1. “The Journey - A day in the life of a Migrant Health GP” Family Practice for Migrant Populations in the Netherlands UMCG Groningen, The Netherlands

2. Disclosure Disclosure belangen spreker Geen (potentiële) belangenverstrengeling Geen Voor bijeenkomst mogelijk relevante relaties 1 International Consultancy in Migrant Medicine (Foundation)  Sponsoring of onderzoeksgeld 2  Honorarium of andere (financiële) vergoeding 3  Aandeelhouder 4  Andere relatie, namelijk … 5  Geen  Geen

3. “A Tsunami of refugees continues to flood the Greek Islands” 250 t.o.v. 4000 Click to add text

4. Migrant crisis: Migration to Europe explained in graphics

5. Death at sea: Syrian migrants film their perilous voyage to Europe | Guardian Docs https://www.google.nl/url?sa=t&rct=j&q=&esrc=s&source=web&cd= 1&cad=rja&uact=8&ved=0ahUKEwis_77GvpbNAhUiKcAKHa9JAg8QtwI IHTAA&url=https%3A%2F%2Fwww.youtube.com%2Fwatch%3Fv%3D Z7vX4ZBGqus&usg=AFQjCNEOa5N-A8t_x- WACQ4xjkoBIdOgDw&sig2=Le1JjdTAXjDhNNuBgUrXkw 5

6. No international quick-fix Human rights cornerstone of civilization Destabilization - Middle East / Northern Africa Emerging democracies Largest mass migration since WWII International relations eg. EU / Turkey

7. Migrant influx Netherlands 2015 52000 asylum applications 70% male 8500 children 60% Syrian 20% Eritrea 10% Other 5000 chose to return EU NL 30000 per year

8. Migrant influx Netherlands 2016 Currently 150 a day Mostly Romania, Bosnia, Ukraine, Georgia, Armenia, Turkey, Marocco, Libya, Tunesia, Sudan Relocators EU - Turkey Deal : Finland, Germany and the Netherlands% children is higher 30- 40% 90% of youth from youth North Africa are addicted

9. Challenges for family physicians when treating migrants Most important: language barrier Cultural variation in presentation of symptoms Endemic diseases (eg. Febris Recurrens) Unfamiliar infectious diseases Unfamiliarity migrant with organization health care in the Netherlands Variations in educational levels migrants and disease perception Unfamiliarity doctors migrant insurance policy (eg FT “ Lijst van Borst) Time factor

10. Migrant Health Care = Family Practice Organisation of migrant health care in NL is unigue GCA: National Migrant Health Care Centres Every AZC has a GCA Family practice + Unique care requirements Outside of consultation hours care 24 /7! 088 112 2113 Access to > 50.000 dossiers NB

11. Migrant Health Status Varies greatly Dependent on health care system in own country Level of education Nutrition status Access to vaccinations Endemic diseases

12. Migrant health problems 90% normal family practice Midwifery needs special attention Medical Refugees eg. Oncology, nephrology, congenital defects Trauma war torn areas / PTTS Infectious diseases: malaria, TB, febris recurrens, leishmaniasis, schistosomiasis, amoebae histolytica, echinococidose, cutaneous diptheria, BRMOs Vaccination status

13. Midwifery Increased number of complicated pregnancies Little or no access to pre-natal care and diagnostics Increased number of intra-uterine infections More neural tube defects Teenage pregnancies / brides Sexual abuse / prostitution and rape No home births

14. Medical Refugees Oncology - Nerve Sheet Tumor (UMCG) Nephrology Metabolic diseases Consanguinity: more recessive genetic diseases eg. Relapsing Mediterranean Fever, CF, Thallesemia, Cilia Dysfunction etc. Misdiagnosis: duchennes, HSMN, Progeria, Williams Syndrome

15. Trauma Physical & Mental War-related injuries eg. Gunshots, bombs, torture Half medical measures transition countries Be aware of risk of hospital acquired community diseases Elective surgery: MRSA and MRMO swabs before referral PTSS, cultural variations in psychiatric disease

16. Tuberculosis Malaria: majority ovale + vivax MRMO (‘BRMO’) eg. MRSA etc. Typhoid – abdominal pain, fever and relative bradycardia Scabies Leishmaniasis Hepatitis Lab: eosinophilia Infections more commonly seen in Migrants

17. Vaccination Status and Endemic Immune Status Limited access to good vaccination programmes DKTP and BMR Splenectomy Exposure to common European diseases severe progression eg. Chickenpox

18. Tips Vitamine D deficiency Vaseline: almost never Helicobacter Pylori > 70% Use the 24/7 availability of the practice line Tuberculosis – Beatrix Oord / GGD Groningen Infectious diseases – GGD Groningen / Infectiologist UMCG Elective MRMO swabs Discuss cultural significance of disease with parents and patients - cancer (curse)

19. Fables Migrant medicine is not family practice: 95% regular family practice Migrants have infectious diseases: Dutch citizens who travel same risk for exotic disease Disease presentation deemed hysterical They always want anti-biotics / medication (perhaps in the beginning)

20. When war comes and I need shelter may I abide with you? https://www.youtube.com/watch?v= ObLcXig_W9w https://www.youtube.com/watch?v= ObLcXig_W9w 20

21. Questions?