According to 2012 figures from UN High Commissioner for Refugees (UNHCR), there are 150,000 refugees and 18,000 asylum seekers in the UK or 0.27% of the population. There is no doubt that seeing refuges or asylum seekers within the limits of a ten-minute general practice consultation presents a challenge to both the doctor and the patient.
For the Home Office a refugee means somebody who is recognised by the UK government as having refugee status. This is a legal status recognised by the government following a number of international treaties; principally the Geneva Convention.
An asylum seeker is someone who has applied to the UK government for refugee status and is awaiting a decision. Both these groups are entitled to free NHS care in general practice and hospitals.
A smile and a welcoming manner can go a long way. Refugees are likely to be polite and willing to prioritise their needs, though health may not be their most important concern.
Asylum seekers tend to come from recent areas of conflict. In 2012, the top four countries of origin were Pakistan, Iran, Sri Lanka and Syria.
They are likely to have been through ‘the triple trauma’ of the refugee. The first trauma is the events in the home country that are severe enough to force people to leave their home. It is estimated that at least 10% have undergone torture during this time.
The second trauma is that of the journey to the UK, which, because of current UK regulations, is almost always via illegal channels.
The third trauma is that suffered after arrival in the UK. Waiting for asylum in hostels, and being unable to work legally are both bad for your health, leading to what has been called ‘Home Office syndrome’.
In many ways dealing with this population in general practice is similar to dealing with other patients. There are only ten minutes for the consultation so the most important task is to show compassion and gain confidence in what is likely to be the beginning of a relationship. One advantage over other patients is that the doctor will not expect the refugee to share his health beliefs, so that he can elicit the beliefs and expectations of the refugee without causing offence. Equally the refugee is typically keen to know how things are done in his new country and will be willing to choose one or two priorities for action.
However, appointment systems will be new to some groups, so that this will require careful explanation. Equally, most refugees come from areas were primary care is little developed, so that explanation will be required about which conditions are treated in general practice and which in hospital in the UK.
Language can be a problem. Family interpreters are only suitable for minor problems. The health service has a duty to provide interpreting services – these may be in person or via a telephone link.
Both mental health problems and epilepsy are strongly stigmatised in some cultures. Whole-body pain is a common symptom of distress. While anti-depressants are not appropriate for every refugee, they are useful in clinical depression which is certainly common in this population.
Another catch is Vitamin D deficiency, which endemic in dark-skinned people, particularly those whose body and face are covered by their dress.
The other common mental health problems are post-traumatic stress disorder (PTSD) and substance abuse. Once the refugee is settled, cognitive behaviour therapy is said to be the treatment of choice for PTSD. If a history of torture or rape as part of torture is disclosed, a referral can be made to Freedom from Torture in London or one of its regional offices.
Physical diseases are typically the same as the UK population, indeed the incidence of coronary heart disease is often higher. One should remember tuberculosis in chronic cough, and be willing to order a chest X-ray.
HIV is common in some parts of the world; treatment is now life-saving, so that testing should be offered to appropriate patients, but it should be offered when trust has been built rather than at the first encounter.
- Felix Kuti is a 27-year-old Cameroonian man. He attends to complain of having blackouts. Direct enquiry reveals that he has been extensively tortured, including by blows to the head causing loss of consciousness. Whilst PTSD and anxiety are possible causes, you also consider epilepsy (common after severe head injury). Epilepsy is heavily stigmatised in many cultures which can make eliciting a history difficult. You should refer to a neurologist, although starting treatment while you wait for the referral is an option.
- Miriam Ali is from Somalia. She is pregnant. She reports having undergone female genital mutilation (FGM) and you perform an initial vaginal examination. FGM is common in Somalia and a band of other countries across West and Central Africa.You discover that the labia are fused together. The patient should be referred for reversal during the ante-natal period – it is better not to do it before the labour.
- Marie Makololo from the Democratic Republic of Congo (DRC) attends in a distressed state. She has brought her husband as an interpreter. While family interpreters can be useful for minor illness, they are not suitable for gynaecological or mental health consultations. The CCG has a legal duty to provide an interpreter, either face to face or via a telephone (Language Line). Rape has been endemic during the long civil war in the Congo and should not be revealed to the husband in the course of the consultation.
Dr Gervase Vernon is a retired GP from Essex. He has previously worked as a medical examiner for Freedom from Torture.
Dr Rayah Feldman currently works for Maternity Action. She has ten years’ experience in refugee health issues.
This is an extract from the book Working with Vulnerable Groups, edited by Paramjit Gill, Nat Wright and Iain Brew published by the RCGP.