Medical care for children of refugees and asylum seekers - a challenge for European paediatricians Dr. Gottfried Huss MPH President ECPCP ECPCP Symposium Prague 1

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: registered refugees in Germany – estimate of non registered every day more arrive in Munich 2

Childrens human rights translated for migrants ´ Protection-> Provision-> Participation 3 Weeks Months Years

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 4

Health Syrian refugees in Munich 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 5

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 … 6

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 7

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 8

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 9

10

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 11

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…. 12

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. 13

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 14

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

Where is medical care offered? Step 2 settle in small settlements Small decentral compounds in the region- housing for refugees - place to stay for month and weeks Some health initiatives - at the moment no health services in all compounds- open issue 16

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 17

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 18

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! 19

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! 20

21