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At the heart of general practice since 1960

Working with asylum seekers and refugees

Dr Sarah Montgomery explains how she came to work with this group of patients and what she gets out of it

Dr Sarah Montgomery explains how she came to work with this group of patients and what she gets out of it

Her English was good enough to respond to the question I always ask at the beginning of my consultations: 'How can I help you?'

In a whisper she replied: 'My breath – it stop – here', pointing to her mid sternum.

Four days ago she had arrived in the port of Dover, hidden in a refrigerated lorry. She had been in there with three other people for nearly 10 hours, and when the door was finally opened they were all half dead. Even as she began, haltingly, to tell me this story she began to hyperventilate and her hand went to her chest. A few days later, she was back again. 'My period no come.'

Weeks before the trauma of the final leg of her journey, she had been forced to earn her passage from Eritrea to Europe through an agent who took the last of her money and then raped her because it wasn't enough. Now she was pregnant at the age of 22, from a culture in which to be an unmarried mother is an unpardonable sin, with no family left alive in her own country, and facing the prospect of becoming one of the 80% of asylum seekers who end up being deported.

Foreign skills
I have been working with asylum seekers and refugees since 1999, when our health authority set up a temporary service using salaried GPs to cope with the waves of people who successfully hid in the Channel Tunnel and ferries and emerged in Dover. I had just returned from four years' voluntary work overseas.

This experience had taught me what it was like to be a foreigner, to struggle in another language and to depend on the kindness of strangers. It turned out to be the best possible qualification for my new role. Bewildered, traumatised people arriving in a strange and often hostile place need a warm and sympathetic welcome.

There are no special qualifications for working with this group of people, and there are few appropriate training opportunities. However, once a year the Department of Health funds a two-day conference run by GPs for GPs. The Medical Foundation for the Care of Victims of Torture also runs training days, and there are useful web resources such as the Health for Asylum Seekers and Refugees Portal (www.harpweb.org.uk) and the Medical Foundation (www.torturecare. org.uk/articles/bibliography/c212).

The skills required are no different from those needed every day by every good GP: excellent communication skills; the ability to tease out the important symptoms and signs from the undifferentiated distress expressed by the patient; the ability to explain complex concepts in straightforward terms; a willingness to see each individual as a unique human being with a unique story. In the first six months, I registered over 700 patients who spoke 43 different languages.

No interpreter service could cope with this range and it was impossible for me to know about the particular cultural or health beliefs that might influence each patient's perception of illness and well-being. The huge variety of symptom patterns I encountered led me to question my own assumptions of normality.

It helped me to become aware that every GP consultation is something of a cross-cultural experience; as a middle-class well-educated person, how much do I really understand about the world inhabited by my patients who live in the most deprived parts of Folkestone?

The best course available for any GP who wants to explore this aspect of their work in more detail is the annual Course in Cross-Cultural Primary Care delivered by Dr Cecil Helman at the Royal Free Medical School.

Frustrations and rewards
Chaos, uncertainty and trauma feature strongly in the lives of all asylum-seeker patients, and these inevitably spill over into consultations. It can be frustrating to find that the demands of the Home Office take priority over healthcare but the truth is that the outcome of an asylum claim is likely to have far more impact on the wellbeing of my patients than anything I can offer.

I have had to learn to work within the boundaries of what is possible and what is not, to be ready to advocate strongly on behalf of patients when necessary and to manage my own wellbeing while absorbing daily accounts of terrible human tragedy.

What keeps me going are the many rewards my patients give me: the shared delight of crossing cultural and linguistic barriers to reach common ground and mutual understanding; the letter from a solicitor telling me my medical report made a significant difference to the success of his client's asylum claim; the smile that greets me a few days after a consultation in which a patient such as the Eritrean lady described above has had the courage to tell me her story.

Dr Sarah Montgomery works as a salaried GP, mainly with asylum seekers and refugees, in Folkestone and Ashford, Kent

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