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Show of the physical exam. The Sudanese Dinka tribe, of which most of the subjects are a part, tends to produce some of the tallest people in the world. One notable Dinka. Manute Bol. formerly of the National Basketball Association's Washington Bullets, stood at seven foot seven inches. Most are tall and appear to be extremely thin. Malnutrition was ever-present during their stay in Kakuma. and they lack general awareness of balanced dieting and nutrition. Immunizations were given to all youth at the time of their initial health screening in Salt Lake. Thirty-six were immunized for diptheria/tetanus/pertussis (whooping cough); 34 were not, due to shortage of immunization. Sixty-seven were immunized for varicella (chicken pox), and all 70 were immunized for measles/mumps/rubella. Immunizations were not given for Hepatitis B, Haemophilus B influenza, or polio virus. Tuberculosis Tuberculosis is a common concern for international, national, and local public health departments and health agencies alike. It is endemic in many developing countries and is a threat in most developed countries, including the United States (CDC, n.d.). Tuberculosis testing is a mandatory part of both the Visa Application health screening and the health screening done upon arrival in the US (Table 3). Only a chest x-ray (CXR) looking for active tuberculosis was performed in Kakuma. Though 20 (31%) x-rays were declared to be "abnormal." only 2 were diagnosed with active Tb. None of the twenty subjects who showed abnormal chest x-rays were diagnosed to be infectious. Non-infectious, inactive Tb subjects who showed abnormal x-rays likely had Tb in the past and showed fibrous residue in the lungs or thickening of the lining of the lung caused by the disease. The Utah health screening included a Tb skin test (PPD) along with a CXR for those showing a positive PPD. Interestingly, 13 subjects refused to receive a CXR, and were referred to the Salt Lake Valley Health Department. No indication was given in the medical records whether or not these subjects ever received a CXR. Those who showed a positive PPD (79%) had the option of taking a Tb drug regimen that would prevent the inactive Tb mycobacteria from being reactivated. Likely reasons this treatment is an option instead of a requirement include concern about patient compliance with a 6-month drug regimen, unpleasant side effects, and cost of treatment. Those who do not take this medication, however, are at risk of the Tb infection becoming active disease. The Centers for Disease Control (n.d.) reports that HIV, diabetes, alcoholism, certain cancers, and being underweight can enhance an individual's chances of reactivating inactive Tb. Health Care Utilization Disturbing information was revealed when the number of the physician visits was analyzed (Table 4). At the time of the study, the 70 youth considered had been in Salt Lake City anywhere from 10 to 17 months. The average number of physician visits per year per subject dropped from 3.22 during the 8 month period of Medicaid coverage to 0.25 after expiration of Medi-caid-a difference of 13 times. Though this data does not encompass all visits made by subjects to any physician during this time (a few were seen in other clinics and ER's), it strikingly reveals the lack of medical treatment currently being received by this population. The referral rate for this group was relatively low: 49 referrals were authorized from among 70 subjects, an average of 0.7 referrals per subject per year. Referrals were made to 19 different specialties, including physical therapy, podiatry, op- tometry, and dentistry. The no-show rate for all physician visits was relatively low-15 appointments were recorded as missed compared to 140 appointments held, which equates to be a 10% no-show rate. Thirty-eight subjects received medication at one point or another. Medications most often recorded were NSAIDs (ie ibuprofen, naproxyn; 28 prescriptions to 22 different subjects) and anti-parasitic medication (mostly praziquantel for schisto-somiasis; 19 prescriptions to 19 different subjects). Commonly-presented Symptoms and Complaints Gastrointestinal (GI) pain and/or difficulty was the most common symptom seen during all screenings and office visits (Table 5). Of the 29 subjects presenting with GI pain/difficulty, 25 complained of chronic, intermittent abdominal pain, for many lasting over a period of months to years. Five subjects presented with hemorrhoids. Of the 25 subjects who presented with chronic abdominal pain, 20 were tested for parasites with 18 testing positive. Of the 7 different parasites discovered through these tests (Table 6), only 3 are problematic-Schistosoma, Blastocystis hominis, and Giardia lamblia. Some doubt the disease-causing ability of B. hominis, but in all 6 cases where B. hominis was the only parasite present, abdominal pain was indeed present. The World Health Organization (WHO) (n.d.) reports that approximately 40% of all individuals infected with Schistosomi-asis around the world are asymptomatic. Considering this, the likelihood is great that several Sudanese youth who have not been tested for Schistosoma have the parasite and are asymptomatic. Schistosomiasis is characterized by disturbances in the small intestine, colon, and rectum, and is contracted when larvae living on snails in infected water pools burrow through exposed skin (WHO, n.d.) Transmission of Schistosoma organisms is not a public health concern, as water sources with snail vectors are not present in Utah. The next most common condition presented was headaches (Table 5). In 90% of these cases, the headaches were of a chronic, intermittent nature, occurring between 2 to 5 times per week. Moreover, in over half of the cases, the headaches have been occurring for several years. Though NSAIDs prescribed in several cases did help alleviate the pain to some extent, they were not always helpful. An important point to mention here is the possibility of psychological disturbances and disorders faced by these youth in light of their harsh past. "Many [refugee] children have witnessed violence to family members or have themselves been victims of violence," reports Gavagan and Brodyaga (1998). "Most child survivors show psychologic symptoms more frequently than physical symptoms. Refugees are often seen as 'somatisizers' who express underlying psychologic problems in terms of physical complaints" (Gavagan & Brodyaga, 1998) Paardekooper, de Jong and Hermanns. (1999) compared over 200 Sudanese children of similar war-laden backgrounds to 80 Ugandan children with the same cultural background but who never had to face war or flee for their lives. "Sudanese children were more often than Ugandan children suffering from headaches, nervous for no apparent reason, and they were more often considered to be behind in cognitive development compared to other children" (Paardekooper et al., 1999) Moreover, Sudanese youth "reported significantly more psychosomatic complaints like dizziness, feeling tired, or lacking appetite compared to the reference group." Paardekooper, de Jong and Hermanns (1999) concluded that "the Sudanese reported significantly more PTSD-like complaints such as trouble with sleep, nervousness, traumatic memories, and behavioral problems as well as depressive 48 Utah's Health: An Annual Review Volume LX |