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Medical care for children of refugees and asylum seekers

- a challenge for European paediatricians

Dr. Gottfried Huss MPHPresident ECPCP

ECPCP Symposium Prague

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Overwhelming migration- are we prepared ?

• 2014: In Germany 15,7 Mio live with foreign nationality ( 80,6 Mio total population ) One out of five of the population and one out of three children have a migrational background

• Since January 2015: 577.307 registered refugees in Germany – estimate of non registered 100.000 - every day 8.000- 10.000 more arrive in Munich

Childrens human rights translated for migrants

´ Protection-> Provision-> Participation

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Providers contribution

Refugee - > Asyl seeker -> I migrants own

contribution

Weeks Months Years

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Manifold barriers to implementation of human rights for refugees

• Frontiers, barbed wire, police, violence • Limited… – access to housing, heating, schools, “kindergarden” – access to social services and to health services – access to preventive services- well baby checks – access to services for chronic illness, rehabilitation,

psychological services

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HealthSyrian refugees in Munich 2015-

result of health screening

• 80% had respiratory viral infections• 40% had some mental disturbance• 10% had skin infections• 40% had incomplete vaccinations if the could

show a document

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A closer look to health serices for migrants in Germany

• Unacceptable delay of diagnosis and treatment• 2006: While 40% have been examined within the

first 4 weeks of stay- 20% have not been examined within the first 6 month of stay

• This shows the clear lack of medical services for migrants

• Scientific evidence: Rising costs if access to health care is restricted

Lit : Public Health institute Heidelberg and Bielefeld, Ratzum et al …

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Routine TB screening after arrival

Background: Fresh TB infections in 35% affect children born outside Germany ( Switzerland 44% )German infection law demands tests for every refugee• < 15 years TB screening with tuberculin skin testing

or interferon gamma release test • > 15 years X- ray

• Problem: it is well known but we are just starting to implement it for all

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Danger from Infections? • Refugees are not a source of infections - they

are not dangerous • They are in danger of acquiring infections on

their route of escape and in crowded compounds

• Early recognition- complete exams- anticipatory guidance- hygiene- vaccination

• If not vaccinated the danger of epidemics in camps rises

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Vaccination• The national schedule is the standard- but

which are the most important ones?• Priorities are Measles, Varicella, Influenza,

Meningitis C, Whooping cough, Hepatitis A Apply catch up vaccination as soon as possible

• Prevent epidemics in camps Measles and varicella outbreaks happen frequently - immediate mass vaccination in the incubation period can stop the outbreak and increase the herd immunity

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Mental and emotional health 1 • Frequently traumatized from

atrocities, violence and abuse• Data from Hamburg H. Adam – 50% were present in bombing– 40% witnessed destruction of their

home – 18% of refugees children have PTSD – 10% feel responsible for the death

of another person

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Mental and emotional health 2 • Many orphans, unaccompanied minors• Sleep problems and behavioral

disturbances, depression, lethargy, panic attacks

• Protection from further traumas – for example horror movies or conflicts

• At the moment we are very far away from adequate psychological treatment

• Think about ways to cope and how to implement resilience building skills in groups with theater, role play, singing….

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Unaccompanied migrant children

• Often cannot documents their age - the pressure for age assessment from authorities leads to useless X- rays, computed tomography and inspection of private parts without informed consent. This is unethical.

• They benefit from early medical care, housing, foster care, families who care, early language courses.

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Where is medical care offered? Can we cope? Step 1

• Large compounds for

500– 2000 refugees in big cities as temporary place to stay for days or weeks – tents, big halls

• Role of Red Cross, NGOs and other voluntary professionals

• Many are waiting up to 2 weeks to registration

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• Big compounds after arrvial• Hundreds of voluntary

physicians and NGOs offer medical care wherever without salary

• TRIAGE - Rapid health screening in health posts with paramedics and physicians

• Simple treatments with donated drugs

• TB- screening? Vaccinations?

Where is medical care offered? Can we cope? Step 1

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Where is medical care offered?Step 2 settle in small settlements

Small decentral compounds in the region- housing for 200- 500 refugees - place to stay for month and weeks

Some health initiatives - at the moment no health services in all compounds- open issue

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Step 3 Medical care in

paediatric offices

Advantage: • Integration in comprehensive child care and routine

preventive procedures • Financial mechanisms more or less clear- they need

insurance cards with all privileges Disadvantage: • Difficulties to find the way and bring a interpreter• Rights and duties - get used to regular appointments

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Help for self help

• Basic health courses in compounds

• First aid for children, nutrition, dental hygiene, vaccination, PTSD, how to handle the German health system

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Do we have to change?Are we prepared?

• Nurses and doctors- we should improve our trans- cultural competences- our attitudes and our knowledge- our communication skills– Why does this lady not shake hands?– Why does this boy not permit to examine his genitals?

• Our society is changing- we will live every day more in a multi- ethnical and multi- cultural society – this is enrichment!

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What can primary care paediatricians do?

• Paediatric associations should be advocates for migrant children and give recommendations

• Support the health of migrants• Equitable access to medical care (including preventive care,

chronic care, mental health and social paediatrics)• Migrants at all age should undergo early vaccinations and

complete medical exam by a paediatrician as soon as possible within the first weeks

• Not only professional help is needed. Refugees need our empathy, spontaneous support and civic courage- give time, give closeness, give joy!

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