may be sparse but homes tend to be clean and orderly. Fam- ilies who have moved into the middle class have all the accoutrements of middle class American life, sometimes including two cars in the garage.
FEBRUARY 1983 THE JOURNAL OF SCHOOL HEALTH 87
REFUGEE HEALTH PROBLEMS There is significant concern nationwide about the
kinds of health problems the Indochinese are bringing into the country with them. The statistics compiled by the Centers for Disease Control (CDC) on refugee health problems indicate an active tuberculosis rate of 1-2%, a 40-50% positive skin test rate and a 64% rate of infestation with intestinal parasites. I
My own experience as a Family Nurse Practitioner working in both the community clinic and a school setting indicates the following to be the most numerous problems in school-age children, summarizing data reported elsewhere from 400 physical examinations: 83% of the children were incompletely immunized; 49% had severe dental decay; 27% had positive tuberculin tests; and 1.5% had active tuberculosis. Personal health problems included 25% with skin lesions, 15% had otitis media, 9% had musculoskeletal defects and 13 To were anemic. *
Although the refugees are said to be screened and basic immunizations started in southeast Asia' our experience has indicated that thorough screening needs to be initiated as soon as contact is made in this country. A screening protocol should include three consecutive stool specimens for ova and parasites, a complete blood count and venereal disease screening tests for all adults and a hematocrit for each child. Everyone needs tuber- culosis testing, hepatitis screening, a urinalysis and a complete history and physical examination. Tubercu- losis skin tests are applied to all but known positive reactors. All tuberculin skin tests are interpreted in accordance with CDC recommendations that positive reactors be x-rayed and then treated prophylactically without regard to previous innoculation with BCG. ' Immunizations must be started for children lacking proof of previous protection, and tetanus innoculations given to adults.
Many of the children have physical problems that we are unaccustomed to seeing in the general school popu- lation in this country. Musculoskeletal malformations appear with some frequency as do congenital defects of all kinds. There is no reason to assume that Indochinese children have more defects than other children. But, since they did not have the medical resources in their homeland to correct these problems, we are seeing their occurrence in an older age group. Ordinarily they would have been attended to when the children were much younger.
For instance, supernumerary digits are compara- tively common among our Laotian children. I have at- tempted to have extra digits removed from the hands of four children, each time encountering parental opposi-
tion for cultural reasons. Apparently there exists among the Laotian people the belief that bad luck or mis- fortune may be associated with this type of correction. While extra digits do not affect the physical health of a child, they can contribute significantly to a delay in per- sonality development.
The only child I succeeded to obtain surgery for was a shy withdrawn boy who was overwhelmed and pre- occupied by his physical problem. I t was this increasing- ly obvious distress over his deformity and his non- participatory behavior in the classroom that finally prompted his parents to agree to surgery. However, other than signing the surgery permit, the family declined to be involved. Consequently, I took the boy for all his pre- and post-operative appointments, paid for the medications not covered by Medical and took him to the outpatient surgical department for the opera- tive procedure. The family was uncooperative to the point of refusing to give the pre-operative medications and the post-operative antibiotics, nor would they make any attempt to keep the dressing clean. It was usual for me to have to search the neighborhood for the child when we had an appointment since no one would bother to have him home and ready to go.
In the summer of 1981 we established an Indochinese tuberculosis prevention program in the San Diego City Schools. Our goal was to see that all 5,000 refugee children registered in the schools were screened for tuberculosis and the positive reactors started on INH chemoprophylaxis. The education and training of translators required a major effort in the initial stages of the project but reaped dividends later. We succeeded in our efforts to screen dozens of children and obtain current records from hundreds more. The translators educated parents and children in the need for Tb screening and the rationale for INH therapy. We were concerned with children who were known positive PPD reactors as well as those with no record of testing.
An additional unexpected finding was the large number of previously known negative reactors that had converted to positive during the previous year. Subse- quently the CDC published data obtained in a con- trolled study in New York which corroborated our find- ings. The Monroe County Health Department was able to rescreen 217 previousIy tested Indochinese refugees. They found 94 (43%) of these individuals had converted to positive. The same article mentioned that Allegheny County, PA, and Pinellas County, FL, have each re- ported conversion rates of 12% and 27%. respectively.' The Laotian population in these studies showed a signi- ficantly higher conversion rate than the other refugee groups. This was also the situation with our Laotian school children.
88 THE JOURNAL OF SCHOOL HEALTH FEBRUARY 1983
PERSONAL EXPERIENCES AT LINDA VISTA ELEMENTARY SCHOOL
Previous articles have documented the numerous health problems of refugee children, as well as their historical and cultural backgrounds and will not be repeated in detail h e ~ e . ~ . ~ . ~ The remainder of this paper will describe some personal experiences I have had dealing with the most commonly encountered health problems of the children.
Poliomyelitis infection remains a problem in southeast Asia and many children show the effects of previous infection. The damage cannot be reversed but many can be helped with orthopedic aids or physical therapy. If families will agree to diagnostic tests and rehabilitation, the children can be helped immeasurably to achieve increased mobility and self-sufficiency. Some families will welcome evaluation but refuse continuing care for reasons that may not be entirely clear. One beautiful Vietnamese girl in our school was to have bracing for a badly deformed foot. The family dis- continued the orthopedic services insisting that the child was opposed to the bracing, although the child contin- ued to assure us she wanted the device. Another Vietna- mese child was braced with excellent results but follow- up appointments were not kept and it is a continuing concern whether or not his appliance will be replaced as he grows.
Epilepsy occurs among the Indochinese as it does all populations. There appears to be a definite reluctance to accept the chronicity of the problem and treat it effectively. Two Vietnamese children I worked with last year were both diagnosed by electroencephalogram and controlled with phenobarbital. Both families eventually discontinued the medication and the children again experienced seizure activity. One child was transferred from the school to avoid confrontation with school authorities. The family was unaware that health records follow children throughout the system. A Laotian child with seizures following encephalitis also was taken off his medication because his parents were convinced that his physical growth was retarded.
Another Laotian child, a seven-year-old girl, was con- stantly falling asleep in the classr...