CHRISTMAS 2015

Responding to the needs of refugeesKnowledge of and skills in human rights medicine will be needed

Frank Arnold convenor, anti-torture initiative1, Cornelius Katona lead23, Juliet Cohen head of doctors4,Lucy Jones UK programme manager 5, David McCoy director 1 6

1Medact, London, UK; 2Royal College of Psychiatrists Asylum Mental Health Working Group, London, UK; 3Helen Bamber Foundation, London, UK;4Freedom from Torture, London, UK; 5Doctors of the World, London, UK; 6Queen Mary University London, London, UK

At the time of writing it is unclear how many people willeventually receive refuge in Britain from encampments incountries surrounding Syria through the UN vulnerable personsrelocation scheme. The government’s current commitment toreceive a maximum of 20 000 over five years, if delivered at aconstant rate, would result in 4000 arrivals a year.1 It is alsounclear when they will arrive and what financial and otherarrangements are being made for local councils to support them.But even if the UK maintains its decision to opt out of the EUrefugee sharing scheme, the number of asylum seekers reachingthe UK by other routes may increase, given that more than halfa million people seeking protection arrived in Europe by sea in2015.Whatever the numbers, many will have high levels of complexphysical, psychological, social, and legal needs arising fromtheir experiences in their countries of origin or during their oftenprolonged and dangerous journeys. This is particularly the casefor people admitted under the UN relocation scheme, whichemphasises vulnerability and damage as primary selectioncriteria.2

These health needs will interact with each other and with widersocial needs (housing, schooling, linguistic, and cultural support)to produce challenges that exceed the experience of most UKclinicians. The issues that the responsible practices and hospitalswill need to address are many and complex but largelypredictable (box). The current crisis must be met by a plan totrain and support clinicians to assist this vulnerable group. Sucha plan would also benefit the many traumatised, tortured, andill refugees, asylum seekers, and undocumented migrants whoare already in the country.So what needs to happen? Government departments shouldmake use of standard handheld records of medical informationgleaned during selection for relocation and ensure that the datafollow the patients to their new practitioners. The EuropeanUnion is developing such a record.3 For people who requiresecondary care the Home Office should provide immigration

status documents and circulate them with advice to relevantofficers to prevent inappropriate attempts to charge user fees.The entitlements of migrants to care are complex, but survivorsof torture and other human rights abuses do not have to payunder the current regulations.4 And unless a general practicehas a policy requiring all new registrants to supply documents,to do so for migrants only would constitute impermissiblediscrimination.5

As health professionals, we are occupationally and morallyrequired to offer the highest standard of healthcare to all patients,including survivors of human rights abuses who arrive on theseshores.6 But clinicians need to be trained and supported to helpthis vulnerable group. The knowledge and skills in human rightsmedicine and psychology developed by a relatively smallnumber of specialist health professionals within the NHS andthird sector organisations needs to be harnessed and used wiselyto enable this to happen. These organisations include FreedomfromTorture (www.freedomfromtorture.org), the Helen BamberFoundation (www.helenbamber.org), and Doctors of theWorld(www.doctorsoftheworld.org.uk/pages/UK-Programme). TheRoyal Society ofMedicine is hosting training sessions organisedby Medact on clinical aspects of torture and trauma. PublicHealth England, which has a helpful Migrant Health Guide,7the royal colleges, the BMA, and other health professionalbodies can also facilitate relevant educational initiatives. Closecollaboration between the statutory and charity sectors will becrucial.The voice and mandate of health professionals also needs to beused to prevent xenophobia and tackle the root causes of therefugee crisis. We should make good use of the expressions ofgoodwill and solidarity frommuch of the UK population towardsthose who need help and highlight the past and potential longterm economic and social contributions that such refugees haveand can make in the UK. We should also seek to educate andengage the UK health community about the need to promote

Correspondence to: D McCoy d.mccoy@qmul.ac.uk

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BMJ 2015;351:h6731 doi: 10.1136/bmj.h6731 (Published 16 December 2015) Page 1 of 2

Editorials

EDITORIALS

Common interacting medical needs of refugees

Psychological• Post-traumatic stress disorder and other mental health problems resulting from trauma

Physical• Consequences of torture such as damage to feet from repeated blunt trauma or brachial plexus damage after suspension byhyper-extended arms

• Screening for sexually transmitted diseases (if rape revealed)• Traumatic war injuries

Social and legal• Adequate interpreting• Access to primary and secondary care and difficulties of negotiating exemption from overseas visitors charging regulations• Protection from subsequent unsafe repatriation or redress may require careful documentation of medical evidence of human rightsabuses, including photographs or clinical notes of physical or psychological damage on arrival

peace and human security, particularly in north Africa and theMiddle East. The refugee crisis will not be resolved otherwise.

Competing interests: We have read and understood BMJ policy ondeclaration of interests and declare that FA, CK, and JC have been paidfor medicolegal reports documenting the consequences of torture.Provenance and peer review: Commissioned; not externally peerreviewed.

1 Smith B, Gower M, Politowski B. Syrian refugees and the UK. House of Commons Librarybriefing paper No 06805, 17 September 2015. http://researchbriefings.files.parliament.uk/documents/SN06805/SN06805.pdf.

2 HomeOffice. Syrian resettlement programme. www.local.gov.uk/documents/10180/11411/Home+Office+Syrian+Resettlement+Fact+Sheet/af2652cc-238a-4bd4-9c2a-ef23ef52662e.

3 European Union Directorate General on Health and Food Safety. Refugees: CommissionerAndriukaitis presents the personal health record in Greece, 20 Nov 2015. http://ec.europa.eu/dgs/health_food-safety/dyna/enews/enews.cfm?al_id=1647.

4 Department of Health. Guidance on implementing the overseas visitor hospital chargingregulations 2015. Paragraph 1.1. www.gov.uk/government/uploads/system/uploads/attachment_data/file/418634/Implementing_overseas_charging_regulations_2015.pdf.

5 NHS England. Patient registration. Standard operating principles for primary medical care.www.england.nhs.uk/commissioning/wp-content/uploads/sites/12/2015/11/pat-reg-sop-pmc-gp.pdf.

6 United Nations. Istanbul protocol. Manual on the effective investigation and documentationof torture and other cruel, inhuman or degrading treatment or punishment. 2004. www.ohchr.org/Documents/Publications/training8Rev1en.pdf.

7 Health Protection Agency. Migrant health guide. 2014 http://webarchive.nationalarchives.gov.uk/20140714084352/http:/www.hpa.org.uk/MigrantHealthGuide/.

Cite this as: BMJ 2015;351:h6731© BMJ Publishing Group Ltd 2015

For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe

BMJ 2015;351:h6731 doi: 10.1136/bmj.h6731 (Published 16 December 2015) Page 2 of 2

EDITORIALS