Case 2

 

Ezekiel has just arrived from Africa …

 

 

 

Refugee health care presents many challenges in general practice. There are language, social and cultural barriers to caring for refugees. Refugees also have complex medical and psychological needs. A systematic approach to refugee health assessment is important to ensure the best health outcomes possible for this vulnerable group of patients.

 

 

Learning Objectives

·        Develop a systematic approach to refugee health assessment

·        Access interpreters for conducting consultations

·        Be aware of the health complaints commonly affecting refugees arriving in Australia

·        Understand the legal and political context within which refugees and humanitarian entrants are entering Australia

 

 

Ezekiel’s Clinical Summary

 

Past Medical History:

            Unknown

 

Past Surgical History:

            Unknown

 

Allergies:

            Unknown

 

Meds:

            Unknown

           

Social History:

            Refugee

            Newly arrived from Sierra Leone

 

Occupational History:

            Unknown

 

Language:

            Unknown

 

 

Case Notes:

 

Ezekiel is new to your practice. He’s just arrived in Tasmania from Sierra Leone in Africa. You are seeing him for the first time today, with a lady named Doris who says that Ezekiel is a refugee.

 

 

What is a refugee?

 

According to the United Nations Geneva Convention, a refugee is a person who, “owing to a well-founded fear of being persecuted for reasons of race, nationality, membership of a particular social group or political opinion, is outside the country of his nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country” (UN Geneva Convention, 1951).

 

What is the difference between a refugee and an asylum seeker?

 

In Australia, A refugee is someone whom the government has decided fulfills the criteria outlined in the Geneva Convention and an asylum seeker is someone who is in the process of applying to be recognized as a refugee.

 

What’s the process for humanitarian entrance into Australia?

 

The diagram below shows a simplified version of the process refugees take to arrive in Australia and the most common visas granted (for more detail on the criteria of each visa, go to http://www.immi.gov.au/refugee/migrating_refugee.htm ):

 

 

 

 

As the diagram shows, Australia has both an offshore and an onshore humanitarian program for processing asylum seekers. Within Australia there are two different types of asylum seekers – authorized and unauthorized.

 

(a)     “Authorized” asylum seekers arrive with a valid visa (e.g. student or tourist) and are usually processed in the community.

 

(b)     “Unauthorized” asylum seekers have no valid visa.  They usually arrive by boat.  These cases are usually processed while person is in a detention centre.

 

 

 

What settlement support does each refugee get?

 

On arrival, initial settlement services are provided by the Commonwealth with other services such as GP visits and State services being accessible as needed. Eligibility for specific services and entitlements will depend on the type of visa (see the table below). The Department of Immigration, Multicultural and Indigenous Affairs (DIMIA) provides various services for about six months through a program called the Integrated Humanitarian Settlement Strategy (IHSS). The IHSS aims to help humanitarian entrants achieve self-sufficiency as soon as possible by providing them with support for the initial settlement period, which, in most cases is about six months, although this can be extended to 12 months depending on the case.

 

 

Refugees – The Tasmanian Context:

 

In Tasmania we receive very few Temporary Protection Visa (TPV) holders or asylum seekers. The majority of refugee/humanitarian entrants are being settled here on a long-term or permanent basis.

 

Currently Tasmania receives approximately 500 refugees a year for resettlement. Tasmania has received refugees and migrants from a wide range of countries over many decades. Recently most refugees have arrived from regions such as Africa, the Middle East, Asia, South America and the former Yugoslavia.

 

Refugees are people who often have a higher proportion of long-term physical and psychological problems than other migrants, due to experiences of long term conflict, persecution, repression, long dangerous journeys, in many cases torture and other severe human rights violations, and will almost all be suffering from separation and displacement issues, as well as trying to adjust to a totally new environment, culture and language.

 

Medical examinations are conducted on refugees before entrance into Australia. The examination includes a physical examination, Chest X-Ray (for TB) and an HIV test (for adults), usually a number of months prior to migration, and is generally valid for 12 months (though sometimes less). However, due to the amount of time spent displaced and in refugee camps, many will not have had access to comprehensive health care for long periods of time, often several years, and examinations will be out of date. There are also health problems inherent to some refugee camps. Patients therefore usually require comprehensive medical assessment with their GP in Australia.

 

How does the refugee patient end up seeing you?

 

The flow of events once a refugee or humanitarian entrant arrives in Tasmania is basically as follows:

 

  1. Refugees are met at the airport by representatives from the IHSS, housed in temporary accommodation and allocated a Community Support for Refugees (CSR) volunteer group (for six months) wherever possible.
  2. An Early Health Assessment and Intervention Program (EHAIP) worker offers initial assessment (verbally) to assess the urgency of medical and psycho-emotional conditions (this may take more than one visit in complex cases or in a larger family group) and will then refer on to a general practitioner and/or to other health professionals
  3. A CSR group volunteer will ring and book the medical appointment, explaining that the patient is a refugee and specifying the language, dialect and gender needed for an interpreter (where required) and the gender preferred for the GP.
  4. The CSR volunteer will usually accompany the patient to their first appointment.

 

 

Issues to Consider:

 

Before this case progresses, consider some of the issues you might need to deal with to assess Ezekiel. What are the immediate problems you anticipate with assessing and managing Ezekiel?


Case Notes:

 

Doris says that she’s Ezekiel’s CSR volunteer – a volunteer who helps him with things like making appointments to see the doctor. She tells you the language Ezekiel speaks. Your waiting room is full. You have a stack of home visits to do at lunch. You can see your day going down the gurgler. Clearly you can’t do all the things you have to do with Ezekiel right now. You are wondering to yourself ‘How do I get an interpreter so that I can see if he can come back when I have more time?’

 

 

Accessing an interpreter:

 

The Department of Immigration and Multicultural and Indigenous Affairs (DIMIA) runs the Translating and Interpreting Service (TIS), which is the recommended translator service for medical consultations.

 

The telephone interpreting service is free to any doctor in private practice for a consultation claimable under Medicare.

 

Face to face interpreters can be arranged within certain hours if booked two weeks in advance however in Tasmania the number of interpreters and languages is very limited. Telephone interpreters are usually preferred and can be pre-booked.

In cases when an interpreter has not been pre-booked, TIS has a special Doctors Priority Line which operates 24 hours a day 7 days a week. For major languages a translator can usually be found within a few minutes.

 

The Doctors Priority Line number is 1300 131 450.

 

In some cases the refugee patient may have a family or community member with them who speaks English, and there may be a temptation to use this person as an informal interpreter. This is strongly discouraged.

 

A professional interpreter is always recommended for medical appointments as they have been independently assessed as having a high level of technical competence in both English and the patient’s language, they are more able to convey complex medical information in an accurate and non-emotive way and are bound by a code of ethics including strict confidentiality. A friend or companion acting as interpreter may prevent the patient from disclosing information fully out of embarrassment or fear of breach of confidentiality.

 

It is important to brief the interpreter:

  • Explain to the interpreter the reason for the consultation, or give a brief overview of what you want to achieve
  • If needed, make them aware of circumstances relating to the patient that is likely to impact on the interview
  • Establish a style of interpreting: you say a few sentences, and pause to allow the interpreter to translate etc
  • Ask the interpreter for feedback – ask them to tell you if they do not understand the terms you use, or if the terms are not easily translated. Ask them to tell you if the patient is expressing a culturally related idea or concept that they think you may not understand
  • Ask the interpreter if they have any concerns they want to share with you before ending the consultation

 

Issues to Consider:

a)      You will have a TIS interpreter on the telephone within a few minutes. What specific issues are you going to discuss at this time via the interpreter?

 

 

Case Notes:

 

Ezekiel tells you, through the interpreter, that he has presented because he is unwell with stomach pains. You are not sure about the causes of stomach pains in African refugees and whether they are any different to anybody else’s stomach pains.

 

 

Chronic diseases in refugees:

 

There are more than 3 million African refugees, out of 13 million refugees worldwide. The African continent has been plagued by ongoing civil wars, political unrest and natural disasters.  Infectious diseases are an ongoing problem on the African continent, and are common among refugees arriving from African camps. Severe mental health problems secondary to trauma, torture, dislocation and persecution are also highly prevalent in refugees.

 

The Royal Hobart Hospital has a Refugee and Humanitarian Arrival Clinic (RAHAC). RAHAC have found the following disease rates among African refugees entering Tasmania:

 

DISEASE

PERCENTAGE AFFECTED

Hepatitis B infection (HBsAg)

 

8%

Past Hepatitis B (HBcAb)

 

47%

Hepatitis C infection

 

2%

Positive Syphilis serology

 

4%

Human Immunodeficiency Virus

 

0

Schistosomiasis

 

38%

Strongyloides

 

8%

Falciparum malaria

10%

Anaemia

10%

Vitamin D insufficiency

84%

Gastrointestinal parasites

37%

 

 

 

 

Issues to Consider:

 

a)      What further history will you need to obtain from Ezekiel?

b)      What physical examination will you perform?

c)      Will any office-based tests be helpful?

d)      What will you consider in your differential diagnosis?

e)      What diagnostic tests are appropriate for Ezekiel?

 

 

 

Case Notes:

 

You take a history and examine

 Ezekiel who tells you, through the interpreter, that he has suffered from stomach pains for the past 5 years. The stomach pains have not become any worse. You tell Ezekiel he will need a thorough history and physical examination when more time is available. He is happy with this. You inform him about the surgery opening times and appointment system.

You explain that this visit has been an introduction and in the next visit a fuller medical history will be taken and a physical examination will be done, and they may be asked to give blood or other samples for testing.

You organise a follow-up appointment

.

 

At the follow-up appointment there is a lot to cover: a comprehensive history, physical examination and investigations. By this time you have located Tasmania’s Refugee Health Manual and the Refugee Health Desktop Guide that accompanies the manual. These resources cover essential history, examination, investigations and referral for refugees.

 

 

 

The Refugee Health Manual:

 

Staff of the Royal Hobart Hospital Refugee and Humanitarian Arrival Clinic, in conjunction with the Public Health Unit and the Divisions of General Practice, have developed a Refugee Health Manual and Refugee Health Desktop Guide to assist GPs in managing refugee patients. Hard copies of the manual are available from the Public Health Unit in Tasmania and copies of the desktop guide from the regional Divisions of General Practice in Tasmania.

 

 

These resources describe a 4-visit process for completing the assessment. The first visit is the introductory visit, where the patient is introduced to you, finds out about surgery opening times and how to make appointments, and interpreter suitability is clarified. It is also a visit where urgent health concerns may be dealt with.

 

The second visit is the most time-consuming – where a history is obtained, physical examination is performed, and investigations are ordered as follows:

 

History – Key Points

 

• General (e.g. weight loss, fever)

• Skin (e.g. rash, scars, wounds)

• Neurological (e.g. seizures, headache, vision, hearing)

• Ear Nose Throat (e.g. caries, discharge)

• Respiratory (e.g. SOB, cough, sputum, haemoptysis)

• Cardiovascular (e.g. chest pain, SOA, palpitations)

• Gastro-intestinal (e.g. nausea, vomiting, constipation, bloody stool)

• Genito-urinary (e.g. pregnancy, discharge, bleeding, female circumcision)

• Musculoskeletal (e.g. limp, pain, swelling)

• Psychological (e.g. depression, anxiety, nightmares, suicidal ideation)

• Developmental status (children)

 

Examination – Key Points

 

• General appearance (malnutrition, temperature)

• Lymphadenopathy

• Eyes

• Head and neck (e.g. lymph nodes, masses)

• Respiratory (e.g. observe cough / sputum production)

• Cardiovascular (e.g. murmur)

• Abdomen (e.g. hepatosplenomegaly)

• Pelvis

• Extremities (e.g. swelling)

• Central and peripheral neurological disease (e.g. neuropathy)

• Skin

• Developmental status (children)

 

Investigations

 

• Full blood count

• Serum electrolytes, liver function tests, calcium and phosphate levels

• Vitamin D levels

• Serum iron, transferrin and ferritin levels

• Hepatitis B surface antigen, surface antibody and core antibody testing

• Hepatitis C serology

• Human Immunodeficiency Virus (HIV) serology

• Syphilis testing (RPR and TPHA)

• Strongyloides and schistosomiasis serology

• Stool and urine testing for schistosomiasis (if from endemic areas)

• Malaria thick and thin films

• Faecal samples for ova, cysts and parasites x 3

• Mantoux testing and a Chest X-ray – refer to Chest Clinic

 

At the third visit, results of investigations are reviewed, and further investigations or treatment for abnormal results are organised. Referrals to specialists and other health professionals or services (e.g. Dentist, Optometrist, Phoenix Centre for victims of torture and trauma) are organised. Vitamin D supplementation is prescribed, and catch-up immunisations are commenced. Vitamin D supplementation guidelines are included as an appendix in the Refugee Health Care Manual.

 

The current edition of the Immunisation Handbook has a section outlining catch-up immunisations. Alternatively, the Refugee Health Care Manual has a section detailing catch-up immunisations. Refugees may be incompletely vaccinated or have unsatisfactory records of vaccination. Immunisation status is not routinely assessed in children and adults entering Australia as refugees. If a child has no valid documentation of vaccination, a ‘catch-up’ schedule should be commenced. If there is a valid record of vaccination, the history of prior doses should be taken into account when planning a catch-up vaccination series. Refugee adults need to be targeted for vaccination against rubella using MMR. This is particularly important for women of childbearing age.

 

Visit 4 is a continuation of visit 3, where immunisations are continued and further investigation results are followed up and referrals organised.

 

Case Notes:

 

You have completed the history, examination, investigations and referrals as outlined in the Manual. It is now 6 months later. Ezekiel is doing well and has enjoyed studying English at TAFE. His stomach pains have settled since you diagnosed and managed his gastrointestinal parasites. Ezekiel is hoping that more members of his family will be joining him in the next year.

 

 

 

Summary:

 

This case illustrates a systematic approach to refugee health assessment. As a result of completing this case you should now be confident accessing interpreters for conducting consultations with refugee patients, be more aware of the health complaints commonly affecting refugees arriving in Australia, and have a better understanding of the legal and political context within which refugees and humanitarian entrants are entering Australia.

 

 

References and Further Reading:

 

American Public Health Association. Control of Communicable Diseases Manual. 18th Edition. 2005.

 

Australian Government Department of Immigration. http://www.immi.gov.au/refugee/migrating_refugee.htm

 

Australian Government Department of Health and Ageing. Australian Immunisation Handbook. 8th Edition. 2004.

 

Department of Health and Human Services. Refugee Health Care Manual. 2005. Hobart.