7.3 Case Studies

Case 1 – A Stab to the Chest

A single mother and her two teenage boys arrived in Canada 3 weeks ago from a refugee camp outside Somalia. One of the teenage boys has stabbed the chest of his brother.

The mother has a three-year history of a seizure disorder. She also has significant history of intimate partner violence, rape, forced prostitution, physical assaults including being thrown out of a three story building, and stabbings.

Upon arrival, she was on/off anticonvulsant and antidepressant medications. The teenage boys showed signs of conduct disorder/antisocial behavior. One of the boys had a history of sexually abuse.

Question: How you would approach this case, considering your role as leader?

Vulnerable Refugees

Question: Who are the most vulnerable refugees?

Potential vulnerable groups:
  • Women and female-headed households
  • Children
  • The disabled
  • The elderly
  • Ethnic, religious, or political minority groups
  • Urban refugees in a rural environment

Refugee Clinic Leader

A refugee health clinic must be prepared to deal with diverse and complex sociocultural conflicts.

Social, cultural, financial, and language barriers will often impact the presentation and outcome of the patients.

[Reference:] (Refugee Health, An Approach to Emergency Situations 1997)

Case 2 – Suicide Ideation

Five days after arrival to Canada from a refugee camp in Bhutan, a refugee woman isolates herself in her room. She is 36 years old. She is staying in a temporary refugee shelter and refuses all food/drinks and speaks of suicide.

The patient was referred to the Emergency Department (ER). Unfortunately, because of language barriers and inadequate interpretation, the ER doc. does not identify any urgent conditions and the patient was sent back to the shelter after receiving IV fluids. No mental health follow-up is arranged.

She lost both her parents at a young age, and for the most part, was ‘left-out’ and alienated by other family members. She suffers from a long history of mental illness. Hopes of starting a new life in Canada vanished the very moment she arrived– she realized that she could not communicate with anyone and had to depend on the same siblings who neglected her for 30 years.

Question: What services or resources would you feel are necessary to ensure this refugee woman gets the care she needs?

Vulnerable Groups and the Leader

Women

The traditional caring role of women and the need to obtain food, water and essential commodities for the family in an environment where these are not readily available makes them vulnerable to abuse and sexual assault. Sexual abuse has been documented in several refugee situations and probably occurs more often than it is reported. (MSF 1997)

Leader’s Mandate
  • Involve women in planning all refugee programmes and take their concerns into account
  • Enrol women as health workers and home-visitors

Children

Children are often discriminated against in times of scarcity, when the principle of survival of the fittest applies. Children have special needs and may face additional risks. Unaccompanied minors are particularly vulnerable.

Leader’s Mandate

An effort must be made to identify and address the risks children may be confronting as a result of their past experiences. Experiences include being sexually or physically abused, orphaned, separated from family, or abandoned by parents who feel incapable of caring for them.

The Elderly

Elderly immigrants and refugees often have diverse needs that increase their individual vulnerability and need for resources and support. Language barriers, dissociation from social networks back home and the naturally declining independence with age makes this population increasingly vulnerable.

Leader’s Mandate

Health professionals must be aware of the increased vulnerability in older immigrant populations and apply proper screening tools for depression, social isolation and elder abuse. A special effort must be made through the use of proper communication and interpreters to respect the autonomy of older adults and ensure their independence and wishes are respected and maintained.

MSF (1997) Recommendations Regarding Socio-Cultural Aspects of Refugee Health

  • Refugees should be respected as human beings and not only treated as victims.
  • It is not only the essential needs of the population that should be taken into account when analysing the situation, but also the social and political consequences of their displacement.
  • Planning should take cultural and ethnic characteristics of refugees into account.
  • Assistance programmes should be both accessible and acceptable to the refugee population as a whole (collecting information, involving refugees in planning and implementation of activities, and identifying vulnerable groups).
  • The position of vulnerable groups should be strengthened (encouraging the re-building of the community, equal distribution of jobs and opportunities).

[Reference] (Refugee Health, An Approach to Emergency Situations 1997)

Videos

Director, Settlement Nongovernment Organization (NGO) – Carl

Read the transcript

When an immigrant who speaks very little English shows up in a health practitioner’s office, there’s a challenge. ‘How am I actually going to understand what this person’s health needs are?’ What are their health statuses and what their health needs are. One of the things that’s important is to help that practitioner, by providing with some kind of previously done screening that’s says these are the issues. This is this person’s heath status. This is their understanding of how to maintain their health. So it’s a big complex area but it should be a high priority because it actually costs us money. The immigrant who comes in who is not able to maintain their health, they can’t work as well as they would like to and as we would like them to. They pay fewer taxes. Overall there is a cost we can calculate for not doing this and it’s not a small amount, it’s a large amount.


Duration: 1 minute

Refugee Settlement Worker – Lucila

Read the transcript

Over the time and for the past few years, because many more immigrants are coming in and maybe it’s not a large number but it’s a good number of immigrants who are coming with either serious medical needs or some medical needs. So one of the initial priorities is, ‘how can I find a family doctor?’ ‘Where can I find it?’ ‘Where can I go when I get sick?’ And so there is a lot of burden in our programs to try to deal with the health care problem in this community, when we call them and they don’t accept new patients.


Duration: 32 seconds

Refugee Settlement Leader – Chamreoun

Read the transcript

Also, we have to understand the health refugee issue, is one of the puzzle related to the sentiment of integration. You know that the sentiment of integration is a big puzzle. And then we’re already looking at the education, look about employment, look about housing. Look at how to make these people feel welcomed but we’re missing that puzzle, this puzzle that links the refugees that just arrived, to the Canadian health system which is based on the preventive.


Duration: 35 seconds

Short-Term Goals for Leaders/Managers

A graph representing the short-term goals for managers. The five main goals are: 1. Be prepared to deal with complicated sociocultural situations, 2. Set clinic priorities, 3. Ensure high quality services are provided to all, 4. Organize and utilize trained medical interpreters, 5. Ensure fair access to medical services. There are also two ongoing goals: 1. Continually educate both medical and settlement staff, 2. Build networks of healthcare providers in the community.

Long-Term Goals for Leaders/Managers

A graph representing the long-term goals for managers. The five main goals are: 1. Connect refugees with providers in the community (Family Physicians), 2. Limited unnecessary referrals to Emergency Departments/Specialists, 3. Educate and integrate refugees into the Canadian healthcare system, 4. Provide routine evidence-based screening and preventive interventions, 5. Identify disease patterns before they spread to the wider population. There are also two ongoing goals: 1. Continually educate both medical and settlement staff, 2. Build networks of healthcare providers in the community.

The Emergency Phase

Population displacement from war or natural disaster often occurs where resources are already limited. Limited resources can rapidly lead to increased mortality rates for displaced populations.

This is called: THE EMERGENCY PHASE

A photo of the wreck left in the wake of the 2005 tsunami in Indonesia. You can see a boat lodged on top of several homes.
Post-Tsunami, Indonesia 2005
Photo Credit: Médecins Sans Frontiètes

In the emergency phase, MSF (Refugee Health 1997) recommends the following steps:

  1. INITIAL ASSESSMENT: Data collection and health priorities identification. Should be done within first few days of arrival.
  2. MEASLES IMMUNIZATION: Measles is responsible for killing 1 in 10 children affected in developing countries. Displacement is one of the factors that facilitates large-scale epidemics. Mass vaccination of children from 6 months to 15 years old should be a priority during the first week of arrival.
  3. WATER AND SANITATION: A sanitized drinking water supply should be set up.
  4. FOOD AND NUTRITION: Malnutrition is frequent in refugee populations. Maximum attention must be given to basic food needs during the first months after refugee arrival.
  5. SHELTER AND SITE PLANNING:I nadequate shelter and overcrowding are major factors in the transmission of diseases with epidemic potential. It is important to organize the site and plan for the refugees arrival: have a limited number of people per site with sufficient space per person and necessary infrastructure for services (e.g. health and nutrition facilities), roads, cemeteries, etc.
  6. HEALTH CARE:Common diseases must be dealt with in a decentralized network of health care facilities (health centres and health posts). Medical needs (material and drugs) should be quickly assessed in anticipation of outbreaks of diseases known to occur locally.
  7. CONTROL OF COMMUNICABLE DISEASES AND EPIDEMICS: Refugee populations are at higher risk of outbreaks of communicable diseases. Measures to control outbreaks vary with each type of disease. They can take the form of detection and rapid treatment for cholera or mass vaccination for measles.
  8. PUBLIC HEALTH SURVEILLANCE: Epidemiological surveillance is a tool for measuring and monitoring the health status of a population. This surveillance should only cover diseases or other health problems that can be controlled by preventive or curative interventions. Calculating disease-specific mortality rates helps in determining the major killer diseases and establishing priorities.
  9. HUMAN RESOURCES AND TRAINING: Once the different activities and tasks have been identified, staff requirements must be determined. Different types of personnel may be required: public health doctors, sanitation specialists, nutritionists, logisticians, administrators, etc. They should be chosen from the refugee or displaced population. Particular attention must be paid to both their training, and to that of other local health staff.
  10. COORDINATION: Good coordination among various operational partners is key to effective emergency relief planning. There may be multiple partners in large-scale emergencies: UN agencies, host-country authorities, local and international NGOs, and representatives from the refugee population.

Case 1 – A Stab to the Chest (Revisited)

After the stabbing, one boy was sent to a Juvenile detention centre and the other was hospitalized because of the injury. The mother started having frequent seizures.

The clinic manger immediately started a collaborative process with legal and health authorities to obtain culturally appropriate mental health assistance for the family and helped to arrange a neurological consultation to address the mother’s seizures.

Two weeks later, the boy in the Juvenile detention centre was released and a community health care provider was arranged for the family. Mental health counselling was provided on site at the refugee clinic by a family physician, and the mental health counsellor assigned by the court. A few weeks later improvement was observed and the family members were reunited.

Currently the boys are engaged in different community activities and attend high school. And the family has been integrated in a community-based family practice.

Case 2 – Suicide Ideation (Revisited)

When the Emergency room referred the patient back to the refugee clinic, the manger organized culturally and linguistically responsive mental health care in addition to medical treatment. Gradually the patient’s mental status started to improve and she started eating and drinking regularly. With ongoing support her condition remained stable and the manager linked her to English as a second language classes.

A panoramic photo of a street in Benin.
Benin
Photo Credit: C. Boudreau