In a strange land
Refugee patients often find Australia’s health system overwhelming, but GPs can provide essential care and support.
Australia may well be the ‘lucky country’, but it could be said that most Australians probably don’t know just how lucky they are.
While some are undoubtedly not as lucky as others, few born and raised Down Under have experienced the ravages of civil war and famine, or the threat of outright persecution. Thousands of people who have faced these challenges reach Australian shores every year as refugees seeking a better life, or sometimes just the chance to have a life at all.1
‘My country, the place where I belong, it’s not there,’ Constance Okot, a refugee to Australia from Sudan and the focus of the documentary, Constance on the edge, told Good Practice. ‘The cities, the villages are destroyed. It’s not there anymore.’
The number of people worldwide who have been forcibly displaced from their homes has hit a record of 65.6 million, while the number of refugees fleeing turmoil, suffering and even death in their own countries has reached nearly 22.5 million.1,2
‘When I was in the refugee camp in Kenya, I heard that my sister was shot,’ Constance said.
By contrast, her life in Australia often seems like paradise.
‘I thought it was a kind of dream, living a very normal life – no fighting, nobody vanished,’ she said.
But while those refugees who come to Australia are often leaving behind traumas many can scarcely imagine, settling into their new country presents its own set of challenges.
‘The migration settlement journey is quite a difficult one, coming from places where there has been conflict, poverty, quite commonly issues of torture and trauma,’ Andrea Vancia, Multicultural Health Program Coordinator for Refugee Health Connect, a Brisbane-based service that links general practices with training in refugee healthcare, told Good Practice.
Many refugees have become accustomed to what could be charitably described as rudimentary healthcare, or even complete lack of access, before coming to Australia.
‘Many people [at refugee camps overseas] can’t afford to go to the hospital, or often there is no advanced hospital,’ Elizabeth Niyokushima, a nurse and health development worker for the Brisbane Refugee Health Advisory Group, and herself a refugee from Burundi in east Africa, told Good
Practice. ‘People often died without having a diagnosis.’
Such limited exposure to any kind of systematic healthcare means refugees who settle in Australia can quickly find themselves overwhelmed by our system.
‘We have a very complex system in Australia and refugee patients are often really lost,’ Dr Aesen Thambiran, GP and Chair of the RACGP Specific Interests Refugee Health network, told Good Practice. ‘They don’t know where to go when they get sick and they don’t know how to find a GP or make an appointment.
‘It can be very confusing for a newcomer as to how to access the appropriate healthcare.’
The situation can also present challenges for GPs who may be unfamiliar with the issues with which these patients can present, as well as necessary practical considerations like the need for interpreters.
Dr Thambiran feels that as Australia’s population continues to become more diverse, GPs need to be provided with more assistance to better help their patients.
‘Australia is changing so much. Looking after people who are from culturally diverse backgrounds really is becoming bread and butter for a lot of general practices, and they need to have the supports to provide high-quality care,’ he said.
Need to know
While GPs are trained to be healthcare generalists with a solid understanding of how to treat whatever comes through their doors, they may be relatively unfamiliar with some of the issues with which refugee patients can present.
‘For example, communicable diseases [like] tuberculosis, especially if patients are from tropical areas, can be common. So can issues around nutrition, both malnutrition and over-nutrition. There can also be issues with chronic disease,’ Dr Thambiran said.
‘Oral health is a real issue, as are issues around women’s health – contraception, never previously having had a Pap smear – then issues around child health. There is often developmental delay, interrupted schooling.
‘Of course, the big one is trauma and torture related to the refugee experience.’
However, there is help available for GPs who encounter such issues and require assistance, such as the Refugee Health Connect service in Queensland, the Refugee Health Network of Australia, or the RACGP’s Refugee Health Specific Interests network.
Despite the relative prevalence of less common healthcare issues, refugee patients do also present with many of the same health issues that GPs encounter every day.
‘Most people of a refugee background have the normal issues everyone else has, you just need to be able to cross that linguistic and cultural boundary,’ Dr Margaret Kay, GP and Multicultural Health Clinical Lead for the Brisbane South Primary Health Network (PHN), told Good Practice. ‘If people are supporting you in doing that, you can treat their diabetes, you can treat their arthritis. You just need to be able to engage.’
In terms of that patient engagement, what may appear to be very straightforward examples of communication can in fact be extremely problematic when dealing with refugee patients, despite the best intentions of all parties.
‘In Australia, people come to your office and you call the patient and say, “How can I help you?”’ Niyokushima said. ‘In Australia, they think it’s a welcoming sentence, but people [in the Burundi community] think it’s rude. They think, “Oh, she has no interest in me, why do I share my information?” So it’s a barrier. Instead, the community members appreciate, “How are you?”
‘The issue in that situation is different perspectives between Australian and refugee backgrounds.’
Some refugee patients speak very little English, making language an even more significant barrier to healthcare. This can make the use of interpreters essential, even if it might not seem strictly necessary at first glance.
‘If someone has a bit of functional English, doctors may think, “This person understands me”, and just keep going with their consultation. But if you asked that person without an interpreter, “What was that consultation about?”, they might have very poor understanding of what has actually occurred,’ Dr Thambiran said.
‘There is also real misunderstanding about using friends and relatives to interpret, which we would definitely not recommend. Using a family member or friend, you don’t really know if that person is actually proficient in the other language, and you may be talking about the liver but they’re interpreting it as the kidney or something like that. It can lead to mistakes.’
Similarly, unofficial interpreters sourced from the community can present problems.
‘If the patient knows this interpreter, they won’t want them to interpret,’ Niyokushima said. ‘Maybe because of lack of professionalism or because, as a patient, they don’t understand very well what privacy means. Maybe they think, “If she’s the interpreter, she’s going tell this to other people in my community”.’
Dr Thambiran emphasised it is always best to use a professional.
‘It’s really important to use someone who’s undertaken interpreter training and is proficient in both English and the language that is being interpreted,’ he said.
Refugees seeking healthcare in Australia may also be experiencing significant psychological problems as a result of trauma experienced while in their home country. Constance Okot found these issues surfaced as she settled in Australia and had respite from the chaos of warzones and refugee camps.
‘When I was very sick [with depression], I felt like it was useless,’ she said. ‘Every day I asked myself, “What am I doing here? I’d better go to my country and die there”.’
Constance was able to face and overcome her depression with the help of her GP, and has since used her knowledge to help ensure other refugees understand the experience and know that they are not alone.
‘[It’s difficult], especially when you don’t understand what is going on with you, because mental health is not an injury people can see,’ she said. ‘So it’s very hard for people to understand what you are talking about – even you yourself, you don’t understand what is wrong.’
Refugee Health Connect provides education to general practices that want to upskill in refugee health. The service, provided in partnership with Mater Health Services, Multicultural Development Australia, Metro South Hospital and Health, and Brisbane North and Brisbane South PHNs, started with a group of passionate GPs.
‘The Queensland Integrated Refugee Community Health Centre ... was started by a number of GPs in partnership with QPASTT [Queensland Program of Assistance to Survivors of Torture and Trauma], and the Mater and St Vincent hospitals. There were a lot of refugees who were very ill and not getting any medical care,’ Dr Kay said.
‘We realised we couldn’t see everyone in all of Queensland, but we started to develop some expertise in the complex cases and could help out the GPs who were seeing [refugees] by default.’
After years of securing funding, building a GP network and providing education through Medicare Locals, and later PHNs, Refugee Health Connect launched in 2014.
‘[Refugee Health Connect] has got one phone number that clinics can ring and say, for example, “I’ve got a refugee patient from the Congo. They arrived six weeks ago and I don’t know what to do. Can you help me?”’ Dr Kay said.
‘If one person has arrived, chances are a few other people have arrived too, so we ask, “Would you like us to upskill you?”’
The upskilling process involves education for staff members throughout the practice.
‘We provide a suite of resources for clinical and administration staff, and we put that in to a folder when we go out to a practice and leave it with them,’ Vancia said.
‘We provide a practice visit, usually with one PHN representative and one refugee health service representative. We also have our GP clinical lead and a registered nurse clinical lead who can then go into the practice and do some more targeted clinical education with either the GPs or the nurses around refugee health clinical issues.
‘We’re a single point of call and if we can’t answer the question, we can link them up to the right organisation. I think that takes out a lot of the stress of working in this space.’
Education provided by Refugee Health Connect helps practices understand how to provide refugee patients with culturally safe care.
‘We are upskilling general practices to be clinically and culturally appropriate,’ Vancia said. ‘This then allows for a better experience for the patient and it gives them easier access to refugee-health-ready practices.’
The service aims to be proactive in its approach by creating links with refugee settlement services, so it can keep up with what is happening on the ground.
‘When the settlement agency brings their clients to Australia, they now tell Refugee Health Connect, “We’ve got 10 clients coming from Iraq who are going to settle in this area”,’ Dr Kay said.
Refugee Health Connect can then identify an appropriate general practice to link with the patients based on their location, complexity of needs and cultural requirements. This system also enables Refugee Health Connect to contact local practices and apprise them of the fact that refugee patients will be arriving, and then offer the appropriate training.
‘I think we’re moving away from having specialist refugee centres,’ Dr Thambiran said. ‘Especially in the larger states like New South Wales and Queensland, people are spread so far and wide that it’s really up to the GPs in those areas to provide the services.
‘So when a GP is faced with a patient and they don’t know much about the diseases or the culture that person is coming from, or they need some help managing a particular problem, having one central phone number they can ring and get advice is a fantastic idea.’
Dr Kay is proud of Refugee Health Connect and its base in primary care, and believes it is a model that can be replicated in other areas.
‘Our desire is that PHNs do something similar that is relevant to their particular area,’ she said.
‘We think it is really good working with the PHNs; complex care is being delivered in a primary care environment. This is GP-led refugee healthcare delivered within the general practice environment, collaborating across the sector to enable quality care.’
- Parliament of Australia. Refugee resettlement to Australia: What are the facts? Canberra: Parliament of Australia, 2016. Available at www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp1617/RefugeeResettlement [Accessed 3 August 2017].
- United Nations High Commissioner for Refugees.
Figures at a glance. Geneva, Switzerland: UNHCR, 2017. Available at www.unhcr.org/en-au/figures-at-a-glance.html [Accessed 3 August 2017].