Care Without Borders: Healthcare for refugees in Netherlands

Loes Visser & Fieke Vrielink

GP Trainees,

European taskforce of the

Dutch GP trainee association

Program

• Background

• Asylum Procedure

• Asylum Seekers Healthcare

• Public Health

• Notable Psychiatric Cases

• Notable Medical Cases

Background

Refugees through history, then and now:

Yugoslavia

Mary and Joseph First World War Rwanda

Syria

Refugees

Persons who are outside their own country and have a well-founded fear of persecution due to their race, religion, nationality, membership of a particular social group or political opinion, and are unable or unwilling to return.

Defined and protected in international law

(1951 European Convention on Human Rights)

Asylum Seekers

Persons who have applied for (legal and physical) protection in another country but have not yet had their claim for protection assessed.

A person remains an asylum seeker for so long as their application or an appeal against refusal of their application is pending

Economic Migrants

Persons who leave their own country not because of a direct threat of persecution or death, but mainly to improve their lives by finding work, or in some cases for education, family reunion, or other reasons.

The European Refugee Crisis and Syria explained (Video):

https://www.youtube.com/watch?v=RvOnXh3NN9w

Quiz

• Use your phone/i-pad/laptop

• Join us at kahoot.it

• Game-pin number is shown on the big screen

• Name: first name of your country, then your own name

• Wifi: Biedribas nams; password: rlb-1868

Asylum Procedure

Applying for Asylum

Asylum applications in the Netherlands: 1993 – 2015

Applying for Asylum

Numbers of Asylum Seekers by Nationalities: 2015

1. Reporting and registration on arrival in Netherlands

• Aliens Police in Ter Apel

• Royal Netherlands Marechaussee at Schiphol

2. Rest and preparation period (6 days)

• Information about asylum procedure

• Assisted by a lawyer

• Appointment with a nurse for medical advice

Asylum Application Process: Netherlands

3. General (short) asylum procedure (8 days)

• Initial interview

• Detailed interview

• Detention

• Decision

4. Extended asylum procedure

• Maximum period of 6 months

• Permission for asylum seeker to work for 24 / 52 weeks may be granted

Asylum Application Process: Netherlands

5. Successful application: Refugee status

• Temporary residence permit valid for 5 years

• Integration course

• Entitled to accommodation & education

• Allowed to do paid work

• Apply for a refugee passport at local municipality

• Apply for Dutch citizenship after 5 years

Unsuccessful application: Return / Deportation

Asylum Application Process: Netherlands

Asylum Application Process: Netherlands

Results of Asylum Applications

• NGO Forensic Medicine (FMMU) – medically examination to assess whether an asylum seeker is physically and

psychologically capable to be interviewed by the IND

• Procedure via advocate – Medical Advisors Office (BMA) advices – Immigration and Naturalisation Services (IND) judges

• Very rare: residence permit on medical/humanitary grounds

– disease leading to death within 3 months, no treatment in country of origin

• More often temporary residence permit; Article 64 of the Aliens Act – medical reasons due to which a refugee can not be deported: treatment TBC

• In case of return the International Organization for Migration (IOM) provides Travel

Health Assistance

Asylum Procedure: Medical Aspects

Asylum Seekers Healthcare

Syria

• Language: Arabic

• Economy: Previously a middle income country

• Conflict: Civil war

• Health System: Good standard; No GP-hospital ref. system

Government paid medical care

No health insurance

Antibiotic overprescription

High use of over the counter medicines

• Demographic: Mostly young male adults

Family reunification

Eritrea

• Language: Multilingual; Tigrinya – most common

• Economy: Low income country

• Conflict: Conscription evasion

• Health System: Health station for first contact doctor

No GP sugeries; No health insurance

Drugs easily distributed

• Demographic: Mostly young male adults

Unaccompanied children (minors)

Centraal Orgaan Opvang Asielzoekers (COA):

Organisation that provides shelters for

asylum seekers in the Netherlands

Asylum Seekers Centres

Asylum Seekers Centres

• Temporary housing, support and guidance

• Organised by Ministry of Internal Affairs

• Healthcare information

• Asylum application information

• Paid interpreter available if necessary

Gezondheids Centrum Asielzoekers (GCA):

health centres for asylum seekers in the Netherlands

Asylum Seekers Health Centres

Asylum Seekers Health Centres

• 85 locations close to asylum seeker centres

• Provide access to family doctor, practice-nurse, counsellor or a doctor's assistant

• Helpline available 24/7

• Triage and Walk-in consultation services

• Mental health counsellor

Regulation Care Asylum Seekers

• Medical expenses regulation set up by COA (2009)

• Offers similar coverage to basic health insurance

• Overseen by Menzis COA Administration (MCA)

• Covers a wide range of health and support services

Regulation Care Asylum Seekers

• Provision of drugs and medicines

• Paramedic services

• Obstetric & maternity services

• Chronic and Specialist care services

• Mental health services

• Dental care

• Devices & mobility support

• Social support services

• Youth education services

Providing healthcare

General Risk factors

• Elderly age, children, pregnant

• Low social economical status

• Lack of social participation, work or integration

• Number of traumatising events experienced

• Length of asylum procedure

• Poor health literacy and knowledge of Dutch health system

Children

Protective factors • High degree of support within family • Wellbeing of parents • Positive school experience

Risk factors

• Exposure to violence • Unaccompanied child, female • Multiple relocations • Single parent or parent with psychiatric disability • Financial problems • Not enough physical exercise

Health Issues Physical health • infectious and chronic diseases • malnutrition and deficiencies • injuries from physical and sexual violence/torture

Mental health • vulnerability, traumatised • loss and bereavement • fear, anxiety, depression, PTSS, etc.

Social stressors • asylum procedure • poor living conditions • education and work, discrimination, etc.

Difficulties in Providing Care

• Languages barriers

(complaints, understanding medical and treatment guidance, compliance…)

• Lack of use of interpreters

• Be aware of cultural differences

• Pre-existent ideas about sickness and health

• Role of family and community

• Be aware of beliefs in religious/traditional healing

Difficulties in Providing Care

• Different behaviour and presentation of complaints

• Complex problems

(physical, psychological and social)

• Health literacy

(nutrition, movement, sleep hygiene)

Difficulties in Providing Care The Refugee’s/Asylum Seeker’s View: • Can I trust the caregiver?

• Does the caregiver understand me?

• Respect, confidentiality and dignity

• Cultural barriers and taboo topics

• Is the help being provided beneficial?

• Looking for information and support

Useful Tips

• Use short sentences

• Use open questions

• One question at a time

• Use visuals aids

• Avoid jargons and metaphors

• Teach your patients

• Learn from yourself: make videos

Useful Tips

Differences within the EU

• Use your phone/i-pad/laptop

• Join us at kahoot.it

• Game-pin number is shown on the big screen

• Name: first name of your country, then your own name

• Wifi: Biedribas nams; password: rlb-1868

Public Health

Public Healthcare

• Municipal Health Services (GGDs)

Immunisation programme

• Children 0-19 years

• Extra MMR at 9 months

Prevention and control of infectious diseases

• Source detection and contact tracing

• Notifiable diseases (Hep B, measles, pertussis, TB)

Public Healthcare

STDs and HIV

• Education and Counselling

• Promote responsible sexual behaviour

Health Promotion

• Collective education

• Support and advice

• Life style

• Screening < 1 wk mandatory on arrival

• Voluntary continuation for 2 years on a

6 months interval for high risk countries

• X ray-thorax

• Check for BCG scar < age 12 yrs

• BCG vaccination for children under age 12 yrs

(when tuberculin skin test and HIV test negative)

• Check sputum when productive cough > 3 wk

• Extra-pulmonary TB e.g. lower back pain in high risk population (m. Pott)

• Reactivation of latent TB in case of immune suppression

Tuberculosis

Notable Psychosocial Cases

• Post Traumatic Stress Disorder (PTSD)

• Anxiety disorders

• Depression

• Dissociative disorders

• Drugs and alcohol abuse

• Psychotic disorders

• Torture, violence, sexual violence

Psychiatric Disorders

• Suicides are twice more likely in refugees

• Important protective factors: Social network

Residence security

• Underuse of psychiatric services

• Plan appointment to prevent frequent consultations

• Explain about Dutch healthcare to gain trust in system

• Emphasize doctor-interpreter-patient confidentiality to reassure patients

Psychiatric Disorders

• Many refugees experienced torture or sexual abuse

• Burns, whipping, crushing hands/toes, electric shocks, forced injection of medication, sleep deprivation, etc.

Symptoms:

• Vague: invalidating musculoskeletal complaints

• Specific: dystrophia, amputation, chronic headache

Torture

• Reliving of traumatic event (nightmares, flashbacks)

• Avoidance of trauma related stimulus

• Insomnia, lack of concentration

• Negative changes in cognitions and mood (passivity, detachment). Dissociation may occur

• Often coexists with other disorders e.g. depression

• Combination with addiction to alcohol, drugs or benzodiazepines

Post Traumatic Stress Disorder PTSD

• Often present initially with physical complaints

• Cultural difficulties in discussing feeling and emotions

• Western cultures (guilt or lack of self esteem)

• Non western cultures (shame or loss of face, no distinction between body and mind)

Depression

Useful Tips

• Start with general questions before asking about feelings

• Ask specific questions

• Explore the use of religious and traditional healing

• Suicide is taboo in Islamic cultures

• Ask if thoughts are compatible with religion

• Taboo topic for many refugees and asylum seekers

• Many refugees are victims of sexual violence

• Lack of knowledge contraception, STDs, HIV

• Inadequate psychological and counselling support

• Female genital mutilation

Domestic & Sexual Violence

Medically Unexplained Physical Symptoms (MUPS)

• Take their complaints seriously

• Always perform physical examination

• Additional investigations on indication

• Explore psychosocial problems

• Be aware of depression or PTSD

• Explain about stress causing chronic physical symptoms

• Try to reach a shared-decision together with the patient

• Psychological support and physical exercise have been shown to be effective

MUPS

Notable Medical Cases

Chronic Diseases

• Obesity and lack of physical exercise

• Diabetes and complications

• Smoking and COPD

• Increased risk of cardiovascular diseases

• Chronic pain

• Medically Unexplained Physical Symptoms (MUPS)

• Highest incidence - Eritrean, Sudanese and Ethiopian refugees

• Many cases are relapses of existing infection

• Milder course with long latent period

• Adequate treatment

Malaria

• Symptoms: intense (nightly) itching

pimple-like skin rash, burrows 0.5-1cm

Fingers, wrist, foot, ankle

• Transmission: by close body and skin contact

Spreading before symptoms start 4-6 wks

• Treatment: Ivermectin tablet 3 mg 0.2mg/kg

loxazol – children, pregnant women

Scabies

• High rates among Syrian refugees a.k.a. ‘Aleppo boil’

• Transmitted by infected sandflies (incubate for weeks)

• Small red papules on face and extremities

• Papules → Ulcers (raised edges, central crater)

• Resolves spontaneously in months to years

Cutaneous Leishmaniasis

• Chronic disease with risk of cirrhosis, liver cancer

• Infection at younger age (≈70% are under age 5)

• Less severe immune response (asymptomatic, tiredness)

• At risk groups (children, pregnant women)

• Screening and vaccination

Hepatitis B

• Lower prevalence in mediterranean region

• Higher risk of complication in adults, pregnant women

• Contact with municipalities in case of outbreak

different skin, same disease

Varicella Zoster virus (VZV)

Take To Work Messages

• Be aware of context

– living situation, procedure, family, home country

• Less known with health care system

• Low health literacy

• Use interpreter services

• Be aware of cultural differences

• Invest in relationships to gain trust

Be curious and enjoy!

War is not an individual, one-time experience

War is the collapse of social world, (history, identity, values, roles)

War causes a train of complex, dynamic and evolving events

Summerfield, 1999

War