rural doctors caring for refugees

AN AUSTRALIAN DOCTOR PUBLICATION MAY 2008

RURAL DOCTORS CARING FOR REFUGEES

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8 | Australian Rural Doctor | May 2008

Woolgoolga GP Dr John Kramerwith Alicia Dayori, 22 months:

“We’re helping to address aneedy population, a very, very

disadvantaged group.”

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Refugees are finding homes in country areas where busy GPs are taking time to care for them – but more GPs are needed.

BushSTORY MELISSA SWEET • PHOTOGRAPHY TREVOR VEALE

For Coffs Harbour, a pretty holiday centre onthe mid north coast of NSW, the “Big Banana”has traditionally been its main claim to fame, butthe area is now also gaining a reputation as amulticultural haven, due to a steady stream ofrefugees settling there.

Coffs is one of several regional and rural cen-tres that the Federal Government has targetedfor refugee settlement, and it also attracts otherswho move there to be reunited with their fami-lies and communities.

The influx has raised challenges for healthservices, already struggling with the inflow ofsea-changers and a doctor shortage that has seensome GPs close their books in an effort to con-trol spiralling workloads.

But the locals are rising to the challenge.Thanks to a collaboration between the areahealth service and division of general practice, afortnightly refugee clinic has been establishedat the Coffs Harbour hospital to better caterfor these patients’ complex needs.

The clinic is funded jointly by the area healthservice and Medicare, with the doctors beingpaid an hourly rate. The patients are treated forfree and are also given medications.

When a call went out for GPs to help staff theclinic, Dr John Kramer, from nearbyWoolgoolga, was one of several to come for-ward. He does one session every two months,and finds the work fascinating.

“I’m seeing stuff there I’ve never seen beforeand I won’t see anywhere else,” he says. “It’s

enjoyable clinically. It’s enjoyable in the broadersense, in that we’re helping to address a needypopulation, a very, very disadvantaged group.”

Anaemia and chronic parasite infections suchas schistosomiasis are common, while malariaand TB also crop up occasionally. The patients,largely from Africa and Burma (Myanmar), haveoften been living in refugee camps for more thana decade.

With the United Nations estimating that up to35% of the world’s refugees have suffered severetorture, Dr Kramer often refers patients to theNSW Service for the Treatment andRehabilitation of Torture and Trauma Survivors(STARTTS), which opened a local office threeyears ago.

Dr Kramer, a senior lecturer in the Universityof NSW’s rural clinical school, has also enjoyedworking in another type of practice. The clinicruns more like an Aboriginal health service, hesays, with a nurse being the first point of patientcontact, and the GPs acting more like consult-ants. “A bit of a change every now and then toget away from the main job reinvigorates youfor your main role,” he says.

The experience has brought other benefits forhis regular practice, making him more aware ofthe benefits of the Translating and InterpretingService. “By working in the refugee clinic, I’veseen the benefit of that.”

The clinic has seen about 240 patients sinceopening in February 2006, with a recent evalu-ation concluding that it was a successful model

that could be useful elsewhere. It does compre-hensive assessments before referring patients forongoing management by mainstream health anddental services, but often struggles to find GPs totake on patients.

Indeed, before the clinic opened, it was thelocal Aboriginal health service that saw mostof the Sudanese arrivals, because GPs had lim-ited capacity for getting involved.

Dr Kramer has no hesitation in encouragingcolleagues to become involved, even by takingon just a few refugee families. Rather than clos-ing their books, general practices will have todevelop different models of practice to copewith the ever-increasing workloads, he says.

A key player in the clinic’s success has beenMichele Greenwood, a public health and refugeenurse at the North Coast Area Health Service,who helped set up the clinic and devised itshealth screening tool.

Ms Greenwood ensures all relevant tests havebeen reported before patients see a clinic doctor.She also stays in touch with patients, makingsure they take their medications appropriately,and has even been known to pay for medicinesout of her own pocket

Ms Greenwood never ceases to be surprisedby the resilience of refugees, who have oftenendured unimaginable loss and deprivation. “I’msurprised they’re as healthy as they are,” shesays. “But they’ve got to have a bit of initiativeand drive to get through the refugee process.”

sanctuary



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Refugees are not newcomers to the bush. Almost 700,000have settled in Australia since the end of World War II,

and many have made their homes outside big cities.But they have recently become more visible in the country,

partly because of federal policies encouraging rural settle-ment for many of the 13,000 refugees who arrive in Australiaeach year. They are also moving to country areas for employ-ment and social connections.

As well as Coffs Harbour, the Department of Immigrationand Citizenship has designated as resettlement areasNewcastle, Wollongong, Goulburn, Wagga Wagga, Geelong,Toowoomba, Townsville, Cairns, the Gold Coast, Launceston,Shepparton, Ballarat and Mount Gambier.

The department says it chooses the settlement location ofonly about 30% of refugees – the rest tend to settle where theyalready have ties. It estimates that just under 10% of refugeeshave settled in rural and regional areas over the past fiveyears, although the figure varies – in Tasmania, for example,about 40% settle outside of Hobart.

A recent immigration department survey of 95 refugees infive regional settlement areas concluded that adequate healthservices are vital for successful resettlement, and suggests thatthere is room to improve these.1 It found that 46% of thoserefugees who’d used the services of a GP had found the serviceto be satisfactory, while 19% raised concerns about the servicesprovided by GPs and hospitals.

Dr Sundram Sivamalai, the national chair of the regionalcommittee of the Federation of Ethnic Communities Councilof Australia and a senior lecturer in the University ofMelbourne’s school of rural health at Shepparton, says manyrefugees’ problems are compounded by the lack of infrastruc-ture and support services in rural areas.

Refugees also often struggle to access rural GPs, especiallygiven their low bulk-billing rates, and can have difficultiesmaintaining confidentiality about sensitive health issues insmall communities, he adds.

Dr Sivamalai advises rural doctors to try to put themselves inthe place of their refugee patients. “You really have to under-stand the need of the refugee from their perspective,” he says,“not that what I’m providing here should be okay for you, but

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Dr Penny Vine sums up her demandingwork in a blunt but colourful turn ofphrase. Her job, she explains, is to helppeople turn the “shitty” aspects of lifeinto fertiliser.

A trauma counsellor at Albury inVictoria, Dr Vine started her professionallife as a paediatrician. She began develop-ing an understanding of the impact oftraumatic loss while working with familiesaffected by cot death, and then movedinto the developmental disability field.

For the past 16 years, Dr Vine hasworked as a grief and loss counsellor, withan ever-increasing caseload of refugees.She also does a lot of voluntary work andin 2004 helped establish a group that hassponsored more than 30 refugees to settlelocally.

Dr Vine, 61, sees many parallelsbetween her previous work in developmen-tal disability and the counselling sessionswhere she hears horrendous stories frompeople who’ve been subjected to sadisticabuse, seen children murdered, and beenattacked by neighbours and others theythought they could trust.

Her role is to help people learn to livewith traumatic loss – to learn how to “turnthe shit into fertiliser, to find new mean-ings in life”.

“It’s very rewarding because I get to see

people in extreme distress and have theprivilege of watching them reclaim theirlives and move on.”

Dr Vine says refugees may be reluctantto talk about the negatives of their livesbecause they don’t want to appearungrateful.

“They don’t want to talk about the pastso you have to make specific inquiries,such as ‘were you raped, were you evertortured?’ because they won’t volunteerthat information. There’s a lot of shamearound the humiliations.

“But you only ask if you’ve got a pur-pose in asking.”

Dr Vine says it’s important to under-stand how patients’ previous experiencesmight affect their health, as well as theirinteraction with health services.

“If you have trouble in the surgery, itmay be because you were tortured in aroom with venetian blinds,” she says.

Dr Vine also advises colleagues to becareful about labelling patients. Many donot appreciate being permanently taggedas “refugees”, which they can finddemeaning.

Dr Vine recalls a patient telling her: “Iwant people to look at me with respectand see me as a person with dignity, notsomeone who’s suffered and is to bepitied.”

Helping refugees find new meaning

Albury trauma counsellor Dr Penny Vine enjoys the

privilege of watchingrefugees “reclaim their

lives and move on”.

Public health and refugee nurse Michele Greenwood, with Baby-girlBarney, is continally surprised by the resilience of refugees.


what is it that you really do want?”Dr Sivamalai also cautions against

treating refugees as a homogenousgroup. “Their needs are so disparate,”he says. “It is often assumed thatpeople from Africa all have the sameneeds and expectations, which is totallywrong.”

Dr Murray Webber, a lecturer in pae-diatrics and child health at theUniversity of Newcastle and clinicallead in the Hunter New England AreaHealth Service refugee health program,has been on a steep learning curve sincehelping establish a clinic for refugeechildren four years ago.

One of the biggest challenges, hesays, has been learning to work withinterpreters and to manage communi-cation barriers.

“I think a lot of doctors haven’t hadany experience of using phone inter-preters and can be a bit reluctant touse them. They can believe it slowsdown the communication, rather thanenhancing it. That is definitely a mis-take – the quality of communicationis much better.”

Dr Webber hopes divisions canbecome more involved in educating andsupporting GPs to use interpreters.“There are medicolegal risks for doc-tors if they’re not using interpreters toget consent,” he adds.

In Toowoomba, where an estimated1.5% of residents are African refugees,the local public health service has beenworking to ease the load on GPs.

Dr John Hooper, a public healthphysician at Toowoomba BaseHospital, says that with Sudanesepatients speaking many different lan-guages, communication is often anissue and consultations can be slow andcomplicated.

He says the hospital’s public healthunit tries to do basic investigations and

assessments and develop a patient careplan before referring refugees to a GP.

He says they’re working with thedivision of general practice to supportGPs taking more refugees into theirpractice.

“Through the division we will runsome education programs for practiceswho may be willing to take on a coupleof patients,” Dr Hooper says.

“We want to make that transitionfor refugee families into a general prac-tice as easy as possible, so the GPs are


Many country people have shown their support forrefugees and asylum seekers, through the forma-tion of groups such as Rural Australians forRefugees.

In the NSW town of Inverell, just a few hours’drive from Tamworth – where the mayor’s con-cerns about refugees drew widespread publicity afew years ago – locals have given time and moneyto help some of the world's dispossessed.

Leading the charge is a retired teacher,Rosemary Breen, who helped establish SanctuaryInverell in 2004. The group has since sponsoredseveral refugee families to settle in the area andprovides help with accommodation, languagetraining and transport.

Before the first Sudanese family arrived, MsBreen put much effort into preparing the commu-nity, by speaking in the media and to local groups.

“The reaction was very, very good,” Ms Breensays. “When they arrived, people in the street

came up, saying, ‘welcome’. Only one person everabused me publicly and said he wanted a whiteAustralia.

“One of the boys did very well with his HSCand is now studying medical science at Armidaleand hoping to train and become a doctor.”

Other groups in the region are doing similarwork, says Ms Joy Harrison, one of two refugeehealth nurses in new positions established by theNew England Hunter Area Health Service last year.

“Tamworth last year had issues about resettle-ment – only six Sudanese sponsored in the pastyear in a population of 45,000 whereas Inverell ofmuch smaller population and services has wel-comed 15,” she says.

Ms Harrison liaises with new arrivals to ensurethey’ve had a health assessment, supports doctorsto use interpreters, and works with the local divi-sions to increase GPs’ understanding of refugeeneeds, especially around immunisation.

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Rosemary Breen with Simon Chol Malual, who isstudying medical science in Armidale and hopes toeventually study medicine and work as a rural doctor.

Country people rise to the challenge

Continued from page 10“We want tomake that

transition forrefugee families

into a generalpractice as easy

as possible.”DR JOHN HOOPER

Refugee Baby-girl Barney at the Coffs Harbour clinic, a collaboration of the area healthservice and division of general practice.


May 2008 | Australian Rural Doctor | 13

Australia’s multiculturalism means that refugees areincreasingly able to see doctors and other health pro-fessionals from their own cultures, or who at leastspeak their language.

Sometimes, these health professionals also bring theextra insights from their own experiences as refugees.

At Coffs Harbour, for example, the Anglicare service,which helps settle refugees, employs an interpreter wholeft Burma as a refugee 20 years ago, Mr Htun Htun.

Mr Htun, 37, who was a paramedic in Burma,moved to Coffs Harbour four years ago and is now inhis final year of nursing training. “I love it here,” hesays. “The council and the community are welcomingand very open minded.”

The 100 or so Burmese refugees in the area are alsofortunate to have a Burmese doctor, Dr Win Thein, whobegan working locally in 2003.

Dr Win initially came to Australia to study businessmanagement after working as a rural GP in Burma,500km from the nearest doctor. About 10% of herpatients are refugees, and a large part of her work isexplaining cultural differences and the health caresystem.

“Because I speak their language, we can develop thedoctor-patient relationship very quickly,” she says.

Dr Win’s sister, Win Than, will also be a boon forBurmese refugees, when she starts work as a GP atNambucca Heads shortly. She has been living with hersister for the past two years, while completing hermedical exams.

Meanwhile, a local doctor from Africa has helpedrefugees in Toowoomba, on Queensland’s Darling

Downs. Congo-born Dr Pungu Mwilambwe arrived inToowoomba in 2004 after working in South Africa for13 years. With French as his first language, heempathises with patients who face language barriers.“Having that African background makes it easier forthem to relate to me,” he says.

Dr Mwilambwe has been helping the local publichealth team by speaking at health forums for refugees,discussing sensitive issues, such as HIV and STDs.“Some of them, when they come from Africa toAustralia, they have the perception that in Australia,there is no HIV,” he says. “They will say, ‘why take precautions?’ Some of them managed to get HIV inAustralia because they didn’t know.”

not viewing them as a difficult group butjust as any new family coming in.”

Meanwhile, Dr Geraldine Duncan, aGP who has been working with refugeesin Wagga Wagga for many years, is push-ing for a clinic to be established therealong the lines of the Coffs Harbourmodel. She says such a co-ordinatedapproach to screening and follow-up isnecessary to stop patients “fallingthrough the cracks”.

The clinic will also help enableresearch on refugees’ needs, to guidedevelopment of better infrastructure andservices, she adds.

While her work with refugees, as bothan advocate and doctor, is time-con-suming, Dr Duncan also finds itextremely rewarding.

“It’s not dissimilar to the rest of med-icine,” she says. “The more you put intoit, the more you get out of it.” •1. Christine Shepley, Regional Settlement inAustralia: research into the settlement experience ofhumanitarian entrants in regional Australia 2006-07.Department of Immigration and Citizenship.

Caring with insight

Burmese doctor Dr Win Thein (right), who cares for about100 Burmese refugees in the Coffs Harbour area, with hersister, Win Than, who will soon start work as a GP inNambucca Heads.

• Profiles of different cultures to service providerswww.immi.gov.au/living-in-australia/delivering-assistance/gov-

ernment-programs/settlement-planning

• Information about interpreting serviceswww.immi.gov.au/living-in-australia/help-with-english

• RACGP guidelines www.racgp.org.au/guidelines/refugeehealth

• Refugee health resourceswww.foundationhouse.org.au/pub_refugeehealth.htm

• Torture and trauma counselling serviceswww.fasstt.org.au

www.startts.org.au

Useful resources and websites

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rural doctors caring for refugees

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