There are approximately 300,000 Indochinese refugees living in the United States (Table 1). and 14,000 more enter each month. Since they are resettling in all parts of the country, many school districts are now or will soon be feeling the impact. Refugee children registering for the first time in American schools are appearing with multiple health problems. The children are unimmunized and generally un- screened for communicable diseases and personal health problems.

School nurses, in particular, will be instrumental in detecting skin lesions, vision and hearing defects, growth and developmental delays and evidence of disease. Health care providers need to be alert to the potential hazard of active tuber- culosis, to the well-being of the refugee child, as well as to the rest of the school population. Effective referral and follow-up of health problems in refugee children is greatly facilitated by an under- standing of their various cultural beliefs.

TABLE 1 US Refugee Population Figures

Summer 1980

ETHNIC GROUP NUMBER

Vietnamese 240,000 Laotian and Hmong 50,000 Cambodian 12,000 TOTAL REFUGEE POPULATION 302,000

The Vietnamese, the most numer- ous refugees, have received the most publicity; and many health pro- viders are familiar with certain aspects of their culture. The Vietna- mese run the gamut from highly educated, sophisticated profes- sionals to illiterate, rural people. Buddhism is the prevalent religion in Vietnam, but a high proportion of Vietnamese in America are Roman Catholic.

I t is important to detemine how long a Vietnamese family has been

in America. Many of the early ar- rivals are now well integrated into our society and have the same level of wellness as most middle-class Americans. Later arrivals and “boat people,” in particular, have endured prolonged suffering and deprivation and consequently have more medical problems. They also

for Americans to pronounce. It is usual for women to adopt the name of their father’s clan, so husbands and children will have one family name while the mother will have another.

The number of Cambodians who have come to the United States is comparatively small. The few

I School Health Screening I of lndochinese

Sheila M. Pickwell

have less experience with the United States health care system.

It is important to realize that the two groups from Laos share virtually no common characteristics. The ethnic Lao lived in the lowlands and the cities, while the Hmong tribespeople inhabited the high mountains. The Laotians are Buddhist, while the Hmong are animists, believing in spirits and the forces of nature. The two groups speak distinctly differ- ent languages and have different historical and ethnic origins. One can learn to differentiate by their surnames. Laotian names, such as Hanesana, Koulavongsa, Ma- havanh and Sysavath, are multi- syllabic. Since coming to America, the Hmong have adopted their clan names as their surnames because they did not use surnames in Laos. Approximately 18 of the 20 Hmong clans are represented here. The clan names such as Chang, Fang, Yang, Moua and Thao are short and easy

families in the San Diego area have been considerably less sophisticated than any other refugees. The Cam- bodian children in the school have shown a surprising degree of violent and hostile behavior, and health problems have been uniformly more numerous and severe. A recent com- munication with a school nurse from Michigan, who has also work- ed with Cambodian families, indicates that she has found the parents to be well educated and the children to be well behaved and in excellent health.

The US State Department claims that, in 1970, secondary education was available to most Cambodians; and there were nine functioning Cambodian universities. ’ It may well be that my experience has been unique and that a great proportion of Cambodians are highly literate and cosmopolitan.

Any new Cambodians admitted from the camps in Thailand will

102 THE JOURNAL OF SCHOOL HEALTH FEBRUARY 1981

undoubtedly be suffering more illness than previous refugees. According to reports of American medical volunteers, refugees walking out of Cambodia and into Thailand now are suffering from mass starvation and the nutritional disease of marasmus, kwashiorkor, beriberi and anemia.2 Several publi- cations refer to the Cambodians as Kampucheans, since their country has been recently renamed. Many Cambodians speak Thai, having learned it while in the refugee camps. Since this has also occurred with the Hmong people, we have had some success communicating with Thai-speaking Cambodians through a Hmong translator.

Resettlement Refugees differ from immigrants

in several significant respects. Refugees do not leave their home- lands by choice, but rather are forced out by intolerable or unsafe conditions. As a result, their de- parture is not a carefully planned, satisfying commitment, but rather a hastily seized opportunity to flee, necessitating the abandonment of family, friends and a lifetime of possessions. Refugees are not screened for financial self-reliance or employment potential, so they must be financially dependent until they develop language and job skills.

The cost of resettlement has been provided by the federal government under the Indochinese Migration and Refugee Act. The Department of HEW (now Health and Human Services) finances English language classes, vocational training oppor- tunities and job placement services. The financial slack is picked up by one of the sponsoring volunteer agencies. There are eight of these agencies functioning in the country. An agency representative meets the refugee family at the airport and takes them to a rented, partially furnished apartment. They find clothing, teach them to shop in

American markets and generally introduce them to American life.

The funding allotted to the voluntary agencies by the federal government is expected to last a family three months. After this time, the family is to be either self- supporting or becomes eligible for state welfare, Medicaid and food stamps. In large communities with many refugees, the small, over- worked staffs of the sponsoring agencies are able to give only minimal time to resettlement. Often there are refugee self-help groups who can take over some responsi- bility. Anyone working with refu- gees should become familiar with all agencies and groups in a community that sponsor or work with refugees for they can provide valuable assis- tance with translation services, transportation difficulties and health information gathering.

Figure 1 Agencies Resettling

Indochinese Refugees

International Rescue Committee US Catholic Conference Lutheran Immigration & Refugee

World Church Services Hebrew Immigrant Aid Society American Council for Nationalities

Tolstoy Foundation American Fund for Czechoslovak

Services

Service

Refugees - Resettlement is funded by the federal government under the Indochinese Refugee Assist- ant Program (IRAP).

~~~ ~

School Health Screening The Center for Disease Control in

Atlanta is responsible for the health screening of the Indochinese before they leave the transit camps in Asia. They attempt to exclude those with active Tb, VD, infectious leprosy, mental disorders and drug addic- tion.’ Since several of these condi- tions have an incubation period, it is

possible for an individual to leave for America with a “clear status” only to be infectious within a brief time after arrival. It does not seem possible for the U S . health teams in Asia to accomplish more than a cursory screening, considering the large number of refugees transiting monthly. There is no organized health screening effort at the U.S. port of entry, and the sponsoring agencies do not feel this is their obligation. If the refugee is suf- fering from an obvious medical problem, the agency will take him to a doctor; but, otherwise, screening falls to the school nurse as the first health professional to have contact with the family.

It is routine at Linda Vista Ele- mentary School in California for the translator to bring newly registered families into the nurse’s office before the child is taken to the class- room for the first time. This visit allows the family to meet the nurse, and it gives the translator a chance to explain school health services. At this t ime, a relat ionship is established with the family; and the child receives an initial physical screening.

Families arriving from the transit camps invariably have lice and fre- quently scabies. The children need immediate treatment before they can be admitted to the classroom. This problem can be handled in a matter-of-fact , nonjudgmental fashion to lessen the family’s embarrassment. Once the family has been treated, it is rare to have a re- currence since cleanliness and hy- gienic habits are adequate among most refugees.

Few refugee children have been immunized, although the CDC an- nounced in February 1980 that in- creased efforts are being made to give an MMR and the first DPT/Td and OPV before the families’leave the transit camps.‘ If these immuni- zations were given, each individual should have a record. If records are unavailable, there is no alternative

FEBRUARY 1981 THE JOURNAL OF SCHOOL HEALTH 103

but to begin an age-appropriate immunization series.

School personnel are particularly concerned about the incidence of tuberculosis and intestinal parasites in the refugee population. The CDC cites data suggesting that the active Tb rate may be as low as 1% to 2%, although the number of positive skin tests may average 41% in chil- dren and 50% in adults.’ Tb testing on over 200 refugee children in our school yielded 22% positive PPD rate and less than 1070 active Tb rate.

Intestinal parasitism is a common public health problem in southeast Asia. In 1971, while in Vietnam, Colwell et a1 found 75% of rural Vietnamese and 56% of urban dwel- lers to harbor one or more parasites.’ Initial surveys by the CDC in 1975 indicated that parasitic infections among the earliest Viet- namese to arrive in America did not differ significantly from the rates estimated for indigenous US popu- la t iow6 More recent data suggest the incidence of parasitism was underestimated in the initial survey.’J

Two years ago, a parasite count on the hundreds of refugees screen- ed in a San Diego clinic found that 70Oi‘o had one or more intestinal parasites. Parasitism is undoubtedly increasing due to the deplorable san- itation in the camps. The CDC has given assurance that parasites are not a public health threat in Ameri- ca because their life cycles are interrupted by adequate sewage dis- posal and the lack of suitable inter- mediary hosts. It would be prudent, however, to suggest stool specimen examination for ova and parasites for any child referred for well child care and certainly any referred for anemia, fatigue or abdominal com- plaints.

Most school districts survey chil- dren for dental problems, vision defects and hearing deficits. Of these three, dental problems will be the most universal and the most severe. Classroom screenings in our

school indicated 75% of the Indo- Chinese children had one or more visible caries. Many also exhibited long-standing periodontal disease. During CHDP examinations, dental decay was so severe in 43% of the children tha t it necessitated immediate referral. Dental care is not a high priority with parents who are preoccupied with acquiring language skills and finding jobs. The children, however, respond enthusiastically to dental health education and take pride in owning their first toothbrush. It is helpful if the teacher reinforces dental health by making toothbrushing a class- room routine.

Except for the occasional under- age or immature child, vision and hearing tests are easily accom- plished. There appear to be more hearing deficiencies than vision problems. Chronic untreated otitis media causing perforation and scar- ring of the drums is a common problem among the Indochinese children. Generally, hearing is not affected. Parents have been re- ceptive to implantation of PE tubes, as well as tympanoplasty when this becomes necessary. Parents and children have accepted the use of eye glasses to correct vision, but they have been resistant to surgery for strabismus.

Depression and aggression are not unusual features among children and adults, and they are difficult to remedy because of language and cultural barriers. Indochinese are not accustomed to sharing intimate feelings, and psychotherapy is gen- erally not acceptable. Genuine interest and concern, coupled with a friendly school atmosphere may help children with depression. Sometimes aggression can be work- ed out in constructive play and physical activity. Many emotional problems will probably remain neglected until alternative ways can be worked out to deal with them.

There is much evidence of folk and traditional healing practices

among the refugees. The Laotians, for instance, tie strings around wrists during a special ceremony called a “Baci,” a celebration designed to call and welcome a rov- ing soul whose absence from the body may be causing i l l ne~s .~ These strings sometimes number into the dozens and should not be removed from the child’s wrist by school staff, even when they become dirty (as they will).

Another cause of alarm for teach- ers is the Oriental practice of physi- cally traumatizing the skin until ecchymosis or bruising occurs. This ancient method of healing may be applied to any part of the body and can be confused with child abuse practices. This treatment, whether accomplished by pinching, the ap- plication of suction or pressure, is not considered successful unless skin discoloration occurs.

Most refugee children will be eligible for free or reduced-rate lunch programs and breakfast pro- grams when available. Some chil- dren have adapted easily to the American diet, but most have not. Universally they dislike milk, cheese and other dairy products. It is quite likely that a high percentage of refugees share the well-documented Asian lactose intolerance and will have diarrhea and stomach aches if encouraged to consume dairy pro- ducts. It is worthwhile to observe eating habits in the school cafeteria and attempt to evaluate the ade- quacy of the diet. Perhaps school cafeterias can be encouraged to include rice and vegetables in the menu. Rice, vegetables, fruit and small amounts of pork, beef, chicken and fish are the mainstay of the Asian diet. This is a more than adequately healthful diet which, unfortunately in our community, is being supplemented by copious amounts of “junk food,” contribu- ting further to dental decay and, in a few instances, to frank obesity in adults and children.

104 THE JOURNAL OF SCHOOL HEALTH FEBRUARY 1981

It is vitally important that we share our individual experiences in order to learn together how to most effectively and humanely help the Indochinese refugee school children with their health and adjustment problems.

Conclusion Fourteen thousand Indochinese

refugees are entering the United States monthly without adequate health screening. The school nurse, as the first health care provider to see the family, is in an ideal position to screen and refer children with medical problems. Problems fre- quently encountered will include incomplete immunizations, lice and scabies, vision and hearing defects, skeletal deformities, positive skin tests, severe dental decay and the physical effects of intestinal para- sites.

Screening is comparatively easy, especially when one is alert to the special health needs of refugees. More time and energy will go into the complications of referral and the complexities of follow-up, com- pounded by cultural barriers, langauge and transportation prob- lems.

Following are a few guidelines to consider when refugee children

begin to register at your school: I . Be aware of the various ethnic

backgrounds represented in the refugee population (Vietnamese, Hmong, Lao and Cambodian) and learn everything possible about their respective cultural beliefs.

2. Become familiar with com- munity resources which might be helpful in the process of referral and follow-up of health and adjustment problems. This includes sponsoring agencies, respected refugee leaders, available translators and the local health department.

3. Develop a network of doctors and dentists who will treat refugee patients, who will accept Medicaid and who are convenient to transpor- tation.

4. Adjust priorities to accommo- date the many conflicts of time, energy and cultural values the refugee family faces in its new homeland.

5 . Be accepting, friendly and non- judgmental. The refugees will sense your good will and good intentions despite language and cultural differ- ences. W

1. Kahlberg K: Medical care of Cam- bodian refugees. JAMA 243:1062-1065, 1980.

2. US State Department: The Khmer Republic. Background Notes 7747: 1-8, 1970.

3. Health status of lndochinese refugees. Morbidity Mortality Weekly Rep 28(33):

4. Immunization program for lndochinese refugees. Morbidity Morfalify Weekly Rep

5 . Colwell EJ, Welsh JD, Boone SC, et al: Intestinal parasitism in residents of the Mekong Delta of Vietnam. Southeust Asian J Trop Med Public Health 2:25-28, 1971.

6. Survey of Vietnamese refugee centers for intestinal parasites. Morbidity Mortality Weekly Rep 24(4):402-403, 1975.

7. Lindes C: Intestinal parasites in Laotian refugees. J Fam Pract 9:819-822, 1979.

8 . Health screening of resettled Indo- Chinese refugees - Washington, D.C. , Utah. Morbidity Mortality Weekly Rep 29(1):4,

9. Olness K: Cultural aspects in working with Lao refugees. Minn Med 62-871 874, 1979.

Acknowledgements Special thanks are extended to George V .

Pickwell, PhD; Toni Farls, RN, MN; Florence Warnock, RN, MN, CFNP, Betty Thompson, MS, and Chuck Mosburg, MA for their helpful comments on the manu- script.

386-390, 395-398, 1979.

29(4):38-39, 1980.

9-11, 1980.

Sheila M. Pickwell, RN, MN, CFNP, Coordinator, Adult Nurse Practitioner Program, AduWChild Health Nurse Practitioner Program, University of California, San Diego, School of Medicine, S-005, La Jolla, CA 92093.

FEBRUARY 1981 THE JOURNAL OF SCHOOL HEALTH 105