TB CULTURAL COMPETENCYglobaltb.njms.rutgers.edu/downloads/products... · medications may be in short supply; however, antibiotics, including anti-tuberculosis medications, are available

IntroductionIncreasingly, TB control in the United States involves

working with populations of people from different countriesand cultures, who have come to the United States for avariety of reasons. Each year approximately 400,000 iimmmmii--ggrraannttss and rreeffuuggeeeess enter the United States. An iimmmmiiggrraanntt issomeone who leaves his or her country of origin to take uppermanent residence in another country. This may besomeone who comes to the United States for employment,or to join family already here. A rreeffuuggeeee is someone who hasbeen officially granted permission to settle in anothercountry after being forced to leave his/her home because ofwar, poverty, political turmoil, natural disasters or persecu-tion based on race, religion or gender. These kinds ofproblems also create iinntteerrnnaallllyy ddiissppllaacceedd ppeerrssoonnss, who areforced to flee their homes, but remain within their country’sborders. As noted in issue #2 of this newsletter (December2004, http://www.umdnj.edu/globaltb/downloads/prod-ucts/Newsletter-2.pdf), there may be particular health needsand concerns in working with refugees.

This issue of TB and Cultural Competency is focused onrefugees from Burma (Myanmar), since over the last severalyears there has been an increase in this population enteringthe United States. Over the next 5-10 years, approximately140,000 Burmese refugees will be re-settled in the UnitedStates.

As will be described more fully below, since Burma is oneof 22 countries with a high-burden of tuberculosis identifiedby the World Health Organization, this will have implica-tions for TB Control Programs in the United States. Someprograms have already begun to feel the impact of thisresettlement. This newsletter will include a brief culturalprofile of Burma as well as some highlights from a TBoutbreak contributed by two public health nurses in a low-incidence state in the upper Midwest.

BackgroundBurma has a complex history including multiple different

ethnic groups and a number of dynasties and kingdoms

with evolvingpower andborders. The landwas first unifiedas a multi-ethnickingdom as earlyas 1044 AD. This was followed by centuries of shiftingpower and interethnic struggles. In the 19th century severalserious conflicts with Great Britain culminated in the totalannexation of Burma in 1885. While the economy of Burmawas transformed from subsistence farming to large-scaleexports of the country’s rich natural resources under Britishrule, power and wealth remained in the hands of foreignersand as a whole, the Burmese people did not benefit from theprospering economy.

In 1948 the Burmese achieved independence from Britainand a parliamentary democracy followed, though ethnicconflicts continued as minority groups demanded autonomyfrom the government. In a 1962 military coup, the BurmaSocialist Programme Party seized power and held it for thenext 26 years. There were no free elections, and humanrights abuses were common. The government violentlyrepressed demonstrations by students, monks, and thegeneral population, including mass national protests in1988. The military fired into the crowds killing thousands.

Continued on page 2

Northeastern Regional Training and Medical Consultation Consortium Issue #7 Spring 2008

TB&CULTURAL COMPETENCYNotes from the Field

REACHING OUT TO BURMESE REFUGEES

Burma, also called Myanmarsince 1989, is located inSoutheast Asia. It is slightlysmaller than the state of Texas.

In September 1988 the armed forcesstaged a coup to restore order but alsoviolently repressed protesters.

The results of 1990 parliamentaryelections, won by the opposition, havebeen ignored and the military groupwho took power in 1988 still rules thecountry. Due to the extreme politicaland economic crisis over the last fivedecades, there has been increasingisolation from the internationalcommunity, and a lack of adequateinfrastructure and access to resources.This affects millions of people in thecountry, who live in conditions ofextreme poverty with little access tohealth and education services.

In September 2007, the army againcracked down on pro-democracydemonstrators led by Buddhist monks.Many were killed, thousands jailed,and more refugees streamed from thecountry. In spite of stronger sanctions,the government continues to resistinternational pressure to open thepolitical process and improve thehuman rights situation.

(Sources: US Department of State, Bureau ofEast Asian and Pacific Affairs 2007, TheBurma Campaign 2007, and United NationsOffice on Drugs and Crime, December 2005)

Burmese RefugeesMany Burmese flee conflict and

violence between the military andinsurgent groups, state oppression and/or political and religious persecution.An estimated 500,000 people, mostlyethnic minorities, are internallydisplaced within Burma. Many mayalso escape to neighboring countries,such as Thailand, Malaysia, India, andBangladesh where some settle inrefugee camps. Refugee camps areintended to be temporary settlements,though many residents may live therefor several years. Living conditions inthese camps can be very difficult.There are a number of refugee campsin Thailand along the Thai-Burmeseborder, and an estimated 150,000

Continued from page 1

2 NORTHEASTERN REGIONAL TRAINING AND MEDICAL CONSULTATION CONSORTIUM

Burmese refugees, largely from theKaren ethnic group, have lived incamps in Thailand, often for morethan a decade. Prior to arriving inThailand, the refugees and asylumseekers may have experienced torture,rape, forcible conscription of theirchildren in the military, and forcedlabor. Many may have lived as inter-nally displaced persons within Burmafor extended periods.

In 2005 the Thai governmentapproved the resettlement of Burmeserefugees from these camps. Significantnumbers of Burmese refugees fromThailand began to be resettled in theUS starting in 2006.

(Source: Thailand: Burmese ResettlementOffering New Opportunities and CreatingComplications, Refugees International 2007)

Burmese in the United StatesThe predicted influx of Burmese

refugees from Thailand is expected tochange the makeup of the Burmesecommunity in the United States overthe next several years. As of 2000,most of the estimated 20-30,000Burmese living in the US were immi-grants. The largest numbers wereliving in California, New York,Pennsylvania, Texas, Maryland,Massachusetts, and Illinois. Most ofthese were ethnic Burman immigrantsand included many educated profes-sionals. The new group of expectedrefugees is religiously, ethnically, andlinguistically diverse Many newrefugees do not follow the migration Continued on page 4

patterns of earlier Burmese immi-grants, and often are originally fromrural villages in Burma. These newrefugees may bypass establishedBurmese communities in the UnitedStates. In the past two years groups ofBurmese refugees have settled inSyracuse, Phoenix, Minneapolis, FortWayne, and Dallas. (UNHCR, 7/27/07).Additionally, as refugees, the needs ofthese new communities may bedifferent than those of communities ofmore established Burmese immigrants.

Refugees undergo a medical assess-ment overseas before being cleared fortravel to the US. In 2007 the Centersfor Disease Control and Prevention(CDC) revised the Technical Instructionsfor Tuberculosis Screening and Treatment(TB TI). These new TB TI are in theprocess of being implemented andhave been already been piloted at theMae La Camp, a Burmese refugeecamp housing mostly ethnic Karenrefugees in Thailand.

AN OUTBREAK AMONGBURMESE REFUGEES

IntroductionLast year two very serious cases of

TB were reported among students inone high school in a low incidencestate in the upper Midwest. Bothstudents were recently-arrived Burmeserefugees. One patient was diagnosedwith pulmonary disease with a multi-drug resistant strain, and the other with

REPORTING REQUIREMENTSIn October 2007 the CDC Division of Global Migration and Quarantine

issued a letter reminding state and local health departments of the reportingmechanisms for Burmese refugees evaluated for tuberculosis after arrival to theUnited States. Since the Burmese refugees from the Mae La camp are the firstpopulation to be screened according to the 2007 TB TI, the results of domesticevaluations are very important for assessment and oversight. It is also importantthat the CDC learn in a timely manner about any Burmese refugees diagnosedwith TB disease after arrival to the US. Full information, including the letter,instructions, and reporting procedures can be found athttp://www.cdc.gov/ncidod/dq/refugee/burmese/index.htm

NORTHEASTERN REGIONAL TRAINING AND MEDICAL CONSULTATION CONSORTIUM 3

BURMA (UNION OF MYANMAR)• Population: The population of Burma is estimated to be between 47 and 55 million. One third are younger than 15

years of age; only 8% are older than 60.

• Name: In 1989, the ruling military junta officially changed the name of the country from Burma to Myanmar. Thetwo words have the same meaning. However, the word Burma was traditionally used informally, especially in spokenlanguage. Mynamar is the literary form of the word, traditionally used in publications and in ceremonial and officialsettings. Opposition groups within the country tend to still use Burma, as a rejection of what they consider to be anillegal government, or the government’s attempt to impose the more literary language.

• Ethnicity and religion: The government recognizes as many as 105 separate ethnic sub-groups in the country. Membersof any of these ethnic groups may be considered “Burmese” because their home country is Burma. However, not allpeople form Burma are “Burman”. Burmans are the majority ethnic group, making up about 2/3 of the population. Othermajor ethnic groups are Shan 9%, Karen 7%, Rakhine 4%, Chinese 3%, Indian 2%, Mon 2%, and others 5%.

Buddhists comprise 89% of the population, with Christians 4% (Baptist 3%, Roman Catholic 1%), Muslims 4%,animists 1%, and others 2% in the minority. The Muslim and Christian populations face religious persecution. Thereare more than 540,000 internally displaced persons, mostly ethnic Karen, Shan, Mon, and other groups. Many havekin in nearby countries and there are nearly 300,000 refugees in camps located in border areas of Bangladesh, India,and Thailand, as well as several thousand more in Malaysia.

• Education and literacy: Overall, the Burmese population is highly literate, with about 90% of those over 15 yearsof age able to read and write in their native language. Ethnic Burmans speak Burmese, as do many others, butminority ethnic groups also speak their own languages. The US Department of State, estimates that functional literacyis much lower. Educational services in Burma have been limited and interrupted in many areas in recent years, withminority populations at a disadvantage.

• Occupations: Most Burmese work in agriculture (70%), with services (23%) and industry (7%) being less prominent.

• Health indicators: Life expectancy is 57 years for men and 63 years for women. In 2003, the infant mortality wasestimated at about 50 per 1000 live births, and the maternal mortality ratio at 380 per 100,000 live births. Infectiousdiseases still predominate as the cause of hospital deaths. Burma has one of the most serious HIV epidemics inSoutheast Asia: HIV prevalence among pregnant women was estimated at 1.8% in 2004, prevalence among sexworkers and IV drug users is much higher. The epidemic may now be self-sustaining in the general population.

• Health system: Nationally, there is a shortage of primary health care workers (nurses, midwives, basic healthpersonnel). In many areas, access to care and qualified doctors may be difficult. There is a large private medicalsector; private health expenditures account for over 80% of total national health expenditure. In the public sectormedications may be in short supply; however, antibiotics, including anti-tuberculosis medications, are available inpharmacies and markets. Traditional medicine is recognized as an integral part of the health care delivery system.

• Tuberculosis: Burma is among the 22 high-burden countries as reported by the WHO; however, the national TB programis showing steady improvement. The 2005 TB incidence was estimated at 171 cases/100,000 population per year. In 2004,4.4% of new TB cases were MDR, as were 16% of previously treated cases. Global targets for TB control have been reachedin Burma despite serious constraints in resources – both financial and human. The greatest challenge facing Burma is tosustain their successes in the context of limited resources, an increasing number of persons co-infected with TB and HIV,and increasing rates of drug-resistant TB. There are strong initiatives to engage the growing number of private generalpractitioners diagnosing and treating TB throughout the country. However, services are needed for populations especiallyvulnerable to TB in Burma, including the Thai-Burma cross-border populations and persons residing in remote locations.

Sources:Central Intelligence Agency, The World Factbook: https://www.cia.gov/library/publications/the-world-factbook/geos/bm.htmlU.S. Department of State, Bureau of East Asian and Pacific Affairs: http://www.state.gov/r/pa/ei/bgn/35910.htmWorld Health Organization, http://who.int/countries/mmr/en; http://who.int/whosis/database/core;http://www.searo.who.int/EN/Section313/Section1522_10916.htm; http://www.searo.who.int/LinkFiles/Country_Health_System_Profile_7-myanmar.pdfWHO Country Office for Myanmar: http://www.whomyanmar.org/EN/UNAIDS (Joint United Nations Programme on HIV/AIDS): http://unaids.org/en/Regions_Countries/Countries/myanmar.aspYOUANDAIDS, the HIV/AIDS Portal for Asia Pacific: http://www.youandaids.org/Asia%20Pacific%20at%20a%20Glance/Myanmar/index.asp

been a reflection of the level of stigmaaround TB in Burma.

The nurse made her second homevisit without an interpreter and metwith the patient’s family. They had fledreligious persecution in Burma,arriving in the US several monthsbefore the patient was diagnosed withTB. The family was very involved inthe activities of a local church groupthat had sponsored their settlement inthe US. The adult family membersspoke limited English, but the schoolage children were fluent. Therefore,the patient and the patient’s siblingsacted as interpreters for the parentsand other adult members of theextended family. This was only atemporary solution, and it createdtensions in the family as it put theyoung people in the role of ‘gate-keepers’ in interactions with the healthdepartment.

The contact investigation expandedto local churches in which the familymembers were active. The interpretersremained hesitant to participate ingroup education and testing, stating “IfI go into a building with TB, otherswill think I have it and will not cometo me for help anymore.” Deacons andyoung people volunteered as inter-preters during the TB education andtesting sessions at the churches.

The health department staff under-took the challenge of educating theinterpreters about the cause andtransmission of TB, and its treatment,emphasizing how TB is not spread andhow soon someone on appropriatetreatment is no longer infectious. Whilethe interpreters may have understoodthis, they remained concerned thatothers in the community would notunderstand and would shy away fromthem. They were, however, willing towork over the phone, since it avoidedface-to-face contact.

Health department staff recognizedthat there would be no easy solution toaddressing the stigma-related issuespresented by the interpreters, anddecided to work around the issues

instead of trying to change the situa-tion. Luckily, a Burmese internationalmedical graduate working in the areajoined the interpreter team, providinga ‘cultural bridge’ between the inter-preters and the health department.Staff felt confident about the accuracyof TB information that she provided,and she acted as a role model for theinterpreters. The interpreters neverbecame comfortable with the idea ofgoing into patients’ homes, but as timewent on, they became more confidentin communicating TB information andbegan helping in other ways: providingclients with transportation to clinic orto apply for social services and helpingout in public events. Because of therole the interpreters served in thecommunity, in time, they began toserve as liaisons who could assist withproviding access to the communityand provide information about theimportance of the health departmentefforts.

Another unexpected challenge inworking with the interpreters had todo with ‘territory’. Sometimes inter-preters from one ethnic grouppreferred to interpret only for patientsfrom their group. They respected the‘territory’ of another group’s inter-preter, saying that each interpretershould stick to the patients withwhom they had already startedworking. In this case it was importantfor the health department to realizethat it was not simply an issue oflanguage, and that the complex socialstructure of religious and ethnicgroups that make up the Burmesepopulation must be respected. Bothcommunity members and interpretersseemed more comfortable followingthe intuitive roles and relationshipsestablished within their cultural group.By demonstrating respect for thisapproach the health department staffwas able to work with interpreters toeffectively meet their public healthgoals in a way in which the inter-preters felt comfortable.

Another challenge around the use of


pulmonary and extra-pulmonarydisease with severe complications.

Fortunately, there was no docu-mented transmission in the high school,but secondary cases and contacts withlatent TB infection were found inchurches and places of employment. Inthe end, a total of five active cases andmany infected contacts were identifiedand treated until completion. Over thecourse of their interaction with thisrefugee community, the TB programstaff faced many challenges related tothe impact of pervasive TB-relatedstigma, the use of interpreters, andcross-cultural communication.

Because of cultural issues specific torefugees, including a history of perse-cution and related distrust ofgovernment, this was a challengingpopulation to work with. In thisnewsletter, we are presenting a vignettefrom one of the cases and highlightingsome of the challenges encountered.We will explore some of the culturalfactors that may have potentiallycontributed to the challenges, as wellas some possible approaches andlessons learned in retrospect. However,it is important to note that there are no“right answers” and the vignette simplypresents issues to think about in thisparticular instance and someapproaches that might be used whenencountering similar situations.

Pervasive Stigma & Workingwith Interpreters

On the first visit to one patient’shome, the public health nurse commu-nicated directly with the teenage patient,who understood English very well andwas receptive to information she offered.The public health nurse contacted theBurmese interpreters who worked withthe department of health for assistancewith the contact investigation and on-going DOT. However, the interpreterswere hesitant to get involved for fearthat they would be associated with TBdisease and rejected by other Burmesecommunity members. This may have


nity, rather than their personal health,may also speak to the community andfamily structure among Burmese andthe more typically non-Western focuson the larger community, rather thanindividuals. In many cultures theindividual is valued most for the rolehe or she plays in family and commu-nity. Another potential contributor tothis seeming disregard for personalhealth may be a perception of healthand illness as something that is givento a person and that cannot becontrolled. It may be seen as the willof God, or the universe, and the finaloutcome of what will happen isalready determined, so the individualmust accept what happens. This isdifferent than the mainstream Westernperspective that views personal healthas strongly influenced by the indi-vidual and the actions he or she takes.

Similarly, even people who arerelatively comfortable in a new culturemay seek guidance and solace fromtheir culture of origin in difficultsituations, such as life-threateningillness. Again, an understanding ofthese concerns, values, and percep-tions of illness may assist the healthworker in addressing the concerns andfears of the patient in order to gaincommitment and adherence to treat-ment, as well as cooperation in thecontact investigation.

Communication IssuesHealth department staff were

surprised to learn that some individ-uals who should have been identifiedas contacts early in the investigationwere not identified until much later.This surprised the health departmentfor two reasons:

• Although trust was initially achallenge in working with thiscommunity, health department stafffelt community members nowunderstood the risks of spreadingTB, communicated openly, andcooperated freely. This was asignificant accomplishment giventhe fact that many communitymembers had little experiencedealing with organized healthcaresystems and many had reasons todistrust or fear such systems basedon previous experiences with anautocratic government.

• Health department staff felt theyhad clearly defined for communitymembers exactly who should beconsidered a “contact.”

Who is a contact?Health department staff defined a

“contact” as someone who had been inthe same space as the original case. Tothe health department staff, thisexplanation seemed an obviousdescription of who should be includedas a reportable contact. In hindsight, itis clear that some community membersdid not consider people who frequentlycome and go to fit this category. Forinstance, health workers learned laterinto the contact investigation that onepatient’s family held 24-hour prayerservices in their home upon learning ofthe patient’s TB diagnosis, with variousmembers of the community stoppingby. It became increasingly clear thatmany of the social groups were inter-related, mostly through their churches.If one family member got a specialtyfood product, they would all gather tohave a potluck meal. However, thistype of event was also typically notmentioned to TB control staff. To thecommunity members this was consid-ered a normal occurrence of everydaylife, not a “visit” or a “reportable event.”

Neighbors and friends continued tovisit the family’s home. However, thepatient reported having no visitors,


interpreters is highlighted in this case:it is clear that the interpreters were animportant part of the community.Because of this and their relationshipswithin the community, they may nothave been able to serve as objectivemedical interpreters, and may havepresented some of the same concernsas using family members to interpret.For more about working with inter-preters, see Making the Connection: AnIntroduction to Interpretation Skills for TBControl, a video and viewer’s guideproduced by the Francis J. CurryNational Tuberculosis Center.

The health department staff alsonoticed that patients themselvesseemed to express more concern aboutthe effect of their disease on their placein the community than about theirown health. The patients, and thoseinterviewed as part of the contactinvestigation were very concernedabout being isolated or shunned bytheir peers and others in their commu-nity. Health department staff had tounderstand these points of view to beable to address their clients’ concernsand gain their cooperation. Due tostigma, association with the diseasecould lead to isolation from theircommunity. In this context, a positiveTB test result was threatening prima-rily because of what it might implyabout an individual’s integration intothe community, and was only second-arily concerning as a health issue. Anapproach that might be useful in thissituation may be to ask the patientwhat their most important prioritiesand concerns are, which would helpprovide insight into how to meet theirneeds, so that the patient could thenfocus on treatment. If in fact, theirbiggest priority is to maintain an activerole in the community, one approachmight to be to emphasize getting wellas the first step to re-entering thecommunity as well as to reinforce theidea that TB itself does not discrimi-nate and anyone can be infected.

This emphasis on TB threateningpatients’ integration into the commu- Continued on page 6

People who have been recentlydisplaced may place a veryhigh value on preservingharmony and participating inthe greater community.



TRADITIONAL MEDICINEThe World Health Organization reports that up to 80% of the world’s poor and rural populations rely on traditional

medicine for primary care. Traditional health practitioners tend to be more accessible than conventional healthcare servicesin many rural areas. Health workers in refugee camps in Thailand find that many Burmese prefer traditional medicine forcommon health conditions – and that belief may be found in Burmese in the US. However, it is important to rememberthat in many cultures traditional and Western medicine co-exist and healthcare workers should not assume that membersof a specific cultural group will use traditional medical practices. It is also important to avoid provoking a direct confronta-tion between the two. Rather, healthcare practitioners should ask patients about their use of traditional medicine so thatthey can coordinate and avoid any potentially dangerous interactions.

Though traditional medical practices vary by ethnic and religious group, the following are examples of some Burmeseethnic traditional health practice. However, the healthcare workers involved felt that these did not play a role in the casestudy described.

“Burmese traditional medicine is based in Ayurveda, the classical healthcare system of India, as well as in indigenoushealth traditions. Health is believed to be related to interactions between the physical body, spiritual elements and thenatural world, referred to as the ‘dat system’, which includes Wind, Fire, Water, Earth and Ether elements. Burmesemedicine also follows concepts of hot and cold, common in many indigenous health systems, which are believed to causefevers and coldness in the body, and can be influenced by diet, seasons and spiritual elements (MacDonald, 1979). Illnesswithin this system is believed to be caused by a physiological imbalance, which may begin on both physical and spirituallevels. Illness is classified as an imbalance and, therefore, treatable, until the very final stages, at which point it is classifiedas a disease.”

“Burmese spiritualism is based on a complex system of sprit worship, not directly related to Buddhism, but whichhas become part of the spiritual practice of Burmese Buddhists. Within this system, belief in spiritual entities and agents islinked with beliefs about the causation, progression and treatment of illness. A panoply of spiritual entities and their agentshas been identified (Spiro 1967). These include witches, demons, ghosts and nats – Burmese sprit beings. Spirit influenceis believed to include possession and illness. Accordingly, treatment methods incorporate spiritual healing and exorcism.”

Muslim Burmese may use amulets around their children’s necks. These are made by a Burmese traditional ‘doctor’ whouses Muslim numerology and Burmese astrology, corresponding a lucky number to a verse in the Koran. “Once the specificverse is identified, it must be written on high-quality white paper, wrapped tightly and neatly in plastic, tied up with athread and worn around a specific part of the body.”

Karen practitioners diagnose illnesses by checking wrist pulses and examining the face and eyes. Most illnesses arethought to be caused by heat in the body, often related to eating the wrong foods for one’s body type. An astrologer isconsulted for problems of external health and well-being, while a doctor would be sought for internal health issues.

Sources: Bodeke G, Neumann C, Lall P,and Oo ZM.Traditional Medicine Use and Health Worker Training in a Refugee Setting at the Thai-Burma Border;Journal of Refugee Studies, Vol. 18, No. 1, Oxford University Press; 2005. Neumann C. Amulets and Tears (photoessay); The Journal of Alternative andComplementary Medicine, Vol. 9, No.1, pp 21-33, 2003. Neumann, C. Vanishing into the Hills of Burma: Traditional Karen Medicine (photoessay); TheJournal of Alternative and Complementary Medicine, Vol. 9, No.4, pp 461-465, 2003.

since those visiting the home hadactually come to see the patient’ssiblings. Over time, the patient and asibling (a secondary case) grew tounderstand that they were under homeisolation, but the family did notunderstand that this meant the wholehouse was under isolation. As a resultof these misunderstandings, the healthdepartment continued to identify newcontacts while patients were stillinfectious.

Cultural Communication StylesLooking back, one might conclude

that this miscommunication aroundwho is defined as a contact occurreddue to differing cultural communicationstyles rather than differing agendas orissues of mistrust. The predominantAmerican communication style valuesunique individual expression and clear,direct verbal clues. This style facilitatesexchange of specific information, facts,or opinions and information is often

presented using a very direct approach.Burmese culture may be described asmore collectively-oriented, favoringindirect, nuance-filled communicationover the literal meaning of the spokenword. Self-expression within thiscommunication style reinforces collec-tive values and identities, and canfunction to prevent disagreement andpreserve harmony. The way communitymembers viewed visitors to the homemay be one example of this. In theevents described here, the interpreters


working with the health departmentwere members of the affected communityand may have felt intrusive or disre-spectful directly translating queries aboutvisits to the home by any person for anypurpose or directly asking who had beenin the home. If that were the case, theinterpreters might have shaded thedefinition to be more compatible withthe traditional communication style.

Faced with such a challenge, healthcare providers can try to bridge differ-ences in communication styles byspecifying the different types of visitorswho may come to house, such as otherfamily members, friends of others in thehouse, people who came over formeals, and state that this type of person,even thought they were not particularlythere to see the patient, is also someonewho might have been at risk. In thiscase, since a contact investigation wasconducted at the high school, otherstudents or teachers who were in thesame classrooms or common areascould be used as an example to demon-strate the concept of sharing space.

Another approach in this situationmight be to discuss communicationstyles in advance with the interpreterand describe the type of informationthat will be presented and gatheredfrom the patient, and ask the inter-preter if they think that there are anycultural or communication style issuesthat may hinder effective communica-tion around these concepts.

ConclusionIn working with refugees or immi-

grants from other cultures, healthdepartment staff will encounter issuesof establishing trust, communicatinghealth information, overcominglanguage barriers, explaining our healthsystem, and clarifying who will dowhat to ensure that diagnoses andtreatments reach a successful conclu-sion. This vignette presents only someof the issues that may arise whenworking with recent refugees fromBurma, or other settings. Whenworking with recent immigrants and

Social Services for RefugeesA range of social services may be useful for assisting refugees who are resettlingin our country. These include pre-school, academic assistance for elementaryschool children, and for adults: English language classes, computer training,companionship, cultural orientation, case management, interpretation, transla-tion, assistance with immigration, navigating the health system, and food banksupport. The following sources have information on these services:• U.S. Department of Health and Human Services, Administration for

Children and Families, Office of Refugee Resettlement lists contractorsreceiving matching grants in many of cities and states where Burmeserefugees are settling www.acf.hhs.gov/programs/orr/programs/mgpss.html

• Human Rights Watch – Refugee Project www.hrw.org• UNHCR (United Nations High Commission on Refugees) – The UN Refugee

Agency www.unhcr.org• Episcopal Migration Ministries www.episcopalchurch.org/emm• Church World Service – Refugees www.churchworldservice.org• State and local health departments also often have an office in charge of

refugee services.

TB Educational MaterialsAs noted earlier, there are a number of different languages spoken in Burma.The following websites provide TB education materials in various languages,including some languages spoken by Burmese refugees:• The Minnesota Department of Health (Karen)

http://www.health.state.mn.us/divs/idepc/diseases/tb/brochures.html• US Committee for Immigrants and Refugees (Burmese, Karen)

http://refugees.org/article.aspx?id=2045&rid=2086&subm=178&area=Participate• The Michigan Department of Community Health

http://www.michigantb.org/hcp/documents/EnglishandBurmesePatientEd.pdf

Additional information on Burmese refugees and resources is available at:http://www.umdnj.edu/globaltb/products/newsletter7.htm.

Continued on page 8

refugees, it is important to considerhow the many cultural nuances impactnot only patients and their families, butalso the social service providers andinterpreters who may be part of thecommunity and share the same valuesand beliefs. We hope that this issue ofNotes from the Field offers a range ofperspectives that will be useful to TBcontrol staff facing these challenges.

By Bill L. Bower, MPH, Margaret Secor, RN,BSN, Kathleen Millard, BA, LaurenMoschetta-Gilbert, MA, Nisha Ahamed, MPH,and Julie Franks, PhD

Thanks to Greg Harrington, MD for hiscontribution to enriching this case study. Wewould also like to acknowledge Carolyn Wagner,RN and Kitty Katz, RN and other members ofthe TB control team who worked so effectivelyon this outbreak in the Burmese community.

Mae La CampThe following information was drawn

from trip reports and presentationsregarding a May 2007 Advisory Councilfor the Elimination of Tuberculosis(ACET) and CDC site visit to the Mae Larefugee camp. The purpose of the visit wasto assess the implementation of new TBTechnical Instructions. Thanks to WandaWalton, Branch Chief, Communications,Education, Behavioral Studies Branch,Division of Tuberculosis Elimination atCDC for providing information andphotos from the trip.

With 573 acres, the Mae La Refugeecamp is the largest camp on the Thai-Myanmar border. As of September2007, about 15,000 refugees from

225 Warren Street, Newark, NJ 07101-1709 (973) 972-3270

www.umdnj.edu/globaltb

this particular camp were expected to resettle in the US.The population in the camp is about 46,000 with 97%identified as Karen. There are 26 schools with 16,460students and 675 teachers.

Resettlement efforts have improved TB case finding in thecamp. The International Office for Migration (IOM) is nowconducting medical evaluations and identifying TB cases.

IOM also conducts life skills training for refugees sched-uled for relocation. These sessions cover TB transmission andpathogenesis. Education, training, and coaching on sputumcollection are provided for refugees who must produce asputum specimen. TB nurses provide individual educationfor those diagnosed or suspected to have TB disease.

Once diagnosed with pulmonary treatment of TB, patientsare isolated in the “TB village” located at the far end of thecamp up a steep hill. In May of 2007, about 200 people werebeing housed in the TB village.


Continued from page 7 All TB patients in the camp receive DOT with treatmentregimens following ATS/CDC/IDSA standards. Patientswithin the TB village are treated by a physician from the aidorganization Doctors Without Borders.

If you would like to provide feedback on this newsletter please visit our website athttp://www.umdnj.edu/globaltb/contactus.htm

Above: Administering DOT.

Left: Information boards, like this onedepicting photos and stories fromrelocated refugees are very popularat the camp.

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