3.4 Blackbelt

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Case 3 – Congolese Refugee Family

A sick Congolese baby.
Photo Credit: Courtesy of United Nations High Commissioner for Refugees (UNHCR) website.

Finally you meet the Jemi family for checkups. You found that the Jemi’s 3 year old daughter is short for her age. Mrs Jemi describes their condition prior to arriving in Canada. According to her, the family has been exposed to lack of food for several months, and that at their arrival in the refugee camp 6 month ago, the daughter displayed abnormal burns, lightening of the hair and oedema or swelling. She also exhibited diarrhea but there was no evidence of loss of muscular mass. You begin to understand that the girl was malnourished before moving to Canada.

Question 1: What nutritional deficiency did the young girl exhibit at arrival in the refugee camp?
Question 2: How would you have treated the condition?
Question 3: Now that the family is settling to Canada, which further steps will you undertake to ensure optimum nutritional care of the child?


Nutritionist’s Perspective

Photo of Dr. Diao Sanou
Dr. Diao Sanou
Public Health Nutritionist,
University of Ottawa

En tant que nutritionniste, je pense que la fille de trois ans souffrait de kwashiorkor. Le kwashiorkor est une maladie qui affecte les enfants de 1 à 5 ans ayant été exposés à une carence sévère en protéines et énergie. Cette carence résulte à une alimentation de faible qualité, la malabsorption des nutriments ou la présence de maladies en particulier les infections.

[As a nutritionist, I believe the 3-year-old girl was suffering from kwashiorkor. Kwashiorkor is an illness that affects children between the ages of 1 and 5 who have been exposed to a severe protein and energy deficiency. This deficiency results in: a low-quality diet, difficulty absorbing nutriments, or the presence of illnesses and infections.]

How would you have threated the condition?

[Steps to take when treating kwashiorkor :

  • Set up an IV to restore electrolyte balance
  • Use antibiotics or anti-parasitic drugs to treat infections
  • Propose vitamin and mineral supplements to make up for nutritional deficiencies
  • Gradually increase calories, carbohydrates and non-saturated fats
  • Gradually increase daily protein consumption]

Optimum nutritional care

Another photo of the sick Congolese baby.
Photo Credit: Courtesy of the United Nations high Commissioner for Refugees (UNCHR) website.

To make sure all current nutritional issues of this child and potential risk factors are identified, I will recommend biochemical analysis including blood glucose, total protein levels, total blood count, anemia, sick cell disease, and treat any potential nutritional issue identified. A dietary assessment should be undertake including current consumption patterns, cultural preferences of foods and past exposure to food shortage.

I will recommend the family to attend a nutrition education session with immigrant and/or refugee service organization in a language that is well understood by Mrs Jami. They should be recommended a local grocery store tour with a community dietitian who will share information on reading food labels and making healthy food choices. The dietitian will explain how to choose healthy fats, how to reduce sugar intake and increase fibre with whole grains, and how to reduce sodium intake.

If possible, I will give a copy of Canada Food Guide for healthy eating, and a list and address of grocery stores including ethnic stores, and local food bank. Introducing the family the Congolese association of any Swahili speaking community will also be helpful.


Case 4 – Navigating Canada’s Health Care as a Congolese Refugee

Photo of a male Congolese refugee.
Not actual patient

Mani is a 28-year-old male who has spent 3 years in a UNHCR refugee camp on the Kenyan border. He had been having abdominal pain on and off for months in the camp. Now that he has been resettled in Canada, he has hopes that doctors here can help him.

After receiving his health card, Mani decides to go to the Emergency Department at the city hospital, since that seems to be a natural place to see a doctor. He waits 10 hours to be seen for chronic abdominal pain.

The ER doctor begins to take the history; however, since Mani can’t speak English or French and the ER has no available interpretation services, they struggle without one.

The doctor encounters difficulties obtaining much of a history and so proceeds to examine Mani’s abdomen and orders a few tests.

Unable to find anything serious, he tells Mani his symptoms are likely due to the stress of his recent travels and the anxiety of starting off fresh in a new country.

Question 1: What are some of the issues faced by Mani in this medical encounter?
Question 2: What are some of the barriers refugees face when trying to access Canada’s health care systems?

The X-Factor

Graph of 6 boxes pointing towards the centre. The centre reads: Barriers affecting refugees' ability to access the Canadian health care system. The six boxes read as follows, in no particular order: 1. Provider beliefs, knowledge, cultural sensitivity, and cultural competence. 2. Trust 3. Language 4. Education 5. Cultural beliefs 6. System barriers: interpretation services, fee for service payments.
Credit: Pottie K, Ortiz L, tur Kuile A. Preparing for diversity: improving preventive health care for immigrants. Our Diverse Cities, Metropolis 2008 Mar 3.

Case 4 – Navigating Canada’s Health Care as a Congolese Refugee (Revisited)

Three months later, Mani’s abdominal pain has not resolved and is getting worse.

An acquaintance he meets at the local grocery store tells him about a new clinic in town that sees a lot of refugees and immigrant patients. Though his faith in Canadian medicine is waning, he decides to try again.

This time there are interpreters on site and a complete history is taken, leading to the discovery of more information about the abdominal pain.

Along with investigating his abdominal pain, this doctor asks more questions pertaining to his health and the challenges he faced during the exodus from his home. He also focuses on prevention and promotion of health.

Question: Now that you have an interpreter available, what would you ask Mani?

Abdominal pain in a refugee:

  • Generally, start with a medical history, including the character, location, onset, duration of pain, whether it moves (radiates), factors that ease the pain as well as those that aggravate it.
  • More specific questions based on the refugee’s migration trajectory are paramount and this is where the expert comes in.

Questions you may consider asking:

  • How long was he in a refugee camp?
  • Did he experience any physical or psychological trauma?
  • What was the quality of the water supply?
  • Was he exposed to TB and other infectious outbreaks?

Pottie K, Greenway C, Feightner J, Welch V, Swinkels H, Rashid M. et al. Evidence Based Guidelines for Immigrant and Refugees. CMAJ in press 2011.

Upon further questioning, you discover:

  • The pain has been present for 6 months
  • It is described as an ache, sharp at times
  • It does not move around but stays in the upper area of the abdomen
  • It seems worse after eating a meal
  • From time to time, his bowel movements have alternated from loose to more constipated

On examination:

  • You find his abdomen soft with good bowel sounds
  • He is tender in the upper aspect but not overly so
  • His chest has a few wheezes on both right and left sides
  • His heart sounds are normal
  • The rest of his exam is within normal limits

Question 1: What are the possible causes for Man’s pain?
Question 2: What investigations would you consider to help you confirm your diagnosis?

Differential diagnosis

  • Untreated parasites (strongyloides, schistosomiasis, ascaris, hookworm, etc)
  • Helicobacter pylori (Gastroesophageal reflux disease), acid refulx
  • Peptic ulcer disease
  • Malaria complications (splenomegaly)
  • Hepatitis
  • TB (disseminated)
  • Anxiety/stress (psychosomatic)

Diagnosis and Outcome

  • The complete blood count showed a mild anemia but was otherwise normal (no eosinophilia)
  • Stool tests for parasites and bacteria were negative
  • Because Mani was from Sub Saharan Africa, blood tests (serology) were ordered to look for parasites as they are not always found in stool tests
  • Mani was diagnosed with Schistosomiasis and was treated with praziquantel. His pain resolved completely over the next few weeks

Prevention

  • Who should we screen and what conditions are we screening for?
  • When a refugee has a specific complaint, we take the appropriate history, physical exam and investigations
  • However, sometimes there are very little or no symptoms. In these cases what is the evidence for screening the various diseases that affect refugees?

Resources

  • To answer these and other questions related to prevention and the care of refugees, we invite you to explore the following resource:
  • CMAJ in press: http://www.cmaj.ca/cgi/collection/canadian_guidelines_for_immigrant_health

Photo of a little girl reaching for a handful of water at a watering hole.

K. Khan, C. Heidebrecht, J. Sears, A. Chan, M. Rashid, C. Greenaway, W. Stauffer, L. Narasiah, K. Pottie, Intestinal Parasites: Strongyloides and Schistosomiasis: Evidence review for newly arriving immigrants and refugees. CMAJ in press

A photo of two doctors wearing masks to protect themselves during an Ebola outbreak.
Ebola Outbreak
Photo Credit: Médecins Sans Frontières