You are a doctor working in an inner-city paediatric emergency department in Europe.
Waleed, a 2 year old boy, is brought to A&E by his mother as he is coryzal and ‘feels hot’. History, examination and observations are all unremarkable. You plan to discharge home with safety netting.
As you explain your plan, Waleed’s mother becomes tearful. She has recently arrived from Syria and the family are seeking asylum in your country. They are not registered with a GP and Waleed is unvaccinated. They have little social support. Mum is concerned about Waleed’s nutrition both in refugee camps prior to their arrival and regarding the food she is currently able to provide for him on governmental asylum support.
You retreat to the doctor’s office to devise a plan to help this family.
A keen medical student overhears you discussing the case with your consultant. They ask you, “What is an asylum seeker?“
Asylum seeker: a person who has left their country of origin and applied for asylum in another country but whose application has not yet been concluded.
Refugee: someone whose asylum application has been successful. The government recognizes they are unable to return to their country of origin owing to a well-founded fear of being persecuted for the reasons provided for in the United Nations Refugee Convention or European Convention on Human Rights (such as persecution due to race, sexuality, political opinions or religion).
Refused asylum seeker: a person whose asylum application has been unsuccessful. Nearly half of UK asylum applications are rejected – yet ~40% of appeals are successful.
Undocumented migrant: someone who enters or stays in a country without the documents required under immigration regulations. They usually have no recourse to public funds or governmental support.
Globally, around 80 million people are displaced from their homes. Around 50 million are internally displaced within their own country; around 13 million are hosted in countries neighbouring their own, predominantly in the developing world. In 2019, two thirds of refugees came from just five countries: Syria, Afghanistan, South Sudan, Myanmar and Somalia. 40% of refugees worldwide are children, many unaccompanied.
It’s so stressful, I don’t know what to do, I don’t know where I’m going to live…. (child refugee)
“The experience that I have is killing me every day” – talking about seeking asylum in the UK
“Being scared was a permanent state of mind. I was always scared. When I went to bed, I always wondered if I would wake up the next morning.” Now they must wait to register for asylum, a process that takes up to two weeks. During those two weeks the family must wait outside the registration centre every day for their number to be called. There are no facilities or shelter from the rain. “I am tired of waiting here all day. We just stand in the rain. But I will tell you something: after everything we have been through, a bit of rain can’t hurt me.”
How do refugee children present to the emergency department?
Evidence suggests that migrant populations use health services less than the native population. Some common challenges include communicable disease, mental illness (such as depression, isolation, PTSD, FGM and domestic/gender-based violence) and untreated chronic health problems. They may have suffered from a period without medical treatment in their country of origin or during the journey to your country. Imagine a child with epilepsy or type 1 diabetes mellitus; medication is crucial for their condition but may have been impossible for parents to obtain. They may be suffering from complications of their untreated illness. They may also have injuries sustained at home or en route.
A recent survey was carried out across Europe with 147 respondents from 23 countries. The authors found that the most common presentations of refugee children to an emergency department were skin and soft tissue infections, safeguarding concerns, mental health problems, weight loss and being generally unwell. Respiratory and gastrointestinal complaints were also common. It appeared that the type and severity of illness were comparable to non-refugee populations. More training may be required, however, for less common presentations such as PTSD or malaria. Cases of Hepatitis B, tuberculosis and incomplete vaccination schedules were also reported. Other studies have suggested sexually-transmitted infection and sexual abuse are common. It appeared that few countries have robust guidelines to aid clinicians in treating refugee children.
Most migrants do not experience mental illness though they are at greater risk due to traumas experienced and lack of social support. People from certain cultural backgrounds may be more likely to somaticize mental trauma in the form of physical symptoms. This requires a sensitive approach. Building trust with those who have experienced persecution can be challenging. They may be deeply distrustful of those in positions of authority. Sourcing appropriate interpreting services to overcome a language barrier is important for all presentations but is crucial when discussing sensitive matters. A useful mental health screening tool for children is the Strength and Difficulties questionnaire, which is available in 89 languages.
You can feel good in your body even though inside you feel poorly. Refugee child
They bring their trauma with them, that that usually manifests itself as PTSD symptoms, mild, moderate and severe. And that’s from past experiences. And in addition to that, I think what happens when they arrive [here] is that they face two main problems. One is the social isolation that comes with being removed from your usual community and not being able to work. The right to work is removed and therefore they don’t have an awful lot to do to occupy themselves. So social isolation is a big factor that affects their health. And the other one I would say was the uncertainty and the hostile environment created by the Home Office around housing stability and the uncertainty around their asylum. Those two factors obviously factor into their mental health but also their physical health so we see a lot of gastric upsets, a lot of physical manifestations of stress. From having those two issues some people don’t eat well or sufficiently so we see people who are underweight or who have gastric problems from becoming quite hungry, many asylum seekers struggle with sleep so don’t always turn up on time to their appointment. HCW discussing refugee patients
How can I assess malnutrition in the ED?
You can consult the RCPCH guidelines. Height, weight and head circumference should be measured as you would do routinely. If malnutrition is then suspected, mid-upper arm circumference should also be measured and compared with age-related norms. The child should be examined for evidence of anaemia and vitamin deficiency (including scurvy, thiamine and Vitamin D deficiency).
Take a good dietary history. Ask about past diet (at home, in transit and in refugee camps) and current diet. Governmental asylum support can be meagre and families may be dependent on food banks. Available foods in your country may differ greatly from that which the family is used to. Many families are placed in hotels and hostels with limited cooking facilities.
If you have concerns about a child’s nutrition, follow-up should be arranged with the GP +/- the health visitor.
I don’t have even have enough money to eat and provide essential things for my family, and I have to spend most of this money on travel going in and out of the hospital with my wife.
Waleed’s mother is particularly concerned about tuberculosis. You wonder whether Waleed requires routine screening for any diseases, considering his country of origin, lack of vaccinations and tumultuous journey to your country.
Does Waleed need screening for diseases such as tuberculosis?
Fortunately, there is online guidance available for specific communicable and non-communicable diseases. This includes guidance for common diseases such as tuberculosis, vitamin D deficiency, anaemia and HIV.
You can also search by country to determine which screening is advised for which country of origin. For example, asymptomatic tuberculosis screening is not required for Syrians. However, Syria is an intermediate prevalence area for Hepatitis B. Anaemia is common (20-40% preschool children) and cases of polio have recently been detected in the country. Due to this, routine screening for Hepatitis B and anaemia should be considered as well as vaccination against polio. Vitamin A and D deficiency is also common.
Routine TB screening is recommended for those arriving from high prevalence areas (incidence of >40/100,000 people): these countries include Afghanistan, Eritrea and Somalia. Children from these countries should automatically be referred to a paediatric TB clinic.
Is there any guidance for catch-up immunisations?
Many refugee children will have uncertain or incomplete vaccination status. Unless there is a reliable history of vaccination, Public Health England (PHE) recommends treating the child as if they were unvaccinated. It is also recommended to plan a catch-up schedule in the minimal amount of time and appointments in order to confer swift protection. The PHE guidance is a useful resource as is the Australian Immunisation Handbook.
Is Waleed entitled to free A&E services?
This is highly dependent on the country in which you work.
Groups entitled to all NHS services free of charge (including free prescriptions and dental/optometry care) include:
- Refugees (those who have been granted asylum)
- Asylum seekers (including those who have mounted appeals)
- Victims of slavery/trafficking and their families
- Recipients of section 95 or section 4(2) support for ‘destitute families’
- Children in care
The following NHS services are free to all regardless of immigration status or country of origin:
- Urgent care centres and GPs
- Services for the diagnosis and treatment of certain communicable diseases such as tuberculosis, HIV, sexually transmitted diseases and Covid-19
- Family planning services (termination of pregnancy not included)
- Treatment for a mental or physical condition caused by torture, domestic violence, female genital mutilation or sexual violence
Secondary care, such as inpatient admission and outpatient appointments, is billable for non-UK residents (aside from those specified above). This includes maternity, paediatric and oncology services. Undocumented migrants and refused asylum seekers are charged 150% of the cost to the NHS and charges must be paid before treatment. The exception to this is ‘urgent and immediately necessary care’ which is billed after treatment (this includes all maternity services). What constitutes ‘immediately necessary care’ is the judgement of the clinician, taking into account pain, disability and risk of delaying treatment.
Most refugees and asylum seekers in the community should have a Medicare card which provides them with publicly-funded free or subsidised healthcare. Through Medicare, the Medical Benefits Scheme (MBS) provides full payment for GP services and 75% costs for secondary care. It does not include dental care or ambulance cover. There is a possibility that a service will charge more than the MBS will cover, in which case the patient would have to cover the extra cost. For example, the MBS will pay $37.05 for a GP consultation; however, if the GP charges $65 for an appointment, the remaining costs would be incurred by the patient. Medicare cards may be linked to visas and often expire, leaving their owners vulnerable to healthcare costs. Undocumented migrants do not have access to Medicare support.
Many refugees, and people seeking asylum in Australia, are held in detention facilities, some offshore in Nauru and Papua New Guinea. For these people, healthcare is provided by the state.
I went to the health centre and it was like an interrogation… “When did you come to Sweden? Why did you come here?” … It was the same as they asked me at the migration authority. … if they find something, how will that affect my chance to obtain asylum, and if they find a disease, will they help or what will happen? (Jonzon et al., 2015)
When you speak to Waleed’s mother and inform her that she is entitled to all NHS care free of charge due to her status as an asylum seeker, she informs you that she attempted to register with a GP but was refused as she had no proof of address.
What barriers are there for refugees, asylum seekers and undocumented migrants accessing healthcare?
There are many barriers to accessing adequate healthcare. Examples include:
- Language barrier
- Lack of knowledge in how to access services
- Administrative difficulties such as lack of identification or proof of address
- In the UK, NHS guidance clearly states that ID/proof of address are not grounds for refusal for registration in primary care. This is a common problem: when volunteers from the charity Doctors of the World approached GP practices, they found that 2 in 5 wrongly refused registration. This leaflet may be a helpful resource for those in the UK.
- Healthcare debts can be reported to the government and affect asylum applications
- During transit through a country, aversion to official registration is not uncommon. Documentation of presence in a ‘safe’ country passed through can harm later asylum applications in the desired destination country; a European regulation allows the UK to return an adult asylum seeker to the first European country reached
- Even if healthcare is free, costs associated with attending appointments may be prohibitive. For those on a low income, costs such as childcare and bus fares to facilitate attendance may be unaffordable
“The language barrier is the tip of the problem. Quite often there’s a language barrier which is massive, so they’re not sure where to go, who to speak to. They’re vulnerable because that’s why they’re seeking asylum in the first place, so there might have been lots of trauma. And then all these other vulnerabilities, in my case if they’re pregnant, they’re homeless, they’re scared, they might be fleeing domestic violence, honour-based violence, FGM. All these vulnerabilities makes them even more vulnerable and then they’re just frightened to access healthcare ‘cause they don’t know where to go.” HCW discussing refugee access to healthcare
“If I had an emergency I couldn’t call 999, how would I speak to them, they wouldn’t understand me in Arabic. I would have to speak to them in English, which I can’t and that’s not good.”
“Resources are limited – I think they are being given £20 per week and they are not allowed to work so I don’t know how a person can survive on that kind of money in this day and age. So there’s these kind of stresses as well. This money is so limited they find it difficult to come to my clinic when coming by bus. Continuity of care is also a problem with this group of people, the Home Office may move them to another city….it’s a multitude of issues which are concerning.” Mr Singh’s story (an asylum seeker), as told by a psychiatrist
What other considerations are there for refugees and asylum seekers?
33-44% of those seeking asylum have experienced torture. This is a strong predictor of a range of mental and physical health conditions. Those who have experienced torture are 4.5x more likely to suffer from PTSD and 2.5x as likely to suffer from depression. Other sequelae include chronic pain, insomnia and headaches. There are many specialist organisations for torture survivors. These include Freedom from Torture (UK), The Center for Victims of Torture (USA) and FASSTT (Forum of Australian Services for Survivors of Torture and Trauma).
Female genital mutilation
Female genital mutilation (FGM) is the partial or total excision of the external female genitalia for non-medical purposes. It is perpetrated mainly against children in Africa and Asia – the highest prevalence countries include Egypt, Sudan, Somalia, Mali, Sierra Leone and Indonesia – and it is estimated that 200 million women worldwide have undergone FGM. FGM is illegal in the majority of the developed world (including UK, Australia, Canada and New Zealand).
Initial complications include severe pain, haemorrhage, infection, shock and death. Delayed complications include difficulty with urination, menstruation, intercourse, childbirth (including increased neonatal mortality) and mental health (such as depression and PTSD).
There are specialist services available for those whom have undergone FGM. In the UK, there are specialist adult, maternity and paediatric clinics. There are also many charities worldwide offering support: Forward UK, the Dahlia Project (UK) and NETFA (Australia). If you are concerned a child may be at risk for FGM, follow local safeguarding procedures. An eLearning module about FGM can be found here.
I have one family who have been through an extremely high level of torture and both adults, and I’ve been trying and trying to get them into the mental health services…The GP said there’s no point referring to primary mental health because they wouldn’t have a clue how to deal with this kind of thing. And there was a period where the psychiatrist kept passing the referral back to primary mental health. Primary mental health were saying we wouldn’t know how to work with them and passed it back to the psychiatrist. This went on for a long period. And just recently the hospital said, oh, I feel they should improve their English before we can see them. HCW
Nijman, R.G., Krone, J., Mintegi, S., Bidlingmaier, C., Maconochie, I.K., Lyttle, M.D. and von Both, U., 2020. Emergency care provided to refugee children in Europe: RefuNET: a cross-sectional survey study. Emergency Medicine Journal, 38(1), pp.5-13.