Health and Cross-cultural issues Dr. Jill Benson Senior Medical Officer Migrant Health Service and Director, Health in Human Diversity Unit Discipline of GP, University of Adelaide

What is a refugee? >“Everyone has the right to seek and enjoy in other countries asylum from persecution” Article 14, Universal Declaration of Human Rights 1948 (signed by member countries, including Australia and NZ) >Under international law, refugees are persons who "owing to well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country of his (sic) nationality and is unable or, owing to such fear, is unwilling to avail himself of the protection of that country... " (1951 Convention relating to the Status of Refugees) >Generally, refugees are people who have been forced to flee their homes, their lands, have lost family and friends, have few possessions and have been the subject of human rights violations.

Refugee profile >Approximately refugees/year to Australia, about 1300 to South Australia >30% from Africa Sudan, Congo, Burundi, Liberia >30% from Middle East Afghanistan, Iran, Iraq >30% from elsewhere Burma, Bhutan, China >Up to 50% aged under 18 >Approx. equal numbers of men and women

Voluntary vs involuntary migrant >Voluntary (choice) Prepare Say goodbye Learn language Bring household items etc with them Have career recognised Look forward to a new life >Involuntary (refugee) No time for preparation Bring nothing Lose contact with family and friends Don’t know language Lose career Often still look back to what they have left behind

Refugee profile >Higher levels of poverty >Families often headed by female >Greater cultural differences >Larger families with lower levels of education Often no education at all or only religious education >Older children responsible for younger ones >Long periods (often >10 years) in flight and/or refugee camps >Limited or disrupted access to health care or education >‘Unaccompanied minors’ highest risk as they lack the support of families >Forced child labour, kidnapping, child soldiers

Flight and Camp >Stateless, no country >No home or privacy >No contact with family >Limited health-care, food or sanitation >Witnessing starvation, rape, murder, death, self- abuse >Mandatory detention in ‘safe’ country >Average stay in Kakuma camp ~ 17 years >Many children born and raised in refugee camps ~ 8 million worldwide >Most have no hope of ever leaving camp

Survival >‘Survival’ is a priority, not necessarily health or education >Coping with challenges of resettlement >Dealing with loss and dislocation >Housing and food >Language >Transport >Loneliness >Clothing >Perceptions of illness >Caring for family >Mistrust of authority >Fear of being ‘sent back’ >Aspirations for a better life

World-view >‘Western’ individualistic world-view Individualism Consumerism Body and mind are separate Secular and conflictual Usually assumes people are responsible for their own misfortune >Collectivist world-view (Indigenous cultures & the developing world) Spiritual Ecological Consensual and communal Spirituality pervades every aspect of the lives of people from most collectivist cultures and cannot be differentiated from either their physical or mental well-being

9 Infections vs Non-communicable Diseases in Africa >Chronic disease contributes over 70% of disease burden in Australia and will increase to 80% by 2020 >In most of Africa the risk of dying at a young age from an infectious disease is much greater than the risk of dying of a chronic disease (NCD) >Mortality from malaria in Africa is 3 million/year >Gastroenteritis kills 2 ½ million and pneumonia 3 ½ million African children per year >About 2 million children die from measles each year in Africa >HIV affects 23 million people in Africa with 1.6 million dying each year of HIV/AIDS >TB prevalence in Africa is >300/100,000 (3 million people) cf Aus 5.8/100,000 About ½ million deaths each year from TB in Africa

10 Nutrition in Africa >14 million people in Africa suffer from malnutrition and starvation >Ingestion of unsafe water, inadequate availability of water for hygiene, and lack of access to sanitation contribute to 1.5 million child deaths per year >Stunting or chronic undernutrition affects 35-40% of children >May cause abnormal liver function tests on initial screening >May be protein, vitamin B12 or other deficiencies.

Pre-departure >HIV > 15 years or high risk >CXR >11 years or high risk >Some have had treatment for malaria and parasites and given MMR as part of voluntary ‘Fitness to fly’ >Some have ‘Health Undertakings’ eg TB >However compliance, inconsistent paperwork, delay in leaving etc mean that investigation and treatment sometimes cannot be relied upon.

Parasites and Infections >Schistosomiasis >Strongyloides >Hookworm >Pork tapeworm (taenia solium) >Giardia >Entamoeba histolytica >Malaria >Cutaneous leishmaniasis >Yaws >TB >Hepatitis B, C and D

Other Health Issues >Chronic diseases Hypertension, diabetes, asthma Nutritional deficiencies – Vitamin D, A, B12, folate, and Iron >Injuries from pre-migration torture and trauma >Dental problems >Rheumatic heart disease >Childhood development problems >Low immunisation rates >Serious mental health problems eg PTSD

Tuberculosis >90% of those with TB in Australia are born overseas >Active TB (infectious) rare >Latent (dormant) TB common > Needs to be treated in children > Can be reactivated if illness or pregnant >Most risk in first 2 years after arrival >Non-pulmonary (not in the lungs) TB more common, especially in children Can be in lymph nodes or bone >Chest Clinic does Mantoux on children through schools

Mantoux test The test needs to be measured hours after the injection

Immunisation >Many refugees come from countries without good immunisation programs >This leaves them susceptible to diseases like measles, rubella and tetanus >Free vaccines are provided by local councils – NARI Clinics, GPs and community health centres

Malaria >About 70% are from areas where malaria is endemic >A ‘fitness to fly’ assessment includes a rapid diagnostic test If positive, given a 3 day course of treatment >We can’t catch malaria here as we don’t have the right sort of mosquitoes >Refugees from Africa might have life-threatening malaria even though they’ve been tested >Children are most at risk >Any newly arrived refugee with ‘flu-like’ symptoms of fever, headache, muscle pain and vomiting might actually have severe malaria and should be taken to hospital immediately

Hepatitis >Hepatitis A is not serious and quite common in children overseas >Hepatitis B is usually contracted from a child’s mother at birth or from having an unclean injection 70% of those with chronic hepatitis B in Australia born overseas Approx 20% of refugees from some countries are hepatitis B positive 90% of those infected at or around the time of birth will have chronic infection with 25% risk of cirrhosis or liver cancer Vaccine available >Hepatitis C is usually contracted from having an unclean injection Can be treated but no vaccination

19 Attitude to food after arrival in Australia >The food in refugee camps is often scarce and of poor quality, so food may be overeaten in Australia >Food was about survival and not about taste or preference and now there is a huge range >Multi-generational deficiencies of vitamins and iron passed from mother to child >Dietary guidelines and a ‘balanced diet’ are completely unknown >Thin means poor, diseased, not loved, despair, >Fat means rich, powerful, doing well, well cared for, blessed by God

The Importance of knowing correct age >Taught at a suitable educational level >Correct vaccinations >Correct medication and dose >Developmental milestones eg urinary incontinence >Dental care >Determining potential emotional resources for dealing with stressful life events >Get married, join the army, drive, receive Centrelink payments or vote >Local authorities fulfil their obligations in providing support and services to vulnerable groups, such as unaccompanied minors aged less than 18 years

Why don’t we know the correct age? >The significance of birthdates tends to be cultural and many may know the year of birth without having noted the day and month. >Banning of calendars (eg in Afghanistan), >Chaotic circumstances surrounding the time of birth (eg during flight), >Child may have spent considerable time separated from the parents >Child is the child of only one parent (eg one wife may come with the children of other wives), >Child may be adopted from another family, >Visa authorities made an inappropriate estimate of the child’s age >Many other systemic or administrative errors or mishaps.

How can we assess a child’s age? >Even if a child has good health, adequate nutrition and a stable environment, behavioural, social and physical milestones vary within a wide range of normality >If there is illness, undernutrition, extreme stress and disrupted socialization, any tools used to assess age are likely to be even less reliable >Use narrative accounts, physical assessment of puberty and growth, and cognitive, behavioural and emotional assessments >X-rays should be used as a last resort

Mental health problems in refugee patients >Post traumatic stress disorder, depression and/or anxiety disorder are present in up to 100% of refugee patients in some studies eg children who have been in detention all had depression, PTSD or personality disorder >Most come from cultures with no concepts of mental health issues >Religion is more likely to be important in the cause and management

Issues in past that affect mental health >Imprisonment, kidnapping, abduction, hostage, forced labour >Loss of family members, home and possessions >Betrayal by family, friends or work colleagues >Torture, rape and/or threats of these >Witnessing torture, rape or murder >Poverty >Political events >Hunger

Mental Health Issues >Pre-migration Grief from loss of family, culture, food, stability Guilt, loss of a sense of hope and meaning in family Child becoming care-giver >Post-migration/resettlement Cultural adjustment Family dynamics Changing gender roles Stresses of resettlement Schooling

‘Continuous Traumatic Stress Disorder’ >Detention >Family reunion >Racial prejudice >Bureaucratic technicalities >Education, esp girls >Foreign culture and language >Poverty >Disintegration of family life >Isolation >Intergenerational issues eg arranged marriages, chaperoning

Pre-existing factors for resilience >Childhood history (especially relationship with mother) >Genetic predisposition >Religion (rules) >Spirituality (relationship with God) >Personality >Finances >Education >Health >Sense of humour >Locus of control

Useful Therapies >Family support >Community support >Learning English >Play, drama, drawing or music therapy >Stability and safety of housing and family >Education and support at school >Religious observance, music, ritual >PTSD treatment with distraction, exercise, etc >Honouring those who have died >Restoration and attachment to other human beings >Development of ‘third culture’

Cultural Awareness >Symptoms of mental health problems may only be conceived in physical or behavioural terms eg Aggressive or withdrawn behaviour ‘Acting out’ in school or social circumstances Physical symptoms such as bed-wetting, pain, eating problems Parents do not have a concept of ‘mental health’ >Using questions such as those in the Cultural Awareness Tool can assist in accessing cultural problems and exploring the aetiology, expectations and possible solutions without being fully aware of the patient’s cultural background or compromising beliefs

Cultural Awareness Tool (1) >What do you think caused your problem? >Why do you think it started when it did? >What do you think illness does to you? >What are the chief problems it has caused for you? >How severe is your illness? >What do you most fear about it?

Cultural Awareness Tool (2) >What kind of treatment/help do you think you should receive? >Within your own culture how would your illness be treated? >How is your community helping you? >What have you been doing so far? >What are the most important results you hope to get from treatment?

Spiritual issues >Discussing the cultural and spiritual causes and implications is extremely important >Don’t be afraid of asking about a child’s spiritual and cultural beliefs >A good relationship may cancel out gender, culture and religious barriers >Often we confuse culture with religion or politics and treat it as taboo

Cultural issues >Culture is just one aspect of a young person’s life >Important in adequate management eg fasting, fatalism, contraception >Most cultural practices are not harmful but important to ask as some might be eg Not giving certain foods if a child is sick eg protein ‘Cupping’, scratching or rubbing with kerosene Female and male circumcision Children should not be fasting in Ramadan but some do Fear of becoming addicted to medication Massaging broken limbs

Recovery >Good social supports >Sense of belonging >Secure environment >Healthcare >Welfare >Education >Housing >Safety >Gender issues >Assistance with learning about transport, shopping, playing >Freedom to practice religion >Music

Self-reflection >Only a small percentage of motives, beliefs and reactions are conscious >The ‘ethnocentricism’ of the health professional or educator needs to be conscious to properly recognise the cultural beliefs and expectations of an individual >In each culture there are different: approaches to knowledge communication styles attitudes toward conflict approaches to completing tasks notions of time decision-making styles attitudes toward disclosure

Self-education >Learn as much as possible about cultural practices Countries of origin and transit Gender expectations Food – past and present Relationships Body language Religion Fasting Cultural practices Spiritual resources

Teachers who care >Mandatory reporting >Legal obligations >School rules and requirements >Limited resources >‘The rest of the class’ >Burnout Helplessness Guilt about enjoying life Anger Disappointment with colleagues Overwhelming emotions Vulnerability Intolerant of conflict

Burnout, compassion fatigue and vicarious trauma >Awareness, balance and connection >Endorphins >Sense of humour >Relaxation >Exercise >Nutrition >Sharing emotions with close friends >Debriefing with colleagues >Inservice and other training >Appropriate expectations of self, family and community >Hobbies >Team work >Safe working environment >Compassion satisfaction

‘If you have come to help me, go home, but if this is about your struggle for survival as well as mine, we can work together to make a difference’ Lila Watson, Aboriginal elder