British Medical Journal
19 December 2015 (vol 351, issue 8038)
Editorials Christmas 2015
Responding to the needs of refugees
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h6731 (Published 16 December 2015) Cite this as: BMJ 2015;351:h6731
Frank Arnold, convenor, anti-torture initiative1, Cornelius Katona, lead23, Juliet Cohen, head of doctors4, Lucy Jones, UK programme manager5, David McCoy, director16
Knowledge of and skills in human rights medicine will be needed
At the time of writing it is unclear how many people will eventually receive refuge in Britain from encampments in countries surrounding Syria through the UN vulnerable persons relocation scheme. The government’s current commitment to receive a maximum of 20 000 over five years, if delivered at a constant rate, would result in 4000 arrivals a year.1 It is also unclear when they will arrive and what financial and other arrangements are being made for local councils to support them. But even if the UK maintains its decision to opt out of the EU refugee sharing scheme, the number of asylum seekers reaching the UK by other routes may increase, given that more than half a million people seeking protection arrived in Europe by sea in 2015.
Whatever the numbers, many will have high levels of complex physical, psychological, social, and legal needs arising from their experiences in their countries of origin or during their often prolonged and dangerous journeys. This is particularly the case for people admitted under the UN relocation scheme, which emphasises vulnerability and damage as primary selection criteria.2
These health needs will interact with each other and with wider social needs (housing, schooling, linguistic, and cultural support) to produce challenges that exceed the experience of most UK clinicians. The issues that the responsible practices and hospitals will need to address are many and complex but largely predictable (box). The current crisis must be met by a plan to train and support clinicians to assist this vulnerable group. Such a plan would also benefit the many traumatised, tortured, and ill refugees, asylum seekers, and undocumented migrants who are already in the country.
Common interacting medical needs of refugees
:: Post-traumatic stress disorder and other mental health problems resulting from trauma
:: Consequences of torture such as damage to feet from repeated blunt trauma or brachial plexus damage after suspension by hyper-extended arms
:: Screening for sexually transmitted diseases (if rape revealed)
:: Traumatic war injuries
Social and legal
:: Adequate interpreting
:: Access to primary and secondary care and difficulties of negotiating exemption from overseas visitors charging regulations
:: Protection from subsequent unsafe repatriation or redress may require careful documentation of medical evidence of human rights abuses, including photographs or clinical notes of physical or psychological damage on arrival
So what needs to happen? Government departments should make use of standard handheld records of medical information gleaned during selection for relocation and ensure that the data follow the patients to their new practitioners. The European Union is developing such a record.3 For people who require secondary care the Home Office should provide immigration status documents and circulate them with advice to relevant officers to prevent inappropriate attempts to charge user fees. The entitlements of migrants to care are complex, but survivors of torture and other human rights abuses do not have to pay under the current regulations.4 And unless a general practice has a policy requiring all new registrants to supply documents, to do so for migrants only would constitute impermissible discrimination.5
As health professionals, we are occupationally and morally required to offer the highest standard of healthcare to all patients, including survivors of human rights abuses who arrive on these shores.6 But clinicians need to be trained and supported to help this vulnerable group. The knowledge and skills in human rights medicine and psychology developed by a relatively small number of specialist health professionals within the NHS and third sector organisations needs to be harnessed and used wisely to enable this to happen. These organisations include Freedom from Torture (www.freedomfromtorture.org), the Helen Bamber Foundation (www.helenbamber.org), and Doctors of the World (www.doctorsoftheworld.org.uk/pages/UK-Programme). The Royal Society of Medicine is hosting training sessions organised by Medact on clinical aspects of torture and trauma. Public Health England, which has a helpful Migrant Health Guide,7 the royal colleges, the BMA, and other health professional bodies can also facilitate relevant educational initiatives. Close collaboration between the statutory and charity sectors will be crucial.
The voice and mandate of health professionals also needs to be used to prevent xenophobia and tackle the root causes of the refugee crisis. We should make good use of the expressions of goodwill and solidarity from much of the UK population towards those who need help and highlight the past and potential long term economic and social contributions that such refugees have and can make in the UK. We should also seek to educate and engage the UK health community about the need to promote peace and human security, particularly in north Africa and the Middle East. The refugee crisis will not be resolved otherwise.