To Categorize is Human An interactive session on implicit bias

Refugee Health: Imagining Our Future

North American Refugee Health Conference Niagara Falls, New YorkJune 12, 2016Patricia F Walker, MD, DTM&H, FASTMH Professor, Division of Infectious Disease and International MedicineDept. of Internal Medicine, University of MinnesotaMedical Director, HealthPartnersTravel and Tropical Medicine Center

DisclosureI receive royalties for the following educational products:

Elsevier Publishing for sales of Immigrant Medicine

UpToDate for publication of Guidelines for Care of Adult Immigrants

Critical Measures, Inc. for on line cross cultural case studies

Imagining Our FutureIntroduction Two case studiesInternational imaginings Domestic imaginingsPhoto Credit:Albany Daily StarJune 6, 2016

When Jim Sutton asked me to speak on the future of refugee health, he commented that refugee health is a movement, and that we have been organizing ourselves around refugee health care the past few decades. It was such an interesting comment to me and as I reflected on it, I realized that that has been the focus of my career, and the career of many of you in the audience, I imagine either for decades or for just a few months I have had the privilege to work with many of you to help define the body of knowledge, attitudes and practices which all have the same goal in mind: good outcomes for those refugees with whom we have had the privilege of interacting over our careers, both internationally and domestically.

http://www.albanydailystar.com/world/400000-syrian-refugee-children-cannt-access-to-education-in-turkey-9290.html

2 million Syrians in Turkey.400,000 Syrian children cant access education in Turkey what will the future hold for them?3

Imagining Our Future/ Khalil Gibran, On ChildrenYour children are not your children...they are the sons and daughters of Lifes longing for itselfyou may house their bodies, but not their souls, for their souls dwell in the house of tomorrow, which you cannot visit, not even in your dreams

As I share my thoughts with you, particularly those of you who are just starting your careers, think about the many areas I discuss and perhaps find your passion/interest in one of these areas there is much work to do find something you love and do it well (Gibran also said On Work: work is love made visible). Jim asked me to challenge us, and my reflections are meant to be a call to action. Every suggestion I make has taken and will take decades to accomplish.

They come through you, but not from youAnd though they are with you, yet they belong not to you.You may give them your love but not your thoughts.For they have their own thoughts.You may house their bodies, but not their souls.For their souls dwell in the house of tomorrow, which you cannot visit, not even in your dreamsThe Prophet is a book of 26 prose poetry essays written in English by the Lebanese artist, philosopher and writer Kahlil Gibran. It was originally published in 1923 by Alfred A. Knopf.

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Imagining Our Future..June 1, 2016BEAM me up, NASA The Bigelow Expandable Activity Module

First imagined in the 1950s- a reality this past weekPBS News Hour June 1stOver the weekend, astronauts aboard the orbiting International Space Station added a module like none other. Think an RV that expands out the back with extra space for sleeping quarters. In the case of the ISS, it was an inflatable Bigelow Expandable Activity Module (BEAM). Its made of a material stronger than kevlar and could be a game-changer. Science correspondent Miles OBrien reports.

It is hard to imagine our future but it has been a very interesting exercise for me.5

Imagining our future requires remembering our pastModern refugee protection movement is less than 100 years old

Always should reflect on our past to help us imagine our future..

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Imagining our future requires remembering our pastProtection of refugees has occurred since antiquityInternational protection began with the League of Nations (1921-1946) https://www.icrc.org/eng/assets/files/other/727_738_jaeger.pdf

Key ref: Gilbert Jaeger, former Director of Protection for UNCHR, writing in IRRC 2001League of Nations period 1921-1946International protection began during this periodICRC was initiator of protection system set up by L of NWWI 1914-18;Balkan War 12-13, Caucasus War 18-21;Greco-Turkish war 12-22.Upheaval in the Russian Empire 1-2 M fled to Europe, Asia Minor, C/E Asia from 1918-1922 and thereafterCharitable organizations did their best but couldnt meet the demand and no central coordinating body existed

So joint commission of ICRC and the League of Red Cross Societies called for conference Feb 1921-invited the Council to appt a High Commissioner to define the status of refugees

Well before WW1 tragedies during Ottoman Empire ie Armenians and many others

These institutions afforded international protection to refugees based on intnl law for first time, within the framework of the L of N1922-1926 first ones were written in reference to Russian and Armenians Defining legal status of refugees, making recommendations re asylees, work, travel,etc

WikipediaThe League of Nations (abbreviated as LN in English, La Socit des Nations [la ssjete de nsj] abbreviated as SDN or SdN in French) was an intergovernmental organisation founded on 10 January 1920 as a result of the Paris Peace Conference that ended the First World War. It was the first international organisation whose principal mission was to maintain world peace.[1] Its primary goals, as stated in its Covenant, included preventing wars through collective security and disarmament and settling international disputes through negotiation and arbitration.[2] Other issues in this and related treaties included labour conditions, just treatment of native inhabitants, human and drug trafficking, arms trade, global health, prisoners of war, and protection of minorities in Europe.[3] At its greatest extent from 28 September 1934 to 23 February 1935, it had 58 members.The diplomatic philosophy behind the League represented a fundamental shift from the preceding hundred years. The League lacked its own armed force and depended on the Great Powers to enforce its resolutions, keep to its economic sanctions, or provide an army when needed. However, the Great Powers were often reluctant to do so. Sanctions could hurt League members, so they were reluctant to comply with them. During the Second Italo-Abyssinian War, when the League accused Italian soldiers of targeting Red Cross medical tents, Benito Mussolini responded that "the League is very well when sparrows shout, but no good at all when eagles fall out."[4]After a number of notable successes and some early failures in the 1920s, the League ultimately proved incapable of preventing aggression by the Axis powers in the 1930s. Germany withdrew from the League, as did Japan, Italy, Spain, and others. The onset of the Second World War showed that the League had failed its primary purpose, which was to prevent any future world war. The League lasted for 26 years; the United Nations (UN) replaced it after the end of the Second World War on 20 April 1946 and inherited a number of agencies and organisations founded by the League.

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Imagining our future requires remembering our pastConvention on the International Status of Refugees - 1933First time the principle of non-refoulment acquired the status of international treaty law

Ratified by 9 states including the UK and FranceFirst time States Parties undertook real obligations on behalf of Russian, Armenian and other refugeesNon refoulment, welfare, labor, relief, education, etc

Source for cartoon:

HomeOromia & OromoOromo Studies @ Gadaa.comChronologyEventsBookstoreGadaaTube.comAbout UsContactThe Unheard Saga of Oromo Refugees: The Unvoiced Weeps from Nairobi to MogadishuPosted: Bitootessa/March 28, 2009 Finfinne Tribune | Gadaa.com | CommentsBy Kadiro A. Elemo*It is not exaggeration if I make a bold statement that Ethiopia is among those countries where the dignity of a human being is absolutely disregarded. This goes from the fact that human rights violations and naked tyranny are commonplace experiences under the regime of Meles Zenawi. There is no trend of improvement in human rights protection in the country and a general culture of impunity for violating human rights is rampant. Lack of respect for the fundamental human rights, arbitrary and illegal detentions, tortures, killings of members of the political opposition and demonstrators, summary executions of suspected insurgents, lengthy pretrial detentions, poor prison conditions, violations of individual privacy rights and laws regarding search warrants, and lack of freedom of the press are among a few characterizing features of the police state of Ethiopia. In Ethiopia, all types of human rights are virtually violated and basic freedoms are infringed now and then. The routines of human rights violation, the lack of trend of improvement in human rights protection, and the culture of impunity for violating human rights by the oppressive regime loom largely over the Oromo nation, a numerical majority, but a political minority in Ethiopia. Horn of Africa: Oromo Refugee SufferingstockIn order to escape persecution and harassment by the repressive regime, an exodus of Oromo refugees cross from Ethiopia into neighboring countries every day and every month. However, to the consternation of Oromo refugees, the other Horn countries are putting salt on the injuries of Oromo refugees. In other words, the reality for Oromo refugees in the other Horn countries squarely fits with the reality in Oromia, a TPLF open-field prison-house. Handing over Oromo refugees to the oppressive regime of TPLF, forcibly sending them back or detaining them with total disregard to international norms are part of common phenomena in the region. This aberration in international law happens repetitively in Kenya, Sudan, Djibouti and Somaliland. The case of Somalia is even worse to mention: the TPLF regime, exploiting the political anarchy and statelessness in Somalia, can jump to there anytime to massacre and torture Oromo refugees living there. In the worst scenario, the TPLF regime uses its warlord vassals in Somalia to wipe out Oromo political dissidents, who are lucky enough to escape from TPLFs torture machinery at home. Oromo refugees are becoming more and more vulnerable to abuses of the state actors and non-state actors in the Horn. These days, being raped, being robbed, being attacked and being abused have become part of Oromo refugees daily lives. Moreover, becoming targets of terror attacks is a new emerging trend. The case in point is the heinous murders of innocent Oromo refugees by two simultaneous hand-grenade attacks in Bosaso restaurants.Every single day, the agonies and plights of Oromo refugees are smoldering and touching. This is the ongoing problem and needs the attention of every person who feels the sufferings of human beings. Are the Behaviors of the Horn Countries Acceptable under International Laws?To understand the protection of the refugee law under international laws, it is necessary to understand the complementarity among the refugee protection law, international human rights law and humanitarian law.International refugee rights are integral parts of the broader international human rights that an individual enjoys by virtue of humanity. Refugee rights have been anchored in several international human rights instruments. For instance, the Universal Declaration of Human Rights (UDHR), the bedrock of international human rights regime that has attained the status of customary international law and jus cogens, has clear provisions about the rights of refugees (asylum seekers). Article 14 of UDHR, the right to seek and enjoy asylum in other countries, is one of those principles, which reached the status of the peremptory norm binding on non-signatory states erga omnez. Right to life, absolute prohibition of tortures, or cruel, inhumane and degrading treatments/punishments, and protection against genocides and crimes against humanity are also considered as some of the fundamental state obligations on the international plane. More importantly, these state obligations and international human rights instruments prohibit refoulement, sending back the refugee to the country where he/she fears persecution. Every country in the world, whether de facto or de jure state, (including Kenya, Somaliland, Puntland, Djibouti, Sudan), has the duty to honor their international obligations by protecting individuals (Oromo refugees) from persecution. Hence, these countries cannot refouler Oromo refugees to Ethiopia since their lives and freedom can be threatened because of their race, religion, political opinions, and membership to particular social group. In case of temporary protection, too, these countries are duty-bound to grant temporary protection status for the mass influx of the people falling outside the competence of 1951 Convention since forcible return can pose substantial threat to the lives, liberty, and security of these persons. Refoulement is tantamount with violation of the international law, and non-compliance with international obligations has consequences (at least in theory) on them. Hence, in this scenario, too, these countries have the incumbent duty to protect the right of refugee until the situation in the refugees country improves or the refugee is resettled in a third country. And also, in case of Protection Elsewhere (Third Host Countries), these countries have to observe their obligation to non-refoulement. The fact that refugee has got or might get protection in third country cannot discharge these countries from international obligation.In a nut shell, these are among a few legal bases for the Horn nations not to hand over (refouler) Oromo refugees to Ethiopian authorities

This was an international milestone for protection of refugees and served as a model for the 1951 UN Convention8

Imagining our future requires remembering our pastFDR and the Evian Resolution 1938Help people fleeing the Third Reich from Germany and AustriaFirst time protection was extended to would be refugees inside the country of potential departure

FDR criticized for not doing enough about the Holocaust he called for this meeting outside the context of the L of NGood news was first time concept of protecting people while in their home countryhowever,33 countries participated, all refused to accept Jewish refugees except the DR, which agreed to accept 100,000 Jews (never happened however- FDR worried so close to US)

Wikipedia:The vian Conference was convened 615 July, 1938, at vian-les-Bains, France, to discuss the Jewish refugee problem and the plight of the increasing numbers of Jewish refugees fleeing persecution by Nazi Germany. It was convened at the initiative of United States President Franklin D. Roosevelt who perhaps hoped to obtain commitments from some of the invited nations to accept more refugees, although he took pains to avoid stating that objective expressly. It was true that Roosevelt desired to deflect attention and criticism from American policy that severely limited the quota of Jewish refugees admitted to the United States.[1]The conference was attended by representatives from 32 countries, and 24 voluntary organizations also attended as observers, presenting plans either orally or in writing.[2] Golda Meir, the attendee from British Mandate Palestine, was not permitted to speak or to participate in the proceedings except as an observer. Some 200 international journalists gathered at vian to observe and report on the meeting.The dispossessed and displaced Jews of Austria and Germany were hopeful that this international conference would lead to acceptance of more refugees and safe haven. "The United States had always been viewed in Europe as champion of freedom and under her powerful influence and following her example, certainly many countries would provide the chance to get out of the German trap. The rescue, a new life seemed in reach."[3]Hitler responded to the news of the conference by saying essentially that if the other nations would agree to take the Jews, he would help them leave:I can only hope and expect that the other world, which has such deep sympathy for these criminals [Jews], will at least be generous enough to convert this sympathy into practical aid. We, on our part, are ready to put all these criminals at the disposal of these countries, for all I care, even on luxury ships.[4]Only two countries, Costa Rica and the Dominican Republic, increased their quotas. The conference thus proved to be a useful propaganda boost for the Nazis.[5]

Wyman Institute:The plight of Austrias Jews in the aftermath of the Anschluss generated pressure from some Members of Congress and journalists for U.S. intervention. State Department officials decided to get out in front and attempt to guide the pressure before it got out of hand. On March 24,1938, President Franklin Roosevelt announced that the United States was inviting thirty-three countries to send representatives to a conference on the refugee problem, to be held in the French resort town of Evian-les-Bains. All of those invited, except Italy, agreed to send delegates. FDR emphasized in his announcement that no nation would be expected or asked to receive a greater number of emigrants than is permitted by its existing legislation. In addition, the Roosevelt administration privately promised Great Britain that Mandatory Palestine would not be discussed as a possible refuge. These conditions greatly reduced the possibility that the Evian conference would produce meaningful results.Assistant Secretary of State George Messersmith bluntly told a private meeting of refugee advocates, shortly before the conference, that the delegates to Evian were likely to render lip service to the idea of aiding the refugees accompanied by an unwillingness, however, to do anything to ease existing restrictions on the admission of immigrants.The conference opened at the Hotel Royal on July 6. Although the delegates all arrived on time, some of the early sessions were sparsely attended. The hotels chief concierge later recalled why: All the delegates had a nice time. They took pleasure cruises on the lake. They gambled at night at the casino. They took mineral baths and massages at the Etablissement Thermal. Some of them took the excursion to Chamonix to go summer skiing. Some went riding; we have, you know, some of the finest stables in France. But, of course, it is difficult to sit indoors hearing speeches when all the pleasures that Evian offers are outside.The proceedings of the conference confirmed the skeptics fears. One speaker after another reafrmed their countries unwillingness to accept more Jews. Typical was the Australian delegate, who bluntly asserted that as we have no real racial problem, we are not desirous of importing one. The only exception was the tiny Dominican Republic, which declared it would accept as many as 100,000 Jewish refugees, although that project never materialized, because the Roosevelt administration feared the arrival of so many refugees in the nearby Caribbean would enable some of them to sneak into the United States.Newsweek, noting the appeal by the chairman of the U.S. delegation to the attendees to act promptly in addressing the refugee problem, noted: Most governments represented acted promptly by slamming their doors against Jewish refugees. Time, for its part, reported that Evian was the source of still and unexciting table water [and] after a week of many warm words of idealism [and] few practical suggestions, the conference took on some of the same characteristics.Golda Meir, who later became prime minister of Israel, attended Evian as an observer. She concluded that nothing was accomplished at Evian except phraseology. At a press conference after the gathering, she remarked, There is only one thing I hope to see before I die, and that is that my people should not need expressions of sympathy any more. Another critic pointed out that Evian was Naive spelled backwards. The problem, however, was not naivet so much as it was calculated indifference. In 1979, the United States spearheaded an international conference at Lake Geneva, near Evian, on the plight of hundreds of thousands of refugees fleeing the Communist victory in Southeast Asia. In an emotional keynote speech, Vice President Walter Mondale compared the gathering to the Evian conference, which he said failed the test of civilization. Mondale pleaded with the delegates to join the U.S. in rescuing the Asian boat people. History will not forgive us if we fail, he concluded. History will not forget us if we succeed. The speech is widely credited with inspiring many countries to take part in the rescue of those refugees. The nations stepped up to the crisis, Mondales chief speechwriter, Martin Kaplan, later recalled. It was one of those rare occasions when words may actually have saved lives.

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Imagining our future requires remembering our pastInternational Refugee Organization (IRO) 1946-1951Established by UN General Assembly to help resettle central European refugees to US, Canada, W Europe, Australia, Israel and Latin America

Photo: Wikimedia Commons: Passenger ship, possibly MS SKAUBRYN, berthed at a wharf (8400394605).jpg

WikipediaThe International Refugee Organization (IRO) was founded on April 20, 1946 to deal with the massive refugee problem created by World War II. A Preparatory Commission began operations fourteen months previously. It was a United Nations specialized agency and took over many of the functions of the earlier United Nations Relief and Rehabilitation Administration. In 1952, its operations ceased, and it was replaced by the Office of the United Nations High Commissioner for Refugees (UNHCR).The 'Constitution of the International Refugee Organization, adopted by the United Nations General Assembly on December 15, 1946, specified the agency's field of operations. Controversially, this defined "persons of German ethnic origin" who had been expelled, or were to be expelled from their countries of birth into the postwar Germany, as individuals who would "not be the concern of the Organization." This excluded from its purview a group that exceeded in number all the other European displaced persons put together. Also, because of disagreements between the Western allies and the Soviet Union, the IRO only worked in areas controlled by Western armies of occupation.Twenty-six states became members of the IRO and it formally came into existence in 1948: Argentina, Australia, Belgium, Bolivia, Brazil, Canada, Republic of China, Denmark, the Dominican Republic, France, Guatemala, Honduras, Iceland, Italy, Liberia, Luxembourg, the Netherlands, New Zealand, Norway, Panama, Peru, the Philippines, Switzerland, the United Kingdom, the United States, and Venezuela. The U.S. provided about 40% of the IRO's $155 million annual budget. The total contribution by the members for the five years of operation was around $400 million. It had rehabilitated around 10 million people during this time, out of 15 million people who were stranded in Europe. The IRO's first Director General was William Hallam Tuck, succeeded by J. Donald Kingsley on July 31, 1949.[1]10

Imagining our future requires remembering our pastIRO was meant to complete its work by 30 June 1950As soon became evident, it was unlikely to say the least that the problem of refugees would be solved by that dateA Study of StatelessnessPhoto Credit: WikimediaThe Palmach - Immigration to Israel

So, the Economic and Social Council of the UN asked the Sec gen of UN to undertake a study of the existing situation in regards to protection of stateless persons, and to undertake a study of the national legislative and international agreements and conventions relevant to statelessness this is the origin of the document:The Study of Statelessness, which is a key document in the modern hx of the protection of refugees11

Imagining our future requires remembering our pastA Study of Statelessness :International travelRight of entry and sojournPersonal statusFamily rightsRights of exercise of trades or professionEducation, relief, social securityExemption from reciprocity, expulsion, taxation and military serviceOriginal photo uploaded by Fischerjs/Wikipedia

So, the Economic and Social Council of the UN asked the Sec gen of UN to undertake a study of the existing situation in regards to protection of stateless persons, and to undertake a study of the the national legislative and international agreements and conventions relevant to statelessness this is the origin of the document:The Study of Statelessness, which is a key document in the modern hx of the protection of refugees12

Imagining our future requires remembering our past

This study served as the main elements of the

UN Convention Relating to the Status of Refugees, 1951

So, the Economic and Social Council of the UN asked the Sec gen of UN to undertake a study of the existing situation in regards to protection of stateless persons, and to undertake a study of the the national legislative and international agreements and conventions relevant to statelessness this is the origin of the document:The Study of Statelessness, which is a key document in the modern hx of the protection of refugees13

Imagining our future requires remembering our pastUS Refugee Program:1600sAmericans fleeing persecution since the Pilgrims 1948 -250,000 displaced Europeans from WWII1940s-50s laws assisting those fleeing Communism (China, Hungary, Korea, Poland, Yugoslavia)1960s- fleeing Cuba1980- US Refugee Act after Vietnam War

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Imagining Our Future/InternationalThe tragic reality is that we have guaranteed job security in refugee health.Yet that allows us to imagine a better future

The world will always be at war# of conflicts

UNHCR:59.5 M forcibly displaced at the end of 2015 19.5 M refugees and 38.2 M IDPSyria topped Afghanistan for # of refugees last year- a distinction which Afghanistan had held for three decadesOne in four refugees worldwide is a Syrian15

Case study number 1The most difficult day in my career as a physicianVietnamese refugee crisis 1988-1989

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Imagining Our Future/InternationalA world where we work for peaceful resolutions of international conflicts (so that we dont have refugees)Photo: Arcadia University

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Imagining Our Future/InternationalA world where we honor key principles of international refugee lawPhoto Credit:University of Baltimore School of LawApril 6,2016

Key principles non refoulementUS has turned back Cubans, Thais the Khmer, Repatriation, reintegration, resettlement

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Imagining Our Future/InternationalA world where governments, IOs and NGOs are prepared for high volume, long term tragedies such as the Syrian conflict

Can respond with emergency relief in a coordinated fashion that honors international HR law

Must stop being reactive and be more proactiveIe in US, a PH emergency pool for crises like Zika, instead of waiting for Congress to approve $ for each crisis

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Imagining Our Future/InternationalA world which views refugee situations as the indescribable human tragedies which they are, and which responds with generosity and compassion

Not anti-immigrant rhetoric Refugees are not the danger they are in danger (Pope pic of Syrian life vest) 5/30 Thai pirates20

Imagining Our Future/InternationalRefugees are not the danger they are in dangerPope FrancisVatican CityMay 28, 2016

Thai pirates.. By Ann Schneible

Vatican City, May 28, 2016 / 09:54 am (CNA/EWTN News).- The story of a young migrant girl who drowned at sea was at the heart of Pope Francis' address to some 400 children who on Saturday had traveled to the Vatican from the southern Italian region of Calabria.Speaking off the cuff to the children who had arrived by the Treno per Bambini Children's Train and who represented various religions, cultures, and ethnicities, the Pope asked them to come up with a name for the unknown girl.Let us think of this little girl: what was her name? I do not know: a little girl with no name, the pontiff said, according to Vatican Radio's translation. Each of you give her the name you would like, each in his heart. She is in heaven, she is looking on us. Pope Francis told the story of the little girl as it was recounted to him by a rescue worker who had attempted to save the child, only to succeed in saving her lifejacket.He brought me this jacket, the pontiff said, showing the life jacket to the children, and with tears in his eyes he said to me, 'Father, I couldnt do it there was a little girl on the waves, and I did all I could, but I couldnt save her: only her life vest was left.'I do not (tell you this because I) want you to be sad, but (because) you are brave and you (should) know the truth: they are in danger many boys and girls, small children, men, women they are in danger, he said.The annual Treno per Bambini, which brings a group of young boys and girls, is an initiative of the Pontifical Council of Culture. The theme of this year's event is Carried by waves, which is meant to evoke the image of both danger and hope experienced by migrants, reports Vatican Radio.

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Imagining Our Future/InternationalA world which denounces anti-immigrant policies - and the politicians and individuals who espouse them

Advocacy- must speak out when we hear lets build a wall or lets close our borders (mosquito pic)Closing borders didnt work with Ebola and cant work in the US on our Southern border, or in Europe humans will always find a way to escape to a more tolerable and hopeful future

BTW, I learned recently that an on line petition in Canada circulated which suggested Trump not be allowed to cross the border- and it garnered million signatures (JK Rowling, NPR, 6/5/16)22

Imagining Our Future/InternationalA world where long term warehousing of refugees is unacceptablewhere durable solutions include local integration, not just repatriation or resettlement

I just got this in a mailing from IRC:Something to think about over a cup of coffee only of all refugee children are enrolled in primary school. One in four refugees is estimated to be in secondary school. Just 1% of refugees reach tertiary educationA world where we think creatively about integrating refugees in to local communitiesRecent comments by the new Director of IRC on NPR 6/2/16:Refugee situations are long term Cambodians, Lao, Bhutanese Nepali, Afghanistan, Iraq, Syria..60% urbanGive refugees work permits every $1 spent gives $2 to local economy Put kids in school

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Imagining Our Future/InternationalA world where leading governments respond by increasing refugee acceptance numbers

Refugees admitted to the US 1980-2015 www.migrationpolicy.org/programs/data-hub/us-immigration-trends

Canada accepted 25K Syrians US promised but hasnt delivered 10K

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After clearing more than a few hurdles, the federal Liberals have made good on their promise to bring 25,000 Syrian refugees to Canada.It represents a significant milestone for the Liberal government, particularly given the divisiveness over the issue of refugee settlement in some other countries.5 things to know about Canada's Syrian refugee program25,000th Syrian refugee lands in CanadaBut what happens now?"It's great to hit the target but it's only phase one," John McCallum, Canada's Minister of Immigration, Refugees and Citizenship, told CBC's Metro Morning. "Phase two is to welcome and settle them properly. But it does feel good."That target was hit on Feb. 27, with 48 hours to spare. In November, McCallum made the pledge after the government revised its campaign promise for meeting the number at the end of 2015 to give themselves a couple more months.There are now well over 25,000 Syrian arrivals here. McCallum said that's leading the way in the world."Canada's one of the few countries which is saying, 'Come on in' to many refugees albeit after their checked properly for security and health," he said."In the United States, they are divided. We have the Obama administration supporting us wholeheartedly on this. But we have Donald Trump saying keep all the Muslims out."He said that in Canada, all three political parties supported the plan, as well as thousands of citizens sponsoring refugees to come to the country."It does show where we stand as Canadians," he said.CBS News 3/1/16

25th thousand refugee landed in Montrel Feb 201625

Imagining Our Future/InternationalA world where upstream PH interventions are supported, and assessment and interventions occur before resettlement

Slide courtesy of Dr Martin Cetron, Director, DGMQ, CDC

Best time to intervene before people leave to resettleUS CDC upstream interventions good for health of refugees, countries of first asylum and resettlement - ie expanded immunizations, parasites, malaria and TB treatmentEnhanced TB diagnostic capacity in countries of first asylum, which benefit the local populationReal time epi studies that inform PH interventionsIe splenomegaly in CongoleseTB diagnostics which, by the way, not only are good for refugees, but for the local community expanding TB diagnostic capacity

and US Govt has responded to more than 11 international and domestic outbreaks among US bound refugees: measles, rubella, varicella, cholera, hepatitis A, Onyong-nyong fever and MDR TB, with importation of infectious disease to the US and secondary domestic transmission including MDR TB and congenital rubella. Outbreaks tax local health depts, halt resettlement, cost hundred of thousands of dollarsInvestment in and enhancement of overseas capacity for dx/rx is a cost effective strategy for educing imported dz, decreasing the healthcare burden for US providers, and improving overall US health security

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OverseasMedical ExamSitesRefugee CampsUrban CentersResettlement CommunitiesMobility: time for health interventions

Prevention, surveillance &Intervention opportunitiesQuarantineStations

Slide courtesy of Dr. William Stauffer

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Imagining Our Future/InternationalA world in which medical providers are prepared for humanitarian crises abroad

15 ASTMH approved diploma courses around the worldWhen I went in 1979? Read two trop med textbooks to prepare myself..Humanitarian disaster Sim courses

Expertise in humanitarian disaster responseExpertise in diseases specific to each unique refugee populationWhere we only send providers with expertise (my MSF example)28

Case Study Number 2 A Karen Burmese refugee who didnt know how to access emergency careMinnesota Medicine April 2013

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Imagining Our Future/DomesticKnowledgeAttitudesPracticesPhoto courtesy of Medicine Box Films: American Heart

Will frame my comments about the future of domestic refugee health programs with using a KAP approach these three key attributes which help define the attitudes, knowledge and care systems needed to provide best outcomes for refugeesKnowledge evidence basedAttitudes compassion, curiosity and characterPractices health system changes needed (access, quality, cost) triple aimKeep eyes on the prize: healthy refugees, healthy communities(# of international migrants, defined by WHO as living outside their country of birth for > 1 year), only keeps growing currently is XXX30

Imagining Our FutureLyudmila Brukhis, CMA

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Imagining Our Future/DomesticKnowledgeA world where transitions of care are seamless as refugees move from country of first asylum to resettlement countries

Seamless transfer of refugees from countries of first asylum to resettlement countries:Transfer of MAR refugeeseSHARE - immunization records Class A and B conditionsGeocoding for hot spots32

Imagining Our Future/DomesticKnowledge A world where we have fingertip access to the knowledge we need about diseases seen in each refugee group

Epi. studies before and after resettlement ie:Splenomegaly in the CongoleseSchisto and strongyloides in the Lost Boys of the SudanB12 deficiency and higher rates of suicide in the Bhutanese Nepali

eSHARE33

Knowledge which didnt exist 35 years ago

Knowledge which didnt exist 35 years ago. Domestic screening guidelinesAustralia http://www.asid.net.au/documents/item/1225

Canada http://www.cmaj.ca/content/183/12/E824

United Stateshttp://www.cdc.gov/immigrantrefugeehealth/guidelines/refugee-guidelines.html

Guidelines developed by the top receiving countries in the last 5 yearsAustralia 2008, updated May 2016Canada 2010US 2011-201335

Knowledge which didnt exist 35 years ago

Dr. Phyllis Kozarsky, CDC AtlantaDr. Jay Keystone, TorontoThe intersection of refugee health and travel medicineCDC Yellow Book:Chapters since 2010 on refugee health

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Imagining Our FutureMardiya Jafri, PA student

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Imagining Our Future/DomesticKnowledge

A world where we have the demographic data we need to provide best care

Granular demography language and country of origin, not just race/ethnicityFew health systems collect this we started 25 years ago with hand written formsA world where health disparities report cards are used to focus target areas for intervention and funding exists that allow the work to occur38

Just count something Atul Gawande, MDEffective data collection is the linchpin of any comprehensive strategy to eliminate racial and ethnic disparities in health. Tom Perez Unequal TreatmentInstitute of Medicine,2003

Advice for medical students in his book, The Checklist ManifestoOur work must begin with data key Q , outcome and satisfaction measures and cut by race/language/COO or insurance as a proxy for SES39

Just count something:Data Collection at HealthPartners*

Language 99%Interpreter Needed 99%Race/ethnicity 98%Country of Origin 40-98%

*Integrated care delivery system (hospitals, medical group with >40 clinics, insurance provider) in the Upper Midwest, US

40Since 2001

Mammography Screening: % of women age 50-75 who have been screened by Mammography in the 18 months prior to and including their most recent primary care visit.HPMG Mammography Screening Disparity by RaceGAP is 7.3%GAP is 12.4%

76.8% 2009 HEDIS national 90th percentile (commercial)

41NOTE: RW added to the data beginning 1Q08. NS added beginning 1Q09.

Disparities in Breast Cancer Screening Rates HealthPartners

White vs all black 10.5%White vs US born black 6.5%White vs FB black 21.4%42

Strategies to Reduce Disparities

The Pink Ticket ProgramSame day mammogramsRidesMobile units

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Imagining Our FutureDr. Steven Richmond, Internal medicine intern

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Imagining Our Future/DomesticKnowledge

A world where providers are trained in the body of knowledge which encompasses refugee health

It encompasses clinical tropical medicine, travel medicine, cross cultural health care requires providers learn something about the history and culture of their patients, not just nematode life cyclesHas been the major focus of my careerSo proud of my mentees in the audience, esp the recent grads of the UMN GH Pathway45

Imagining Our FutureFowsia Musse, RN

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Imagining Our Future/DomesticKnowledgeA world where providers acknowledge expertise in other disciplines, and avail themselves of that knowledge

Community based participatory researchSocial determinants of healthThere is rich research data which exists in social sciences on many issues ie:How to counsel patients to increase uptake on preventive servicesHow to empower refugees with chronic diseases to care for themselves47

What Really Creates Health?Determinants of Health Model based on frameworks developed by: Tarlov AR. Ann N Y Acad Sci 1999; 896: 281-93; and Kindig D, Asada Y, Booske B. JAMA 2008; 299(17): 2081-2083.

Social and Economic Factors along with Health Behaviors are the two things that require a relationship with the community.

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Imagining Our FutureDr. Darin Ruanpeng, Internal Medicine resident

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Imagining Our FutureKathy Lytle, MSW, Social Worker

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Imagining Our Future/DomesticKnowledgeA world where providers have access to colleagues and experts which is timely and easy to access, and where we leverage that expertise more effectively

This conference as an exampleSociety of N American Refugee HC providers listserveCDC DGMQ visionary work in connecting with refugee HC providers they are here today they have been both listening to and advising us for decades -latest is Refugee Centers of Excellence grantsState health departments refugee health programsMore collaboration ie ASTMH clinical tropical medicine update course will be held in conjunction with this conf next year in TorontoASTMH this fall will have CDC organized Refugee Simulation

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CDC Refugee Centers of Excellence

Your chance to:Identify the support and information you needDetermine best practices in refugee healthImprove refugee health guidelines52

Imagining Our Future/DomesticKnowledgeA world where providers and patients have access to an international data base of patient education material tailored to language and health literacy of refugees

Empower patients with knowledge they understand and are inspired by Where we stop reinventing the wheel/learn from each otherNeed a central clearing house od material which is written appropriately, updated regularly and in multiple languagesGlobally: 862 million illiterate 70 percent live in three regions: Sub-Saharan Africa South and West Asia Arab States and North Africa United Nations, 2000

United States: 90 million with limited health literacy One half of all adults

National Assessment of Adult Literacy 2003

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Imagining Our Future/DomesticKnowledgeA world where providers and patients have access to an international data base of patient education material tailored to language and health literacy of refugees

Empower patients with knowledge they understand and are inspired by Where we stop reinventing the wheel/learn from each otherNeed a central clearing house HealthReach?Globally: 862 million illiterate 70 percent live in three regions: Sub-Saharan Africa South and West Asia Arab States and North Africa United Nations, 2000

United States: 90 million with limited health literacy One half of all adults

National Assessment of Adult Literacy 2003

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Imagining Our Future/DomesticKnowledgeA world where refugee health care providers do more science clinical research and publishing

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Imagining Our Future/DomesticKnowledgeA world where providers routinely ask Where were you born, and where have you traveled? and know what to do with the answerPhoto Credit:IOM via WHO

And where anything less than that is unacceptable from a medical education perspective we must acknowledge that there is no such thing as diseases over there and diseases here

WHO:There are an estimated 1 billion migrants in the world today of whom 214 million international migrants and 740 million internal migrants. The collective health needs and implications of this sizeable population are considerable. Migration flows comprise a wide range of populations, such as workers, refugees, students, undocumented migrants and others, with each different health determinants, needs and levels of vulnerability.In a globalized world defined by profound disparities, skill shortages, demographic imbalances, climate change as well as economic and political crises, natural as well as man-made disasters, migration is omnipresent. Migration is also essential for some societies to compensate for demographic trends and skill shortages and to assist home communities with remittances.

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Imagining Our Future/DomesticKnowledgeIn the field of observation, chance favors only the mind which is prepared Louis Pasteur

Maltreatment of Strongyloides: case series and worldwide survey of physicians in trainingBoulware, Stauffer, HendelPaterson, Walker et alAM J Med 2007

Am J Med. 2007 Jun;120(6):545.e1-8.AbstractBACKGROUND: Strongyloidiasis infects hundreds of millions of people worldwide and is an important cause of mortality from intestinal helminth infection in developed countries. The persistence of infection, increasing international travel, lack of familiarity by health care providers, and potential for iatrogenic hyperinfection all make strongyloidiasis an important emerging infection.METHODS: Two studies were performed. A retrospective chart review of Strongyloides stercoralis cases identified through microbiology laboratory records from 1993-2002 was conducted. Subsequently, 363 resident physicians in 15 training programs worldwide were queried with a case scenario of strongyloidiasis, presenting an immigrant with wheezing and eosinophilia. The evaluation focused on resident recognition and diagnostic recommendations.RESULTS: In 151 strongyloidiasis cases, stool ova and parasite sensitivity is poor (51%), and eosinophilia (>5% or >400 cells/microL) commonly present (84%). Diagnosis averaged 56 months (intra-quartile range: 4-72 months) after immigration. Presenting complaints were nonspecific, although 10% presented with wheezing. Hyperinfection occurred in 5 patients prescribed corticosteroids, with 2 deaths. Treatment errors occurred more often among providers unfamiliar with immigrant health (relative risk of error: 8.4; 95% confidence interval, 3.4-21.0; P 400 eosinophils/microL). US residents' helminth knowledge is limited and places immigrants in iatrogenic danger. Information about Strongyloides should be included in US training and continuing medical education programs.

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Imagining Our Future/DomesticKnowledgeA world where we remember that migration is circular and we routinely ask are you planning to travel back home? (the Visiting Friends and Relatives or VFR traveler)

A unique opportunity to both address health disparities more malaria, TB, typhoid, etc in the VFR traveler, and to provide PH service to your country and communityNY Times article 5/31/16 MD in NY spending a lot of time advising VFRs planning to travel to the Dominican Republic this summer re Zika and a patient who commented they didnt know re sexual transmission they dont tell us enough58

Imagining Our Future/DomesticAttitudesRefugee health providers are guided by a shared set of core values, but..What attitudes could we use a little more of?

CompassionHealth EquityHumility Trust RespectWalker PF, Barnett ED; Immigrant Medicine;Ch1Elsevier, 2007.

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Imagining Our FutureMr. Ken Nguyen, Vietnamese interpreter

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Imagining Our Future/DomesticAttitudes we need more ofAdvocacy/calm outrageAbout anti-immigrant attitudesAbout health disparitiesLeading by example: Academic excellence Mentorship and feedback

Anna as an example her academic work and advocacy re RSV in first born nations children at Mayo we called that a triple threat research, clinical care and teaching !

More outrage at health disparities of refugeesAcademic excellence-set the Q and service bar high, study, teach, publish must believe and behave as though there IS a body of knowledge in refugee and immigrant health Mentorship and feedback- tell your colleagues if not using professional interpreter, or not generating an adequate DDX -61

Imagining Our Future/DomesticAttitudes we need more of

These are folks who have lived through unimaginable trauma," he says. "Just from a point of decency, to cut those people off from the care that they need just doesnt seem like the Canada that I know.Dr Meb RashidCBC News, CanadaMay 11,2012

Remember HIV and Act Up?More public discourse62

Advocacy actually can make a difference

Imagining Our Future/Domestic PracticesA world where refugees have universal access to a basic set of health and social services

https://www.projectworthmore.org/tun-lin-bus-passes-for-refugees

Project Worthmore Colorado NGO helping refugees TUN LIN | Bus Passes For Refugees03Dec 2015My name is Tun Lin. When I was 13 years old, I moved from my home in Myanmar to Malaysia. My parents stayed in Myanmar. They said they were too old to start a new life in a new country. I was young, so I left. I lived in Malaysia with my brother for three years as a refugee. After that, we moved to America. I came here on January 14, 2014. Now I am 18. I go to South High School and I work at night and on the weekends to pay my bills.I probably spend about two or three hours everyday on the bus. I walk to the bus stop and take #73 and transfer to #11. Overall it is not too bad to ride the bus. I usually read a book or listen to music. Sometimes, if its not too loud, I try to take a nap. Once I saw a fight between two guys. That was pretty crazy. Everyone just sat there watching them. Ive never seen anything like that before.The hardest part about taking the bus is when it gets cold outside. The bus is usually late, so I wait in the snow until it arrives. I remember the first time I saw the snow. It was amazing how cold it was outside. I have never been in weather like that before. My life is not easy here. I have had to grow up really quickly. I am responsible for myself in every way.Will you give a bus pass to refugees like Tun Lin?

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Imagining Our FutureDr. Ann Settgast, Internist

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Imagining Our Future/Domestic PracticesA world where refugees are empoweredWe leverage technology and social media more effectivelyCell phones for new arrivalsPortable health records are the norm

We connect to refugee communities the way we all connect via cell phones, radio, TV66

Imagining Our Future/Domestic PracticesA world where our staff reflects the communities we serveIdentify and mentor refugees in health careers earlySupport International Medical Graduates

Ontario newcomers programMinnesota IMG grants67

Imagining Our FutureDr. Anteneh Zewde, graduating resident

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Imagining Our Future/Domestic PracticesA world where we listen more really listen to the voices of refugees To understand the other as otherRiche: 15th century explorer to China

While every refugees story is different and their anguish personal, they all share a common thread of uncommon courage: the courage not only to survive, but to persevere and rebuild their shattered lives. Antonio Guterres, United Nations High Commissioner for Refugees

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Refugees telling their stories

If We Knew Their StoriesDocumentary filmmaker Chris Newberry

http://www.medicineboxproject.org/

Quote from "Laying on Our Backs, Looking Up at the Stars"Sing-Along Lyrics for July 4 Show

Laying on Our Backs Looking Up at the Stars

ON JULY 4, 1988, Garrison Keillor was on the cover of Newsweek magazine. The edition featured a three-page essay by Keillor called "Laying on Our Backs Looking Up at the Stars." In it he talks about the United States, the Revolution, the Declaration of Independence, and the country's immigrants:Everyone makes fun of New York cabdrivers who can't speak English: they're heroes. To give up your country is the hardest thing a person can do: to leave the old familiar places and ship out over the edge of the world to America and learn everything over again different than you learned as a child, learn the new language that you will never be so smart or funny in as in your true language. It takes years to start to feel semi-normal.

And yet people still come - from Russia, Vietnam, and Cambodia and Laos, Ethiopia, Iran, Haiti, Korea, Cuba, Chile, and they come on behalf of their children, and they come for freedom. Not for our land (Russia is as beautiful), not for our culture (they have their own, thank you), not for our standard of living (it frankly ain't that great), not for our system of government (they don't know about it, may not even agree with it), but for freedom. They are heroes who make an adventure on our behalf, showing us by their struggle how precious beyond words freedom is, and if we knew their stories, we could not keep back the tears.71

Imagining Our Future/Domestic PracticesA world where community based services are the norm, not the exceptionCommunity Health Workers

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Imagining Our Future/Domestic PracticesA world where use of family and friends to interpret occurs < 1% of the timeIn personTelephone in every roomVideo interpreting

Leverage technology73

Imagining Our FutureShashi Dahal, RN

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Imagining Our Future/Domestic PracticesA world where health disparities report cards using granular demography are routine (and money flows where it is needed most)HealthPartners Disparities Report Card

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Imagining Our Future/Domestic PracticesA world where electronic health records are used more effectively Smart sets/check lists

CDC Refugee CoE grant looking at this76

Imagining Our Future/Domestic PracticesPop up reminders (Global Health Wizard)Registries (ie tracking of hepatitis B carriersThis patient is from a country where Hepatitis B prevalence rates exceed 2%.CDC recommends screening such patients for Hepatitis B

Imagining Our Future/Domestic PracticesA world where incentives are aligned:Providers arent discouraged financially from caring for refugeesRefugees are paid to complete basic preventive services

Works for mammography uptake pay patients instead of their doctors78

Imagining Our Future/Domestic PracticesA world where we learn more quickly where feedback loops between international and domestic refugee health are fast and bidirectional(Providers- that means we need to publish more)

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Leveraging big data in global health

Kamran Khan, MD,MPHUniversity of Torontowww.bluedot.globalA social benefit corporation launched in 2014

Our researchersKamran M. KhanMD, University of Toronto; MPH, Columbia UniversityAffiliationsScientist in the Li Ka Shing Knowledge Institute of St. Michael's HospitalAssociate Professor, Department of Medicine, Division of Infectious Diseases, Department of Health Policy, Management and Evaluation, University of TorontoStaff Physician, Department of Medicine, Division of Infectious Diseases, St. Michael's HospitalScientist, Centre for Research on Inner City Health, St. Michael's HospitalClinical SpecialtyInfectious DiseasesResearch InterestsGlobal migration and infectious diseases, international air travel, infectious disease pandemics, mass gatherings, immigrant and refugee health, tuberculosis, mathematical modeling of infectious diseasesResearch ActivitiesInfectious diseases are emerging faster than at any other time in human history. At the same time the world is becoming a much smaller place. Today more than two billion passengers board commercial flights every year creating unprecedented opportunities for local infectious disease threats to rapidly transform into international epidemics that threaten global health, security, and economic prosperity. Furthermore, the mass migration and resettlement of millions of immigrants and refugees around the world today requires novel approaches to identify and treat potentially serious infectious diseases that enable immigrants to achieve their full potential and concurrently minimize risks to public health. Other ActivitiesThe Bio.Diaspora Project A multidisciplinary study of global population mobility via commercial air travel and its role as a conduit for the international spread of infectious diseases with pandemic potential.

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Imagining Our Future.. Take the long view, and be hopefulSmallpox eradicated 1980 (work started in 1967)1986 Carter Center sets goal to eradicate Guinea worm (3.5 million cases worldwide)This year to date: only two confirmed casesI just want to get rid of the last case of Guinea worm during my lifetime, that's what I want to do.Well, with the number of cases this year, it's looking very good.It does look good so far NPR June 3, 2016

NPR June 3rdFormer President Jimmy Carter may be on the brink of celebrating the birthday wish he made last year: the global eradication of Guinea worm disease. This year, there are only two confirmed cases, compared to 3.5 million a year in the 1980s. It's a medical milestone that took a nearly 30-year effort by the Carter Center and its partners.Carter spoke to NPR's Robert Siegel about the fight against Guinea worm. An edited version of the interview follows.Interview HighlightsYou must be gratified to see Guinea worm almost gone.Well, it is very pleasing for me.How did you first become aware of this disease, and what moved you to spend so many years supporting efforts to eradicate it?My czar of drugs, Dr. Peter Bourne, became the assistant secretary general of the U.N. and they put him in charge of a "Decade of Water." And he came down to the Carter Center to give us a report on diseases caused by impure water. He talked about Guinea worm, and I decided at that time, since no one else was addressing the disease, that the Carter Center should take this on as a major responsibility. So we began to consult with the Centers for Disease Control Dr. Don Hopkins was there and eventually he came over to the Carter Center to take charge of the program. And later became in charge of all of our health programs.Why has it taken 30 years to make this progress?We had 203,600 villages that we had to contact and teach each one of them how to [filter their water and avoid going in water to ease the pain when a Guinea worm emerges]. And that's what's taking 30 years.Guinea worm would be one of the many diseases that remind us how problematic humanity's relationship to water can be.

It's getting more serious every year because the population is increasing and the streams [that] provide drinking water for people are now shrinking up. So with smaller streams and more people, the competition for water is going to get increasingly more intense in years to come.And when we speak of eradication of Guinea worms: Is there a possibility that there could be a recurrence of this disease?Once a particular water hole which has to be stagnant water has Guinea worm [gone], the only way it can be revived in that particular area is for someone with Guinea worm coming out of their body to wade out into the water and let more eggs to be planted. So we've never had a case when we've completely eradicated from the village of Guinea worm recurring unless some stranger comes from a distant place and [contaminates] the water with Guinea worm. But the villagers know to keep people out of the water. And once they do that the Guinea worm is gone forever.I've learned that river blindness is next on your hit list. Where does that effort stand?We've taken up the task of eliminating river blindness in individual countries or entire sections of the world. We've shifted from controlling the disease to eliminating it completely. And we're making very good progress on that.Speaking of health, you're doing OK?I'm feeling fine. I'm doing quite well. We're checking very carefully to see if the brain cancer comes back and so far there's no sign of it. I just want to get rid of the last case of Guinea worm during my lifetime, that's what I want to do.Well, with the number of cases this year, it's looking very good.It does look good so far.81

Imagining Our Future.. maybe it is not rocket scienceTransforming how we think:It's not a technical issue, at least not to me. There are so many amazing ways in which the risks of epidemics can be minimized with innovative technologies, but ultimately I think we need to radically transform the way we think about pandemics and contagion. They're less about invasions of foreign microbes and much more about the way we live and our shared social responsibilities.Author Sonia ShahFuture of Public HealthJohns Hopkins Bloomberg School of Public healthJune 9, 2016

FUTURE OF PUBLIC HEALTHQ&A with Sonia Shah: Transforming How We Think About PandemicsIn advance of Thursdays Future of Public Health event at the Johns Hopkins Bloomberg School of Public Health, were offering a preview Q&A with each of the writers who will be speaking. Well start today with Sonia Shah, author of the new book Pandemic: Tracking Contagions from Cholera to Ebola and Beyond; and The Fever: How Malaria Has Ruled Humankind for 500,000 Years.What will you be talking about at Whats Next? The Future of Public Health?I'll be discussing the rising risk of pandemics and what I see as some of the most difficult challenges in taming them, historically and today.What do most people not realize about the issue youll discuss?It's not a technical issue, at least not to me. There are so many amazing ways in which the risks of epidemics can be minimized with innovative technologies, but ultimately I think we need to radically transform the way we think about pandemics and contagion. They're less about invasions of foreign microbes and much more about the way we live and our shared social responsibilities.

Do we need to radically transform the way we think about refugee health? It will always occur in the context of our own countries, our own states or provinces. We need to keep pushing the envelope about health care in general?

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The future is in great handsNew York Times June 3, 2016Symbol of Hope: Refugee Team Named for Rio Olympics

83A squad of 10 athletes, from South Sudan, the Democratic Republic of Congo, Syria and Ethiopia, will march behind the Olympic flag in the opening ceremony in August.

The future is in great handsNew York Times June 3, 2016

Youre an athlete; you dont think like youre Syrian or from London or from Germany, Mardini, 17, said in a video produced by the I.O.C. You will just think about your race. You have your lane, your swimming cap, your swimming lesson. Thats it.

84A squad of 10 athletes, from South Sudan, the Democratic Republic of Congo, Syria and Ethiopia, will march behind the Olympic flag in the opening ceremony in August.AdvertisementSupported byOlympicsSymbol of Hope: Refugee Team Named for Rio OlympicsBy VICTOR MATHERJUNE 3, 2016Continue reading the main storyShare This PageContinue reading the main storyPhotoPopole Misenga, left, a judoka who defected from the Democratic Republic of Congo, practiced in Rio de Janeiro last month. He was one of 10 athletes chosen Friday to represent refugees at the Olympics.Credit Felipe Dana/Associated Press Ten athletes were chosen on Friday for a team that will represent the worlds refugees at the Olympic Games in Rio de Janeiro.

The team will march behind the Olympic flag in the opening ceremony on Aug. 5, taking a place just in front of the host country, Brazil.The group would be a symbol of hope for refugees worldwide and bring global attention to the magnitude of the refugee crisis, the International Olympic Committee said in announcing the teams members.The I.O.C. had identified a pool of about 40 potential Olympians and narrowed it down based on sporting level, official refugee status verified by the United Nations, and personal situation and background, the committee said.AdvertisementContinue reading the main storySome of the athletes were discovered at the Kakuma refugee camp in Kenya, near the border with South Sudan, where tens of thousands have fled war.Five South Sudanese, all runners, were chosen: three men (James Nyang Chiengjiek, 400 meters; Yiech Pur Biel, 800 meters; Paulo Amotun Lokoro, 1,500 meters) and two women (Rose Nathike Lokonyen, 800 meters; Anjelina Nada Lohalith, 1,500 meters).PhotoYolande Bukasa Mabika, also from the Democratic Republic of Congo, was tearful as she and Misenga were named to the team.Credit Pilar Olivares/Reuters The South Sudanese have been training in Nairobi with Tegla Loroupe, a two-time New York City Marathon champion and three-time Olympian from Kenya who was named the leader of the refugee delegation.Popole Misenga and Yolande Bukasa Mabika, two judo practitioners who defected from the Democratic Republic of Congo at the 2013 world championships in Brazil, were also chosen for the team.The other athletes selected for the team were Rami Anis and Yusra Mardini, two Syrian swimmers living in Europe, and Yonas Kinde, an Ethiopian marathoner living in Luxembourg.None of the athletes selected appears to be a likely medal contender. For example, the South Sudanese runners, while said to be promising, are untested in top competition.Misenga was eliminated in the first round at the 2013 world judo championships, and Anis placed 14th of 30 swimmers in the 100-meter butterfly at the 2010 Asian Games. Kindes time of 2 hours 17 minutes 31 seconds was good for 29th place at the Frankfurt Marathon last year, and dozens of potential Olympians can break 2:10.Athletes have marched behind the Olympic flag before, usually as a result of geopolitical conflict. In 1992, athletes from Yugoslavia competed under the Olympic banner because of sanctions against the country related to the war in the Balkans. Athletes from the new nations of East Timor in 2000 and South Sudan in 2012 competed under the flag because those countries formal Olympic committees had not yet been formed.But this will be the first team of refugees at an Olympics.Youre an athlete; you dont think like youre Syrian or from London or from Germany, Mardini, 17, said in a video produced by the I.O.C. You will just think about your race. You have your lane, your swimming cap, your swimming lesson. Thats it.

My final thoughtsListen moreLearn moreAdvocate moreChange the system more

Thank youMahad sanid.. Galatome.Krop khun kha..Gracias..Ameseginale

Special thanks to.My patients My parentsMy familyMy colleagues

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