 During the late 1970s to mid-1980s, laws were passed in Bhutan that marginalized the citizenship rights of Bhutanese nationals of Nepali origin. Following protests in the early 1990s, more than 100,000 ethnic Nepalese fled Bhutan. The vast majority found their way to Nepal. By 1992, the government of Nepal and UNHCR, the UN Refugee Agency, had established seven camps in eastern Nepal for the Bhutanese refugees. The Bhutanese camps in Nepal are among the best refugee camps in the world. The government of Nepal and the UN Refugee Agency deserve considerable credit for ensuring security, shelter, education and health care. There have been 15 rounds of bilateral talks between the government of Nepal and the government of Bhutan, but not one refugee has repatriated. Although Bhutanese refugees enjoy considerable latitude by the government of Nepal's benevolent open camp policy, Bhutanese refugees are not legally allowed to work, own property, run businesses or vote. This situation has remained static for the past two decades. After exhaustive efforts towards repatriation failed, a core group of countries and the UN Refugee Agency initiated a plan for third country resettlement. This plan was endorsed by the government of Nepal in November 2007. UNHCR is always the first step for refugees seeking resettlement. Refugees submit a declaration of interest form and thereafter UNHCR interviews the family to determine eligibility and also to determine the most appropriate country of resettlement. Following UNHCR referral to a country of resettlement, the International Organization for Migration, IOM, assumes primary responsibility for resettlement. Based in Damak, a small town in convenient proximity to the seven refugee camps, IOM is engaged in a wide variety of activities. The IOM Overseas Processing Entity, the OPE, interviews refugee cases and prepares government forms for resettlement country selection missions. IOM organizes these selection missions and accommodates officials at the IOM guest house. As will be described later in great detail, the IOM Migration Health Department conducts health assessments for refugees in accordance to the specific protocols of the resettlement countries. The IOM Cultural Orientation Unit provides five-day courses to answer questions and to prepare refugees for life in their new country. The operations unit runs a fleet of 15 buses to provide ground transportation for refugees between the seven camps and Damak. In addition, operations organizes 10-12 charter flights each week for resettlement-bound refugees from eastern Nepal to Kathmandu. In Kathmandu, refugees are accommodated at the IOM Transit Center for one to three nights prior to the flight to the country of resettlement. The Transit Center can accommodate 400 individuals per night. IOM organizes all resettlement flights from Kathmandu to final destination in the country of resettlement. Operation staff arrange flights in coordination with the settlement agencies in the receiving countries, assist refugees through airport formalities at Kathmandu Airport, and provide flight escorts when required. That completes the overview of Bhutanese refugee resettlement from Nepal. The remainder of this slideshow focuses on the health assessment activities of the Migration Health Department. Every morning, up to 300 refugees arrive at the MHD Refugee Health Clinic at Damak's Lifeline Hospital. Upon arrival, refugees are divided into groups based upon activity, initial health assessment, further diagnostic visit, treatment, and pre-departure check. Thereafter, the MHD team of five international and 60 national staff conducts the required assessments, investigations, and treatments. The health assessment always begins with a counseling session to ensure that refugees understand the purpose, procedures, and timelines. Refugees receive basic information about HIV, tuberculosis, and immunizations. At the end of the counseling session, refugees sign a consent form. Counseling is not a one-time step. Counselors also provide post-test counseling, health education, answer questions about individual processing status, and assist with the management of patients on TB treatment. Although not in the protocol of resettlement countries, health education is essential. Refugees are provided information on TB, leprosy, diarrheal diseases, personal hygiene, immunizations, in-flight fluid intake, and other topics. Many Bhutanese refugees are illiterate, and therefore information is imparted in an easy-to-comprehend manner. Following the counseling session, refugees proceed to the nursing plaza where nurses capture height, weight, vital signs, visual acuity, and detailed medical history. The next stop is phlebotomy. Laboratory staff draws blood for syphilis, HIV, and hepatitis. Staff wear protective gear and dispose of needles safely. All medical waste is incinerated. Bhutanese refugees receive vaccines according to the same vaccination calendar as Nepali citizens. In the event that a country of resettlement requires vaccinations beyond this level, MHD provides additional vaccinations. In order to maintain the cold chain, vaccines are transported to Damak via IOM charter flights in cold boxes. Vaccines are then stored in designated refrigerators with backup generator power. Temperatures are checked by nurses twice a day and recorded in a log. Nurses are trained in vaccination techniques, management of adverse effects, and record keeping. Bhutanese refugees are given an information sheet about the vaccines they receive and also an immunization record. Since nearly all resettlement countries require a chest x-ray to investigate TB, the radiology unit is an important component of MHD. A quality analog x-ray machine is linked to a computerized radiography system. The unit features engineering and individual radiation protection for staff and refugees. All refugees, regardless of age or sex, are shielded with lead skirts. Pregnant women are given double shielding. A computerized radiography system with bar-coded cassettes speeds up processing and minimizes data entry mistakes. IOM radiographers check the quality of images and send them electronically to the on-site radiologist. If additional images are required, the radiologist can request these while refugees are still at the clinic. The radiologist interprets chest x-ray images immediately after they are captured. Computed radiography allows adjustments of technical characteristics of films, better visualization of details, and easy retrieval of previous images for comparative reading. The radiologist writes a report that is electronically sent to the migration health physicians. In the absence of an on-site radiologist, films are interpreted by radiologist consultants in other locations. Resettlement countries can receive chest x-ray films as a hard copy or as an electronic copy, either on a CD or accessed online. The beauty of this system is that physicians are in possession of each individual's personal history and radiological findings at the time of the physical examination. As such, the vast majority of health assessments can be completed in a single day. IOM physicians perform physical examinations, refer refugees for additional testing or treatment, define fitness to travel and travel requirements, treat patients with tuberculosis, and record information according to the requirements of the resettlement countries. All MHD physicians are well-versed in the technical guidelines of the resettlement countries and are trained to recognize, manage, and report conditions of public health concern. The information provided to physicians is sent to the resettlement countries and is used to make special arrangements for accommodation, treatment, medical follow-up, and the rehabilitation of refugees with special health needs. At all stages of the health assessment process, particular attention is paid to the identification of refugees. In other words, there is physical verification of the individual at every step of the process to ensure that there is no substitution. Refugees are given photo IDs which are checked at every step. Laboratory specimens are coded and a bar coding system is used for entering bio-data in the radiology database. MHD has established a state-of-the-art seriological and microbiological laboratory which performs tests for HIV, syphilis, hepatitis B, hepatitis C, malaria, and tuberculosis. The laboratory is licensed by the Ministry of Health and Population. Microbiological testing for tuberculosis is the largest part of laboratory activities. Overall, approximately 10% of refugee chest X-rays shows a suspicion of TB. All refugees with suspicious X-rays are required to produce sputum samples on three consecutive days between the hours of 6 and 8 in the morning. Trained laboratory staff assist refugees to obtain good specimens. IOM constructed specially designed sputum collection centers in all of the camps. They are well organized and protection measures have been established to ensure the safety of both staff and refugees. The MHD-TB laboratory is biosafety level 3. There is physical separation between safe and hazardous zones by double door locks. In the hazardous zone, negative pressure is maintained. The lab is equipped with three biosafety cabinets, ultraviolet irradiation, and HEPA filters. The laboratory performs sputum microscopy using zeal nilson and fluorescent techniques and sputum cultures on solid and liquid media. It has three liquid media midget machines which can process 3,000 specimens at a time. Liquid cultures allow rapid detection of mycopacterial growth and therefore enables the quick start of treatment when required. The laboratory performs drug susceptibility testing for first and second line drugs. Drug susceptibility testing enables the physician to choose the optimal treatment regimen. The laboratory uses modern molecular techniques based on DNA amplification, which allows detection of drug resistance within one day of sputum collection. If the rapid test detects drug resistance, the treatment can be adjusted quickly and a case can be isolated much earlier in the process than would be possible if conventional methods were used. If the patient is diagnosed with tuberculosis, IOM provides a full course of treatment. Directly observed therapy, DOT, is delivered in the camps by AMDA. AMDA, the Association of Medical Doctors of Asia, is an IOM implementing partner. DOT health workers ensure that all doses are taken, that records are kept, and that side effects are identified in a timely manner. Every week, AMDA DOT health workers meet as a group at the IOM clinic to discuss individual patient progress and also to receive the following week's supply of medication. All IOM physicians are trained to detect and manage tuberculosis, including drug resistant forms. Several physicians have received training at the National TB Centers in the United States and at the WHO TB Center in Latvia. IOM's approach to TB treatment is patient-centered. Each patient on TB treatment is carefully monitored through monthly physical examination and regular laboratory and radiological tests. Patients with drug resistant forms or highly infectious tuberculosis stay in IOM's Magic Mountain TB treatment center until they become non-infectious. Nine individual inpatient accommodation shelters were constructed to provide maximum ventilation and minimize TB transmission. Open recreational areas assist TB patients to maintain mental health in isolation. Nurses, counselors, and doctors visit the facility regularly. When refugee resettlement activities began in Nepal, there were two different protocols for TB detection and treatment for Bhutanese refugees. One was the protocol for all refugees, and another, more effective in terms of TB detection and treatment, for refugees in the resettlement track. Thanks to funding from the U.S. and Canadian governments, IOM was in a position to harmonize the protocols. Since 2008, all Bhutanese refugees with suspected TB undergo the same laboratory testing and optimized treatment. Another important focus is public health surveillance. IOM monitors trends of communicable diseases at different levels. In the camps, in surrounding communities, within Nepal and throughout the world, in order to provide early response and avoid interruptions in refugee resettlement departures. Health assessments are conducted according to international infection control practices. All rooms have adequate ventilation and are equipped with shielded ultraviolet lights and HEPA filters. MHD staff are required to wear respiratory protection gear and undergo regular health checks. MHD has established a computerized system of scheduling, documentation, and tracking, which enables quick retrieval of records for any refugee at any stage of the process. Queries from resettlement countries are answered within a matter of hours. The Migration Health Department emphasizes continuous staff development. All staff participate in regular clinical conferences and presentations in Damak, covering topics from specific diseases to general public health. In addition, staff participate in specialized training at various courses in Nepal and abroad. MHD uses a computer health information system. Throughout the health assessment process, each refugee's medical information is entered into IOM's institutional database. MAMOSA, Migrant Management and Operational Systems Application. MAMOSA contains electronic versions of all medical forms. MAMOSA allows safe storage and easy retrieval of information, eliminates handwritten reports, and has the potential for the exchange of information with health information systems in receiving countries. The database contains a separate module for registering TB treatment and monitoring. Dedicated IT staff ensure the maintenance of the network, the MAMOSA server, and the digital radiology system. A satellite dish connects MHD Damak to the rest of the world. On the day before departure from the camps to Kathmandu, MHD conducts a pre-departure check of all departing refugees. Trained nurses armed with individual health records reassess each refugee to determine fitness to travel. Nurses conduct the assessment considering conditions that could prevent travel, such as communicable diseases and unstable chronic diseases. If such symptoms are presented, a migration health physician is called upon to make the final determination. In addition, nurses provide treatment for intestinal parasites, treat minor illnesses, and ensure that refugees with chronic diseases have an adequate supply of medications. On the following day, refugees take an IOM organized charter flight to Kathmandu. Upon arrival in Kathmandu, refugees are accommodated at the IOM Transit Center for a period of one to three days. MHD staff at the Transit Center conduct health education sessions, including information on health recommendations during travel. They also perform room-by-room surveillance for communicable diseases and provide treatment for last-minute illnesses. All refugees receive a final pre-embarcation medical check one day prior to travel from Nepal to the country of resettlement. Migration Health Department provides medical escorts for refugees with serious medical conditions from Kathmandu to final destinations in the countries of resettlement. By the end of 2009, the IOM Migration Health Department had conducted health assessments for over 30,000 Bhutanese refugees and more than 25,000 had started new lives in the seven countries of resettlement. The success of this project is directly attributable to the government of Nepal, the UN Refugee Agency, the countries of resettlement, UNHCR implementing partners, and the International Organization for Migration. This has truly been a team effort.