Refugee medicine in the United Kingdom

Authors: Peter Cross 

Publication date:  26 Jun 2004

What's new in refugee medicine? Peter Cross went to a recent conference organised by the black and ethnic minority health section of the Royal Society of Medicine to find out

“I'm very grateful that Britain wasn't as horrible to me as it is to refugees now,” says conference delegate Dr Edward Herst, a retired psychiatrist who came to the United Kingdom over 60 years ago as a refugee from Nazi Germany. “The hardship that refugees suffer now is absolutely horrendous,” he continues, “and I think the Home Office is making it infinitely worse by making them wait so long for a decision. Pre-existing psychological problems are made worse by uncertainty.”

Health needs

Dr Peter Le Feuvre, a general practitioner (GP) in Dover who has worked with asylum seekers and refugees since 1999, argues that there is little objective information on refugees' physical health needs. Refugees often report poor health, but the prevalence of chronic illness is low. In contrast, he explains, levels of psychiatric complaints are high.

Edward Herst also advises doctors with refugee patients to be aware of “the enormous psychological problems that are present. An awful lot of refugees are not receiving psychiatric treatment. There is very little psychotherapy for refugees, quite often they don't even get antidepressants.”

“Triple trauma paradigm”

Peter Le Feuvre agrees that refugees have presentations unique to their terrible experiences: “Psychological problems, insomnia, nightmares, psychosomatic symptoms.”

He explains that these arise from the so called “triple trauma paradigm” of loss, torture, and witnessing atrocities and the adverse impacts of the asylum process itself: “The distress exhibited by refugees can be seen to have physical, psychological, social, spiritual, and existential aspects.” He adds, “This presents a challenge for health workers trained in scientific disease orientated medical care who risk compartmentalising the distress that is present into a model that is congruent with their training. Health staff should receive training in issues surrounding race and culture.”

Enhancing teaching skills

Training practices have their work cut out for them. Delegate Terry John, GP in a northeast London training practice, has had refugee doctors doing clinical attachments with his practice. He feels they have made a big difference: “They enhance our practice in a variety of ways. We have been asked to extend our teaching skills to refugee doctors who have different needs. That enhances our teaching skills. Secondly, we have a variety of ethnic groups in the practice and if we are seen to have refugee doctors that says something positive to the community.”

Social issues

Kamaldeep Bhui, professor of cultural psychiatry and epidemiology at Barts and the London School of Medicine and Dentistry, has been interested in cultural psychiatry since he was a senior house officer. He spoke about his current research on geographical mobility and the effects on mental health of Somali refugees.

Kamaldeep Bhui explains that refugees often present to GPs asking for help with social issues such as housing, not mental health: “If you simply diagnose a particular illness you may not be successful. That may not be why they have come to you. Refugees may have a very different illness model from yours. They may wish you to address a different aspect of their suffering or even a social issue because you're the gatekeeper to their resources. You have to take account of the hierarchy of need that they have, and to some extent be willing to get involved in social intervention either as an individual or as a team.”

Treat them as human beings

Imagine a refugee walked into your consultation room tomorrow. “The first thing I would say is don't be frightened,” advises Peter Le Feuvre. “They have the same everyday concerns and illnesses as the rest of your patients. Treat them as human beings. Find out where they come from, look at the atlas, find out where that country is, find out what language they speak. Find out what language you have in common. Work out how you are going to communicate. What interpreters are around? Recognise that you will need a lot more time to do an initial consultation, but if you can spend some time with them it is likely to be repaid in the years to come. At some stage you may well need to spend 30 or 40 minutes.”

A systems approach

“GPs shouldn't underestimate the importance of medical evidence,” adds Kamaldeep Bhui. “In some cases doctors have to over-medicalise in order to secure people's medical interventions. What is more important is not just to battle on, in a case by case basis, but take a systems approach. If there is a systematic problem you come up against, address it with the organisation, with your practice or PCT [primary care trust] and resolve the issue. It is time well spent if, say, a PCT nominates someone to work with the housing agency and gets a policy in place which addresses prejudices that lead to exclusion.”

Kamaldeep Bhui also stresses a need for research into new models of trauma, so that doctors know when to leave well alone and not delve into details of horrific war stories that cause further harm. His premise, that geographical mobility, migration, and complex needs of refugees challenge existing services and practitioners, ought to be a wake-up call to policy planners. “There is a need for political awareness and political interventions,” he says. “We had to involve an MP [member of parliament] to ensure a refugee wasn't evicted from high support accommodation.”

Further information

  • [Link] —the refugee doctors pages of the international section include the data collection form for the BMA/Refugee Council database and the guidelines on clinical attachments produced by the Refugee Doctor Liaison Group

  • [Link] —refugee health professional contact network

  • [Link] —website of the Barts and the London refugee doctors project with lots of useful information and links

Lack of interest

However, as Neil Gerrard, MP for Walthamstow, London, and chair of the all party parliamentary group on refugees, told the conference: “It is difficult to get MPs interested. Only an MP in the big city who sees refugees on a regular basis is likely to get involved. The application of Section 55 of the National Immigration and Asylum Act, leading to people being refused all support and sleeping rough or staying with friends, has made access to health care more difficult for many asylum seekers. Refugee policy is driven by the media and public attitudes. There have been calls in certain sections of the media for the compulsory testing of migrants and asylum seekers for infections such as TB [tuberculosis], HIV, and hepatitis, followed by restrictions on their access to health services.”

Daily Mail thoughts

“I do wish the media would shut up and stop denigrating refugees,” says Edward Herst, while Kamaldeep Bhui believes “so called Daily Mail thoughts are felt and expressed far more widely than you might think.” He adds, “We have a job to do raising consciousness about how we treat refugees in our society.” Will it change? He smiles, “I'm always an optimist.”

Peter Cross freelance journalist London  petercross@medix-uk.com

Cite this as BMJ Careers ; doi: