Tag Archives: refugees

BJGP Open: adapting primary care for migrants

Photo by shawn at Morguefile.com

The aim of this paper was to provide some insight into how primary care is managing to offer care to migrants. In particular they were interested in looking at the challenges and the ways in which practices and practitioners were adapting to meet this need.

The first phase was an online survey. During this they surveyed 70 primary care practitioners. They then used responses to select eight case studies for a further qualitative phase. They had a mix of mainstream GP practices as well as specialist services that offered tailored services to refugees, asylum seekers and other migrants. There was one group interview (with three GPs from the same city) and seven further in-depth interviews. The descriptive analysis was structured around the principles of equitable care that drew on the framework from Browne et al.

They found that practitioners tended to focus on working with community and external agencies and adapted their own processes in order to avoid care. This was particularly evident in areas such as screening, vaccination, and health checks. The biggest barrier was the lack of funding and this was cited in 73% of cases. The organisation and partnerships were regarded as particularly important to ensure there is an awareness of wider social determinants, the impacts of trauma and violence, and all this had to be wrapped up into culturally-competent care.

Opinion: There is a small section in this paper that caught my eye in relation to burnout. Just over one-third (34%) cited personal fatigue/burnout/capacity as a barrier to developing services. The additional workload ramped up the stress for some healthcare professionals and in one of the services they had introduced life coaching. In another they had adopted debriefings that are similar to those used in conflict areas.

“I think in terms of values, everyone sees the work that we do in serving vulnerable groups as a privilege.”

I’d put a positive spin on the burnout angle – it can be enormously re-invigorating to get involved with marginalised groups. As one ‘mainstream’ GP stated: “I think in terms of values, everyone sees the work that we do in serving vulnerable groups as a privilege.”

There are some fine examples in this paper on how primary care can be developed to give a more “equity-oriented service”. It showcases how, despite all the appalling strain on the system, there are still ways for primary care to innovate to reduce health inequalities. More than anything we should be driven by the principle that we need to reduce health inequalities to improve our societies. And sometimes we need to hunt these people down. Whether it is people with learning disabilities, or the mentally ill, or people who inject drugs, the homeless or as in this case migrants and refugees – these are the groups of people that need our attention.

ResearchBlogging.orgSuch, E., Walton, E., Delaney, B., Harris, J., & Salway, S. (2017). Adapting primary care for new migrants: a formative assessment BJGP Open DOI: 10.3399/bjgpopen17X100701

Volunteering in the Calais ‘jungle’

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Niamh and Emily en route to Calais

Niamh Scally graduated from Norwich Medical School in 2013 and completed foundation training in Manchester. She is currently enjoying an F3 year before starting her paediatric training in London later this year. She has an interest in health inequalities and care of hard to reach groups.

Emily Player is a GP trainee on the Norwich VTS scheme. She graduated from Norwich Medical school in 2013 and has completed an academic foundation programme in Norwich. She has an interest in medical education and nutrition as well as migrant health and healthcare for vulnerable groups.

We are both junior doctors, feeling helpless and frustrated by the current refugee crisis we decided to travel to Calais to help in whatever way possible with this crisis on our doorstep. We used our annual leave and boarded the Eurostar for the one hour journey across the channel.

We arranged volunteering through the ‘Refugee First Aid and Support’ group on Facebook. We booked our accommodation in the local youth hostel where we met fellow volunteers, arranged lifts to camp and recruited more volunteers including student mental health nurses and dieticians to our medical team.

As undergraduates we had both volunteered in an orphanage in Kenya and later, on elective placements worked in developing countries providing healthcare at a basic level. Now we volunteer in France, there were no ‘grown ups’, and a distinct lack of authoritative presence, with the exception of the police vans which guard and intermittently blast tear gas across the camp.

The days go rapidly, like in the NHS there is not much time to drink or wee and for this we are grateful as we have seen the toilets. We mostly saw URTIs, wounds, scabies and were often confronted with the symptom ‘all over body pain’. We are still unsure if this is due to the cold and damp conditions people sleep in, the malnutrition, the fatigue from ‘trying’ all night or if it is somatisation of the mental pain they suffer everyday when contemplating their situation – this bottleneck they have arrived at here in Calais, twenty miles across the channel from their goal of a better life in the UK. ‘Trying’ itself is an incredibly dangerous activity; one refugee died ‘trying’ in the 5 days we were in Calais.

14259_0_supp_3_795wqtWe were seeing around 200 patients a day when all three caravans were up and running, which solely depends on volunteers. We referred a handful of patients a day to the Le Passe clinic; a service ran by the government hospital in Calais. MSF had been running a similar service until the beginning of March, when their contract expired and their main efforts were relocated to Dunkirk. Examples of cases we referred to Le Passe included febrile children, a non-weight bearing unaccompanied 16 year old child who incurred a police brutality injury, a head injury inflicted by a local fascist group that requiring suturing and a 65 year old Syrian man alone on the camp complaining of palpitations, clinically in AF with oxygen saturations of 88%.

As healthcare professionals along with the refugee’s working as translators we treat numerous tear gas injuries, the dietician was able to give advice on refeeding syndrome to refugees on a hunger strike and together we refer on average 10 unaccompanied children to the youth team a day. The youth team, also volunteers, ensures the children have food, shelter and phone credit, they offer emotional support and a safe place to be during the daytime. They also provide information on staying in France and seeking asylum or expediting their application to the UK as vulnerable minors.

We couldn’t comprehend that there are children alone in the camp; other volunteers reassure us that there are often elders and friends looking out for them, but this doesn’t reassure us, this situation is not normal for anyone let alone a child. It is not normal to run away from tear gas. They are incredibly vulnerable to exploitation. More must be done by the EU governments to ensure these children are being protected. As one of the translators eloquently put, “we are living in the jungle but we are not animals”.

‘An eye for an eye makes the whole world blind’ – reflections on working with Syrian refugees

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Dr Nikesh Parekh

Nikesh Parekh is a GP trainee, a research fellow in ageing and part-time public health medical associate in London. Colin Tourle is a semi-retired GP in Hailsham.

There are 1.5 million Syrian refugees in Lebanon, of which the vast majority are hidden away in camps near the Syrian border. These are some of the most impoverished victims of the war in Syria, who lack the financial resource to travel further afield for safety.

With the support of Iasis medical charity (www.iasis.org.uk), we were privileged to travel to three refugee camps within a mile of the Syrian border in Lebanon’s Bekaa Valley to provide medical clinics.

The camps encompass vast swathes of land with back to back tents. Word would spread that doctors have come to offer free help and before long a mass of people, usually 75% women and children, would be gathered outside eager to be seen. Crowd control was nothing short of the chaos at a sporting event! It was hard seeing children queuing outside a dust filled tent waiting for us to see them when one could only feel they should be playing in a garden somewhere with a football or trampoline.

We had never quite anticipated how varied the presentations might be, from the expected urine and skin infections, to eczema, to renal stones, to muscle pains, to hypoglycaemic episode, to a likely bone malignancy. Recognising the likely bone cancer in a 7-year old boy was particularly moving. This child needed a haematologist and costly intervention. How on earth will this really happen – where is there a specialist hospital unit? Will the Lebanese doctor discriminate against the Syrian? Who will transport the child back and forth? Who will cover the costs? Who will look after the immunocompromised child if chemotherapy is the treatment of choicer? Is it too late anyway? These were all the kinds of questions one reflects on, and the unknowns are heart breaking.

Making a diagnosis is always a game of probability, but never really more so than in this resource limited setting, where health literacy of patients was minimal and gathering a good history was challenging even with translators. Attention was often diverted onto their painful stories of loss and despair in this prolonged war with no end in sight. The refugees just want to go back to Syria, the land where they grew up, where they had a living, where they had good memories with their families and friends, and where they were individuals as opposed to ‘refugees’. They certainly do not want to make a trip to Europe as far as possible.

Various pressures were on us and it is emotionally, physically and logistically intense – seeing as many people as wanted to be seen, being in a completely unfamiliar clinical setting where the concept of privacy in a medical consultation is non-existent, knowing that unless someone is life-threateningly ill you wanted to avoid hospital because patients knew that it was chargeable and would be reluctant to go. No one has money, and dignity is dying out fast.

There were some just excited by the opportunity to see some new faces in their camp. We knew they were not sick and they knew they were not sick but we accepted this and made a non-verbal deal; We would examine them and show off the stethoscope and they wouldn’t spend too long pretending to have a problem with every organ system. These sorts of cases made us both reflect on a question one inevitably has at the back of their mind but we didn’t dare ask for fear of the answer – how much of a medical difference am I truly making? – but we realised that we don’t need to answer this question because there was no doubt that the presence of a doctor to show care and provide reassurance without asking for anything in return was worth gold. It gave back some dignity, reminded these innocent victims that they are humans and that the world cares for them. They are not forgotten despite their isolation behind white plastic tent sheets labeled with the blue, bold letters ‘UNHCR’.