29 June 2017

Supporting the health needs of refugees.

As a General Practitioner (GP) who specialises in refugee health and mentors registrars (GPs in training) in this field, I see a common theme; refugees receive the common Australian healthcare ‘routine’. However, many factors need to be considered, such as their country of birth, their past and current living conditions or their cultural beliefs.

It was Refugee Week recently (18-24 June 2017). Whilst it is a week of celebrating the positive contributions made by refugees to Australia society, I thought it timely to take a moment to reflect on how we as GPs can support the health needs of refugees.

A brief history.
The social determinants of health, exposure to different environmental conditions and infectious diseases, lack of health infrastructure, ethnicity, under-nutrition, and the sequelae of torture and trauma, are just some of the factors likely to impact on the health of refugees after they arrive in developed countries.

In 2014 the United Nations High Commission for Refugees (UNHCR) estimated that there were more than 61 million ‘uprooted persons’ worldwide and 13 million refugees. Only about 1% of the ‘people of concern’ are submitted by the UNHCR for possible resettlement. In 2011, 62,000 refugees resettled in 22 industrialised countries. Who is settled in each country, depends on the international political situation, decisions made by the UNHCR and the country’s Government. Many have been in ‘transit countries’ living in refugee camps or unsafe and unstable conditions for many decades.

It has been estimated that more than 200 million people, 2% of the world’s population, live outside their country of birth. This migration is more obvious in countries such as Australia and Canada where up to 25% of the population are born overseas. The health of these new residents will be influenced by many factors, including the social situation in their country of origin, that of any transit countries and by the circumstances in which they live in the new country.

The definition of a refugee.
Refugees are forced migrants who leave their country in order to ‘save their lives or preserve their freedom’. They are unprotected by their own country and usually leave with little preparation, very few belongings and little paperwork. Their future and even their freedom is usually uncertain. In contrast, migrants choose to move so as to improve their economic, career or education prospects. Asylum seekers are seeking international protection but have not yet had their claim for refugee status determined. Internally Displaced Persons (IDP) have been forced to flee from their home but have not crossed their country’s border.

Health challenges that refugees face.
The health profile of these different types of migrants is usually going to be vastly different and the health profile of one cannot be extrapolated to the other. For those who come as voluntary migrants, the social determinants of health are likely to be similar to those of the new country and they can prepare for their arrival by such activities as learning the language, establishing networks and ensuring their career is recognised. After resettlement in a developed country, the social determinants of health for refugees will certainly improve and there will be a ‘catch-up’ in their health status. However there will still be a differential and their health and socio-economic status is still likely to be lower than the majority of the population in the new country as they struggle with the transit as well as language difficulties, stigma and discrimination.

Some health issues will be specific to certain populations, others common to all people of refugee background and others at a different prevalence than the rest of the population. Waves of refugees will reflect the areas of conflict in the world, and their health needs may change. The health system needs to be able to evolve to cater for the needs of this constantly changing population and be prepared to develop guidelines that are able to be adapted to cater for new and emerging issues. Health professionals working with newly-arrived refugees also need to be constantly on the alert as to different health profiles that might emerge. Examples would be the higher rates of malaria in African refugees, use of lead-based cosmetics in those from Myanmar, schistosomiasis in Africa and Asia and the higher prevalence of Vitamin B12 deficiency in those from Bhutan.

It is not only the prevalence of infectious diseases, nutritional deficiency and immune dysfunction that are influenced by the social determinants of health. Chronic diseases such as cardiovascular disease, diabetes, hypertension and some cancers are also more common. These diseases with more long-term, chronic or insidious morbidity may not be at the forefront of the minds of either refugees or health professionals soon after arrival.

Treating a refugee.
Appropriate health-care of newly-arrived refugees will not only improve their immediate health but is also likely to decrease the long-term health burden on the individual, their family, the society and the health system. If refugees are only given ‘routine’ health care, their health is likely to be suboptimal and this will further compound their difficulties in resettling in the new country. This could potentially lead to increased morbidity over the person’s lifetime, mortality and escalating costs to the health system in the future. The imperative is not only about the individual and their place in their new society, but deeper issues of the inequity of health care.

For most of the rest of Australia, it is difficult to relate to the poverty, fear, trauma, isolation and lack of previous social determinants of health or health care experienced by refugees. Similarly for the health profession, the diseases of poverty and overcrowding are rare, and being rare, are not routinely screened for. There is limited exposure in many Australian medical schools to teaching on the social determinants of health. Doctors who have worked with other vulnerable patient groups are more likely to be aware of the impact of the social determinants of health on disease profiles. Otherwise, the assumption is likely to be made that once refugees have settled in Australia, their health profile will match that of the rest of the Australian population.

When deciding whether to screen for an illness as part of a preventive health strategy, evidence-based guidelines such as those from the Royal Australian College of General Practitioners (RACGP), can guide decision-making. These guidelines might also direct screening for higher risk patients, for example, Vitamin D in those with dark skin or who wear extensive covering for cultural reasons, or Hepatitis B in those who come from high prevalence countries, regions or ethnicities. Refugee health guidelines such as those written by the Australasian Society for Infectious Diseases (ASID) or the desktop guide published by the Victorian Refugee Health Network are more appropriate for newly arrived refugees.

Hence when seeing a patient from a refugee background, particularly if they are newly-arrived, screening should be different to that for the rest of the Australian population. However, unless health practitioners are aware of their particular needs, the health care provided to a newly-arrived refugee is likely to be similar to that for the rest of the health professional’s patients. Clinical decision-making in refugee health is complex and will involve a variety of different activities. As well as looking at the national guidelines to see if they are relevant, it is important to look at specific refugee health guidelines, but might also involve a review of the literature, discussing the issue with other refugee health practitioners or doing internal audits.

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