TB issues loom large for 1,100 migrants
A placid town by a river in south-central Maine is suddenly grappling with a big case of culture shock. Since spring of last year, 1,110 Somali refugees have streamed into Lewiston, a village of 36,000 people, many descended from French-Canadians who arrived in the 19th century to work in the red-brick textile mills that still dot the shores of the Androscoggin River.
Flocking from refugee settlements across the country, the Somalis have been drawn by reports that Lewiston is a safe and affordable place to live — and, some add, by reports of Maine’s generous welfare benefits. Most Lewiston residents have been working hard to make the newcomers feel welcome; but the social services in the town are stretched thin, and state TB experts are struggling to see how an already tight budget can be stretched even further to cope with the new arrivals.
"We were already having a tough time dealing with 300 refugees a year," says Kathleen Gensheimer, MD, MPH, state epidemiologist and head of the TB control program. "This seems almost overwhelming."
The Lewiston newcomers aren’t the first of their kind in the state, which has another enclave of Somalis in Portland, to the south; but the speed with which the immigration has taken place has caught townspeople by surprise. "Typically, a city starts out with a small refugee resettlement program, and then other family members and friends join them over a long period of time," says Phil Nadeau, Lewiston’s assistant city manager. "Here, it’s happened almost overnight."
Nadeau says a majority of the immigrants came from metro Atlanta, where they’d reportedly became fed up with steep rents and high crime rates. Several years ago, the Atlanta Somali community dispatched several "scouts" to scour the country for something better. Their favorable reports from Maine triggered an exodus from Atlanta; and soon the word spread to Somali communities in Minnesota, Ohio, and as far away as Canada.
By the start of last summer, almost a thousand Somalis had settled in, and another thousand were rumored to be on the way. The town decided it was time to put on the brakes and asked the newcomers to tell their friends and kin to stop coming, or at least wait. Last month, the mayor published a letter making the request formal; reaction to that letter has been decidedly mixed among both Somalis and Maine residents. But overall, the go-slow strategy seems to be working: instead of the expected 1,000, only 200 more Somalis arrived over the summer.
Scattered across the countryside
Gensheimer says she’s still in the planning stages as she tries to decide how to approach the newcomers. "Among primary refugee populations who have come to Maine in the past, we know that rates of latent TB infection are 50%-60%," she notes. "Translate that to a thousand people, and you can see there’s the potential for a substantial impact. We don’t want to sit back and just let these cases develop."
But before screening and treatment can even begin, there are questions to answer. Have the Somalis have already been screened during their original resettlement process, and if so, what were the results? Have they been treated for latent TB infection, and if so, have any completed treatment? Finding the answers hasn’t been easy, since the immigrants have come from many different parts of the country, frequently with neither records nor clear recollections about past treatment.
Once the community’s screening needs have been determined, finding a way to get access to everyone won’t be easy, Gensheimer says. Most of the Somalis have settled in the downtown area, in tenements vacated after mill closings several years ago. There they have established a mosque and even a small halal market, Nadeau says.
But entry-level jobs suitable for those with no English or with minimal job skills are scarce. About half the adults have found some sort of work, but they are toiling in egg factories or seafood processing plants flung far across the Maine countryside, not in a single worksite where targeted testing, for example, could readily be carried out.
Doing school-based TB screening might offer another approach, but Gensheimer worries about stigmatizing kids whose race and culture already set them apart. Doing nothing, of course, is hardly an option, she adds. "If active cases do develop, that would not only be terrible from a public health standpoint, it would also run the risk of provoking an anti-immigrant backlash," she says.
Reports from other cities
Meanwhile, Nadeau and others have been working to establish job training programs, English language classes, and adult education courses. The town is forging partnerships with sister cities where entry level jobs are available, and Nadeau is trying to convince a job training program to send staff to work on-site in Lewiston. Classes also are being held for potential employers who have never worked with someone of another culture, Nadeau adds.
It helps that the small town is home to two major hospitals. "Clearly, that enhances our abilities to respond to this group’s problems," says Nadeau. No one suggests there will be a shortage of health problems, he adds.
TB experts who have worked with Somalis say it hasn’t been easy. In Seattle, it’s been "challenging," says Charles Nolan, MD, director of the TB control program at Harbor View Medical Center. "Even among all the other refugee groups we’ve seen, their background and culture are very different," he says. "Probably in part due to the terrible events they’re endured, this group has been as overwhelmed by the resettlement process as any we’ve seen. Because of their cultural understanding of TB as a disease, it’s a difficult diagnosis for them to accept, and it’s especially hard when you’re trying to get a program going for targeted testing."
In Columbus, OH, home of the nation’s second-largest community of Somalis (after Minneapolis, with the biggest), TB controllers echo such comments. "In Somalia, TB is a disease that causes a lot of shame, much like HIV here," says Debbie Coleman, RN, director of the Infectious Disease Division of the Columbus Health Department. "They don’t want to talk about it, and they don’t want anyone else to know they have it." Having lived with scarcity for so long in refugee camps, the Somalis tend to hoard medications, she adds. "In their culture, it’s hard to get medications, so you stockpile them until you feel sick," she notes. "But that makes it hard to know if you’re getting medication into people for prevention," an issue that’s of special importance with children.
A different sense of time
Getting patients to show up at the clinic on time has also been tough, given the Somali concept of time. "You tell someone to come to the clinic at 2 o’clock tomorrow, and they might take that to mean sometime tomorrow,’" Coleman explains. "They show up after everyone has gone home, and they can’t understand why the clinic isn’t still open."
Strange as it sounds, telling one patient from another is much harder than you’d think, she adds. That’s partly because most Somalis typically don’t keep track of birthdays (many claim Jan. 1 as their birthday), or even their birth years; but also because many share just a handful of names, Coleman says. Thus, clinic nurses may be confronted with two patients with the exact same name, both of whom also claim to have been born on Jan. 1. (Sometimes the clinic resorts to taking photographs to keep patients straight.)
Columbus TB controllers have responded by holding many hours of educational sessions to make sure all employees are up to speed on the culture. They’ve also printed Somali-language versions of all the pertinent brochures (even though, as Coleman notes, "the language looks so strange and unfamiliar to us that we find we have to label stuff. It’s not at all like Spanish, where you can pretty much tell what something is by looking at it").
Most important, TB controllers in Columbus say they finally hit on the strategy of hiring two ethnic Somalis, both with backgrounds in health care, to work hand-in-hand with the outreach nurses. Getting the Somalis on the payroll was tough, Coleman adds, since both fled their homeland hurriedly, with no time to take work records or any evidence of having completed educational classes.
Hiring insiders did the trick
But the effort to get the two certified and hired has really paid off, she adds. "They can relate to the patients in a way that we cannot," she says. "They can build a relationship with the family." They also are less expensive than interpreters, since with their medical backgrounds, they also can do skin tests, bring patients in for chest X-rays, and help get them registered when they walk into the clinic.
That’s not to say that Columbus’ experience now is trouble-free. There’s considerable friction between the Somalis and the town’s African-American community, so much that sometimes community mediators must be called in to defuse trouble. Some native-born residents also resent the sheer volume of services the Somalis require, from TB care, to immunizations, to extensive dental care for teeth unaccustomed to a high-sugar Western diet.
The male-dominated Somali culture also forbids women from being examined alone, often prevents them from speaking for themselves, and generally makes it hard for clinicians to communicate effectively with their female Somali patients, notes Coleman.
Despite the hurdles ahead, many Lewiston citizens seem determined to make the Somalis feel welcome and help them find their place in this small town. "They’ll have to do their share, too," warns Nadeau. "It’s definitely a two-way street."
Perhaps because Lewiston’s citizens, including Nadeau, trace their roots to French-Canadians who faced considerable prejudice when they settled in the area back in the 1800s, most townspeople seem determined to react positively to the changes in their lives.
"I don’t look at this as a problem, but as an event which will someday be regarded as a success," Nadeau says. "The way I see it, we really have no other choice if we want to come through this intact as a community."