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Healthcare challenges from the developing world:
post-immigration refugee medicine
Kristina M Adams, Lorin D Gardiner, Nassim Assefi
Worldwide, there are approximately 13 million refugees and asylum seekers.1 Flight of refugees often Summary points
occurs in the setting of war, famine, or human rights violations, resulting from a “well-founded fear of being The complex medical needs of refugees are often persecuted for reasons of race, religion, nationality, unmet owing to inadequate training of healthcare membership in a particular social group, or political opinion.”2 Physicians in host countries increasingly encounter refugees in their practices and, owing to Medical problems include infectious diseases, inadequate training, may not fully meet their complex psychiatric disorders, and complications from HarborviewMedical Center,School of Medicine, Sources and selection criteria
Symptoms of infectious diseases and history of exposure to trauma and ritual female genital Limited evidence exists to support many aspects of surgery should be sought in the medical history refugee health care. When scientific evidence is not available, recommendations stem from our experience Routine laboratory screening for infectious in caring for a diverse group of refugees (East African, diseases may detect parasites, sexually transmitted Balkan, and South East Asian) in a multidisciplinary setting involving primary care physicians, obstetrician- gynaecologists, psychiatrists, nurses, cultural interpret- Further information on post-traumatic stress ers, and social workers. This article is based on clinical disorder, somatisation, and ritual female genital expertise and a review of the literature obtained from a surgery may enable physicians to care better for Medline search using the key words “refugee” and “asylum seekers.” We suggest an approach to obtaining the refugee history, screening for infectious diseases and common psychiatric disorders, and dealing with mal), and testing for syphilis and HIV. Enhanced health special problems such as ritual female genital surgery assessments may also be done to identify prevalent dis- eases that may serve as future public health targets before immigration. For example, frequent diagnoses Refugee camps and medical
of malarial (7%) and intestinal (38%) parasites in Barawan Somali refugees led the Centers for Disease interventions before embarkation
Control to recommend mass treatment for all Refugee camps represent the first point of escape, but non-pregnant refugees older than 2 years; this continued interethnic strife, sexual violence, and consisted of single oral doses of sulfadoxine- disease epidemics often perpetuate the dangerous pyrimethamine and albendazole before departure.3 environment from which people fled. Although theUnited Nations High Commission for Refugees prom- Medical history and physical
ises protection and basic medical care, refugees may examination
actually have higher mortality in camps than in theirhome country. Major causes of mortality in refugee Interpreter services are essential for obtaining the camps include diarrhoeal diseases, measles, acute medical history and caring effectively for refugees. The respiratory tract infections, tuberculosis, and malaria.
lack of translators, particularly for new or small groups Mandated medical screening of refugees before arrival of refugees, is an important barrier to health care. Ide- in the United States identifies those with “inadmissible ally, the interpreter not only translates but also acts as a conditions,” including active infections such as mediator to explain the cultural context of a patient’s tuberculosis, leprosy, and HIV infection. Typical symptoms. On first meeting the refugee, we clarify the screening of adult refugees involves a physical purpose of a routine visit to a physician, the role of the examination, brief mental health assessment, chest interpreter, and the concept of preventive screening.
radiograph (sputum testing for tuberculosis if abnor- Eliciting sensitive information, such as exposure to BMJ VOLUME 328 26 JUNE 2004
from the Harvard trauma questionnaire (box 1).6 Manytranslations of the questionnaire exist to facilitate Box 1: Medical history*
taking the trauma history. Questions about depressive Life story
symptoms may need modification for each refugee group, and medical interpreters are helpful in this • Country of origin and reason for escape regard. For example, one direct translation of “depres- • Life and employment before immigration sion” into Somali is “wal-wal,” which also means “crazy.” • Medical problems or stress in home country A complete physical examination may reveal pathological and non-pathological conditions, includ- • Time spent in refugee camps, location of the ing lymphadenopathy, goitre, and evidence of previous traditional medicine techniques. African and South East Asian refugees often have circular scars consistent • Losses of family members or friends and reasons with dermabrasion from coining or moxibustion. Signs of torture may be subtle and include occult fractures Infectious diseases
from beatings or 1-2 mm clustered scars from electrical • History of disease or exposure: tuberculosis, malaria, parasites, hepatitis, and sexually transmitted infections• Review of systems: • Recurrent fevers, night sweats, weight loss Routine screening
Guidelines for screening of refugees are mainly based • Diarrhoea, visible parasites in stool on studies documenting a high prevalence of infectious diseases and medical disorders.8 9 Obtaining • Vaccine status: previous records and history of records from overseas refugee screening may prevent repetitive testing. We begin with a complete blood Traditional medicine and substance misuse
count with differential and infectious disease screening (box 2). Common causes of anaemia among refugeesinclude deficiencies of iron and other nutritional • Acupuncture, moxibustion, coining, other modalities • Use of substances other than tobacco and alcohol and glucose-6-phosphate dehydrogenase deficiency.
Sexual history and genital surgery
Eosinophilia warrants investigation for pathogenic parasites, even in mild cases. In a group of South East • Gravidity, parity, outcome of previous childbirths Asian refugees with eosinophilia and negative stool • Sexual activity, desire for testing for sexually ova and parasite testing, a parasite was eventually transmitted infections, contraception or pregnancy Screening for infectious diseases includes testing • Ability to have intercourse, dyspareunia for tuberculosis, intestinal parasites, hepatitis, and • Chronic urinary tract infections, pelvic pain, scar sexually transmitted infections. Whether to give empirical treatment or to screen for parasites remains • Desire for revision of circumcision (defibulation) controversial. Estimates of cost effectiveness are based Trauma history†
on a five day course of albendazole, whereas many • Deprivation of food, water, or shelter• Being lost, kidnapped, or imprisoned• Enforced isolation• Undergoing torture or serious injury Box 2: Screening*
• Complete blood count with differential • Rubella IgG (women of reproductive age) • Syphilis, gonorrhoea, chlamydia, and HIV-1 *Contents of the box are based on clinical expertise as guided by limited scientific evidence†Components of the trauma history are adapted from • Stool ova and parasite examination (three morning specimens, different days)• Oral examination and dental referral• Vision and hearing screen trauma, may begin by asking the patient’s “life story” Optional
and focusing sequentially on life in the home country, reason for flight, details of escape, and status of family members (box 1).4 5 We also do a complete review of • Urinalysis (if concern about schistosomiasis) infectious diseases by body system and inquire about • Peripheral blood smear (if concern about malaria) use of traditional or herbal medicines. We ask African • PPD = purified protein derivative as used with women about ritual female genital surgery, as it can have important implications for gynaecological health.
*Screening items are in addition to recommended tests After rapport and trust have been established, we for healthcare maintenance (pap smear, mammogram, directly inquire about torture, rape, or other physical or psychological trauma by using an approach adapted BMJ VOLUME 328 26 JUNE 2004
(Trichuris trichiura), roundworm (Ascaris lumbricoides),and Giardia lamblia.9 Classic complications of parasi-taemia obstruction (roundworm), Loeffler’s syndrome (pul-monary hypersensitivity or infiltrates due to Strong-yloides and Ascaris), cholangiocarcinoma (Opisthorchissinensis), and bladder cancer (Schistosomiasis hemato-bium). A screening urinalysis for urinary schistosomia-sis is indicated in refugees from areas of highprevalence such as West Africa. Malaria is uncommonin refugees, as most are empirically treated; however,untreated pregnant refugees are at risk.
Hepatitis B is endemic in Africa and South East Asia, with rates of current or past infection as high as50-80%. Death from cirrhosis or hepatoma occurs inup to one third of carriers who acquired hepatitis Bperinatally. We screen for hepatitis C in any patientwho has had a previous blood transfusion, ritualfemale genital surgery, or surgical procedure, and weroutinely screen African and South East Asianrefugees (prevalence of 5% and 2.5%).16 Mental health and trauma
World Health Organization classification for ritual female genital Tackling the complex mental health needs of refugees surgery. A (type I or Sunna): excision of the prepuce with or without is particularly challenging for both primary care excision of the clitoris. B (type II): excision of the prepuce andclitoris and partial or total excision of the labia minora. C (type III or providers and mental health professionals. Many stud- pharaonic): excision of part or all of the external genitalia and ies report refugees to be at a higher risk of psychiatric stitching or narrowing of the vaginal opening. Type IV circumcision disorders such as depression, suicide, psychosis, (not pictured) describes procedures that do not fit the previous post-traumatic stress disorder, and substance misuse, classifications: piercing, cauterisation, or stretching of the clitoris orlabia with the aim of narrowing the vagina. Reproduced courtesy of often directly related to past physical or psychological Nahid Toubia, president of the RAINBO organisation trauma.17–20 Understanding a patient’s trauma history iscritical to treating psychiatric and medical disorders.
centres administer a single dose.11 Depending on the Approximately 5-10% of refugees in the United States history of sexual activity, testing should include screen- have experienced a form of torture, including electric ing for gonorrhoea, chlamydia, syphilis, and HIV-1 shocks, beatings, caning of the soles of the feet, rape, (and HIV-2 for West African refugees). In lieu of vacci- and forced witnessing of torture or executions.21 Sexual nation records, testing for antibodies to indicate expo- violence is prominent in the torture of women and sure to or vaccination against disease should be done.
may be spontaneous or systematic (“rape camps”). The Antibody testing is more cost effective than varicella problems of many refugees, however, may not be vaccination in refugees older than 5 years.12 However, adequately described by Western psychiatric catego- the positive predictive value of a varicella history is ries.22 Demoralisation and bereavement may be 93-100% and may be adequate for documentation in incorrectly labelled as depression. An effort should be certain refugee groups. Additional components of made to simultaneously explore psychiatric symptoms, screening include an oral examination, dental referral, exposure to trauma, and potential social and economic and screening of vision and hearing.
factors contributing to a refugee’s mental health.
Referral to social workers, cultural case mediators, and Tuberculosis, parasites, and hepatitis
community organisations may be appropriate.
Tuberculosis is the third leading cause of mortality Post-traumatic stress disorder
from infectious diseases after HIV/AIDS and diar-rhoeal diseases; for example, one in three people in Post-traumatic stress disorder is the most common Africa are infected.13 In one study, 7% of newly arrived consequence of violence and describes at least one refugees had active tuberculosis, and the risk of devel- month of recurrent, painful re-experiencing of a trau- oping tuberculosis remains high years after immigra- matic event, emotional numbing or hyperarousal, and tion.14 15 At the United States Center for International avoidance of trauma related memories.23 Critical Health, 23% of tuberculosis cases were extrapulmo- factors in developing post-traumatic stress disorder nary.8 For example, back pain (Pott’s disease) or include severity, duration, and closeness of exposure to menorrhagia (endometrial tuberculosis) may be the the trauma. Although studies of drug treatment in presenting symptoms of tuberculosis. Other extrapul- refugees with post-traumatic stress disorder are rare, monary sites include the prostate, parotid, chest wall, selective serotonin reuptake inhibitors are considered a good first line treatment.24 25 Earlier studies Despite mass treatment before embarkation, recommended an 8-12 week drug trial, but recent persistent parasitaemia is relatively common. The most studies have found symptomatic improvement as soon common parasites detected include hookworm (Neca- as 2-5 weeks. However, severely traumatised refugees tor americanus and Ancylostoma duodenale), whipworm may fail to respond to drugs alone. Both exposure BMJ VOLUME 328 26 JUNE 2004
logical findings, and mental health, focusing care onfunctional improvement rather than cure.
Additional educational resources
Journal articles
Ritual female genital surgery
Walker PF, Jaranson J. Refugee and immigrant healthcare. Med Clin North Am 1999;83:1103-20 Ritual female genital surgery, also known as female cir- Burnett A, Peel M. Health needs of asylum seekers and cumcision or genital mutilation, is mainly done in Africa and affects 130 million women and girls world- Burnett A, Peel M. Asylum seekers and refugees inBritain: the health of survivors of torture and wide.32 Ritual female genital surgery continues to be organised violence. BMJ 2001;322:606-9 done for complex cultural reasons, although con-demned by the World Health Organization because of Websites
its serious health consequences. In 1990 the Centers US Committee for Refugees (www.refugees.org)—Listsstatistics, news, and information pertinent to refugees, for Disease Control estimated that 168 000 girls and and lists international refugee assistance organisations women in the United States were likely to have under- EthnoMed (www.ethnomed.org)—Provides culture gone ritual female genital surgery, and subsequent specific information on health beliefs and healthcare Somali immigration greatly increased this number.
barriers for multiple refugee and immigrant groups.
Although discrete WHO classifications of ritual female Factsheets on hepatitis, breast cancer, and diabetes are genital surgery exist, people doing the procedure are informally trained, resulting in inexact surgical Harvard Program in Refugee Trauma(hprt-cambridge.org)—Provides questionnaires and outcomes (figure). Physicians in host countries may checklists for assessment of mental health in several encounter long term complications of ritual female genital surgery, including dyspareunia, inability to have questionnaire, Hopkins symptom checklist-25, and a intercourse, chronic pelvic inflammatory disease, recurrent urinary tract infection, and scar abscesses.
Research Action and Information Network for the Gynaecology referral for defibulation (take down or Bodily Integrity of Women (www.rainbo.org)—Aninternational non-governmental organisation working revision of ritual female genital surgery) may be to eliminate the practice of ritual female genital indicated for pelvic examination or treatment of result- surgery. The website provides information on ing medical complications, or before labour and obtaining technical manuals for healthcare providers Conclusion
therapy and cognitive behaviour therapy have been Providing culturally sensitive and competent health found to be beneficial for post-traumatic stress care to refugee populations can be as rewarding as it is disorder in refugees.26 27 Treatment may begin with an challenging and often has a major impact on the life of adequate trial of a selective serotonin reuptake inhibi- a new refugee. Primary care for refugees begins with tor; if minimal response occurs, consultation with a understanding reasons for flight and a group’s particu- psychiatrist is indicated to determine if additional lar exposure to infectious disease and psychological drugs ( blocker), therapy, or both should be added.
trauma, which may focus medical history and Psychologists specialising in the mental health of refu- screening. Increased knowledge about the complex gees may represent an additional source of expertise, medical needs of refugees can help the primary care particularly with a form of therapy. Lack of availability physician to care more effectively for this special popu- of psychiatric care appropriate to culture and language lation. A society’s moral strength can be measured by may, however, represent a barrier to effective how it treats its most vulnerable citizens.
Contributors: KMA and NA made substantial contributions tothe intellectual content of the entire text of the manuscript and Somatisation
took active roles in its drafting and revision. LDG’s contributionto the manuscript was limited to the content and drafting of sec- Psychological trauma may present as somatic com- tions related to the trauma history and psychiatric diseases.
plaints in refugees. A diagnosis of somatisation KMA is the guarantor of the manuscript.
disorder requires symptoms of pain (at least four sites), Funding: Supported in part by HD-01264 from the National two gastrointestinal symptoms, one sexual symptom, Institutes of Health. The funding source represents a career and one pseudoneurological symptom.23 Physical development award for KMA and had no influence on the con-tents of the manuscript. LDG’s contribution was independent of complaints must begin before age 30, result in consid- a funding source. NA is now working for a non-governmental erable impairment, and lack a medical cause. Refugees organisation in Afghanistan to improve women’s health. Her may be at risk for somatisation because psychiatric dis- contribution to the manuscript predated her current position, ease is often not culturally accepted, and somatic rather and this organisation had no influence on her contribution tothe manuscript.
than psychiatric complaints increased their previous chances of accessing health care. In addition, painthresholds may be lower in this population as a result U.S. Committee for Refugees. World refugee survey 2003. (Available from of psychological distress and depression. Somatisation occurs more commonly in unemployed and less Convention relating to the status of refugees. New York: educated refugees.29 30 Epstein suggests an approach Miller JM, Boyd HA, Ostrowski SR, Cookson ST, Parise ME, Gonzaga PS, for patients with unexplained somatic symptoms that et al. Malaria, intestinal parasites, and schistosomiasis among BarawanSomali refugees resettling to the United States: a strategy to reduce mor- includes acceptance of suffering, tolerance of uncer- bidity and decrease the risk of imported infections. Am J Trop Med Hyg tainty, and limitation of iatrogenic harm.31 The Kinzie JD. Evaluation and psychotherapy of Indochinese refugee patients.
physician simultaneously considers symptoms, patho- Am J Psychother 1981;35:251-61.
BMJ VOLUME 328 26 JUNE 2004
Mollica RF. The trauma story: a phenomenological approach to the trau- 19 Gorst-Unsworth C. Adaptation after torture: some thoughts on the long- matic life experiences of refugee survivors. Psychiatry 2001;64:60-3.
term effects of surviving a repressive regime. Med War 1992;8:164-8.
Mollica RF, Caspi-Yavin Y, Bollini P, Truong T, Tor S, Lavelle J. The Har- 20 World Health Organization. WHO/UNHCR mental health of refugees.
vard trauma questionnaire: validating a cross-cultural instrument for measuring torture, trauma, and posttraumatic stress disorder in Indochi- 21 Pincock S. Exposing the horror of torture. Lancet 2003;362:1462-3.
nese refugees. J Nerv Ment Dis 1992;180:111-6.
22 Watters C. Emerging paradigms in the mental health care of refugees. Soc Goldfeld AE, Mollica RF, Pesavento BH, Faraone SV. The physical and psychological sequelae of torture: symptomatology and diagnosis. JAMA 23 Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association, 1994.
Walker PF, Jaranson J. Refugee and immigrant health care. Med Clin North 24 Friedman M, Davidson J, Mellman T, Southwick S. Pharmacotherapy. In: Foa E, Keane T, Friedman M, eds. Effective treatments for PTSD: practice Stauffer WM, Kamat D, Walker PF. Screening of international guidelines from the International Society for Traumatic Stress Studies. New immigrants, refugees, and adoptees. Prim Care 2002;29:879-905.
10 Nutman TB, Ottesen EA, Ieng S, Samuels J, Kimball E, Lutkoski M, et al.
25 Smajkic A, Weine S, Djuric-Bijedic Z, Boskailo E, Lewis J, Pavkovic I. Ser- Eosinophilia in Southeast Asian refugees: evaluation at a referral center.
traline, paroxetine, and venlafaxine in refugee posttraumatic stress disor- J Infect Dis 1987;155:309-13.
der with depression symptoms. J Trauma Stress 2001;14:445-52.
11 Muennig P, Pallin D, Sell RL, Chan MS. The cost effectiveness of strategies 26 Otto MW, Hinton D, Korbly NB, Chea A, Ba P, Gershuny BS, et al. Treat- for the treatment of intestinal parasites in immigrants. N Engl J Med ment of pharmacotherapy-refractory posttraumatic stress disorder among Cambodian refugees: a pilot study of combination treatment with 12 Figueira M, Christiansen D, Barnett ED. Cost-effectiveness of serotesting cognitive-behavior therapy vs sertraline alone. Behav Res Ther compared with universal immunization for varicella in refugee children from six geographic regions. J Travel Med 2003;10:203-7.
27 Paunovic N, Ost LG. Cognitive-behavior therapy vs exposure therapy in 13 World Health Organization. The world health report 2004—changing the treatment of PTSD in refugees. Behav Res Ther 2001;39:1183-97.
history. www.who.int/whr/2004/en (accessed 16 June 2004).
28 Redwood-Campbell L, Fowler N, Kaczorowski J, Molinaro E, Robinson S, 14 DeRiemer K, Chin DP, Schecter GF, Reingold AL. Tuberculosis among Howard M, et al. How are new refugees doing in Canada? Comparison of immigrants and refugees. Arch Intern Med 1998;158:753-60.
the health and settlement of the Kosovars and Czech Roma. Can J Public 15 Zuber PL, McKenna MT, Binkin NJ, Onorato IM, Castro KG. Long-term risk of tuberculosis among foreign-born persons in the United States.
29 Lin EH, Carter WB, Kleinman AM. An exploration of somatization among Asian refugees and immigrants in primary care. Am J Public 16 Debonne JM, Nicand E, Boutin JP, Carre D, Buisson Y. [Hepatitis C in tropical areas.] Med Trop (Mars) 1999;59(4 pt 2):508-16. (In French.) 30 Westermeyer J, Bouafuely M, Neider J, Callies A. Somatization among 17 Kinzie JD, Boehnlein JK, Leung PK, Moore LJ, Riley C, Smith D. The refugees: an epidemiologic study. Psychosomatics 1989;30:34-43.
prevalence of posttraumatic stress disorder and its clinical significance 31 Epstein R. Somatization reconsidered: incorporating the patient’s experi- among Southeast Asian refugees. Am J Psychiatry 1990;147:913-7.
ence of illness. Arch Intern Med 1999;159:215-22.
18 Bhui K, Abdi A, Abdi M, Pereira S, Dualeh M, Robertson D, et al.
32 Toubia N. Caring for women with circumcision: a technical manual for provid- Traumatic events, migration characteristics and psychiatric symptoms ers. New York: Rainbo Publishers, 1999.
among Somali refugees—preliminary communication. Soc Psychiatry Psy-chiatr Epidemiol 2003;38:35-43.
Lesson of the week
Charles Bonnet syndrome—elderly people and visual
hallucinations
Anu Jacob, Sanjeev Prasad, Mike Boggild, Sanjeev Chandratre
Not all elderly
When a patient presents with vivid visual hallucina- His medical problems included chronic lymphatic tions, a doctor probably considers common diagnoses leukaemia, which had been in remission for the past presenting with
such as delirium, dementia, psychoses, or a drug five years. He was registered blind and had been diag- related condition. Charles Bonnet syndrome, however, nosed as having gross bilateral macular degeneration.
hallucinations
is a condition characterised by visual hallucinations He had never had hallucinations before. He also had have dementia
alongside deteriorating vision, usually in elderly chronic obstructive airways disease and essential people.1 The correct diagnosis of this distressing but hypertension. He had had no other neurological not uncommon condition is of utmost importance, illness and no mental health problems. He did not considering the serious implications of the alternative drink alcohol or smoke. He had been taking oxprenolol for hypertension for the past 10 years. He Case report
His cognitive examination was normal for his age, after the loss of vision was taken into account. His Neighbours brought an 87 year old white widower— visual acuity in both eyes was 1/60 with loss of central who lived alone in a flat—to the medical assessment field. Fundi showed macular degeneration. The rest of unit of a district general hospital. They were concerned the neurological examination was normal.
that he was becoming demented. Apparently he had Detailed investigations (including a full blood reported seeing people and animals in his house— count; glucose; electrolytes; and tests for renal hepatic including bears and Highland cattle. He verified these statements and said he had been seeing them for the and thyroid function, vitamin B-12, and folate levels) previous six weeks. He had also often seen swarms of yielded normal results. Detailed psychiatric assess- flies and blue fish darting across the room.
ment did not pinpoint a cause and suggested more He knew that these visions were not real and they detailed investigations for delirium. As a metabolic didn’t bother him much, but he thought he might be and infection screen was normal and he was otherwise losing his mind. The visions lasted for minutes to well oriented, delirium did not seem a likely diagnosis.
hours, and the cattle used to stare at him while quietly Electroencephalography and magnetic resonance munching away at the grass. The visions tended to imaging showed no important abnormalities. No occur more in the evenings before he switched on the diagnosis was apparent even after a week of inpatient tests and ward rounds. An early dementia seemed to BMJ VOLUME 328 26 JUNE 2004

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