Caring for refugees
===================

* Erica Weir

Background and epidemiology: The escalating violence in the Middle East draws attention to the plight of international refugees escaping persecution and to Canada's role in helping them to resettle and rebuild their lives. Physicians have a major role to play in this process.

![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/166/11/1441/F1.medium.gif)

[Figure1](http://www.cmaj.ca/content/166/11/1441/F1)

Figure. **One of the 10 million refugees worldwide** Photo by: Canapress

Of the more than 10 million refugees and asylum seekers counted worldwide in 1997, more than half (5.7 million) came from the Middle East, with the next highest numbers coming from Africa (2.9 million), Europe (2 million) and South and Central America (1.7 million).1 Canada signed the 1951 Geneva Convention Relating to the Status of Refugees and has adopted its definition of a refugee: a person “with a well-founded fear of persecution based on race, religion, nationality, political opinion or membership in a particular social group.”2 In 2001 Canada received 26 513 refugees, of whom 7321 were sponsored by the federal government. Another 3560 were privately sponsored, 3746 arrived to be reunited with their families, and 11 996 arrived on their own.3

People who arrive with no assistance or permission have their claims for refugee status reviewed by members of the Immigration and Refugee Board (IRB), who are trained in refugee law and have access to up-to-date information on conditions in the various refugee- producing countries. Refugees who meet the selection criteria must demonstrate an ability to eventually re-establish their lives in Canada and pass medical, security and criminality assessments.2

In recent years the federal government has started to redefine Canada's Refugee and Humanitarian Program because the refugees most in need of protection have difficulty meeting selection criteria and because private sponsorship rates are declining, refusal rates are high and processing time is lengthy. Citizenship and Immigration Canada has shifted the balance toward protection rather than ability to settle successfully, and it has striven to undertake concurrent processing of all members of a refugee family as well as an expedited way to process people requiring urgent protection.2

As part of the process of being accepted into Canada, each claimant is examined by a designated medical practitioner working for Health Canada.2,4 Routine screening of adults includes chest radiography, a laboratory test for venereal disease and urinalysis. Selective screening of children for intestinal parasites, on the basis of the children's country of origin, is also recommended.4 Essential health services are available to claimants under the Interim Federal Health Program; IRB-confirmed refugees become eligible for provincial health coverage within 3 months after acceptance in most provinces.2

Once a claim is accepted the refugee is expected to apply for permanent resident status, but this may be refused if the applicant has unsatisfactory identity documents (e.g., passport and birth certificate) or if the person or any dependant is inadmissible for criminal or security reasons. The waiting period to apply for permanent residence for refugees who lack identity documents has recently dropped from 5 to 3 years.

Clinical management: Refugees arriving in North America have a relatively high incidence of hepatitis B, and positive results for purified protein derivative and parasites are common. Depression, post-traumatic stress disorder and difficulty adapting to a new culture are also common.1 With help from a cultural interpreter, a history should be taken that addresses family health and nutritional status, childhood immunizations, mental health, pain, infectious diseases and preventive screening.4,5 Physical examination targets should include vision and hearing deficits, dental caries, anemia, asthma, orthopedic problems, and signs of trauma and torture (e.g., scars, burns and old fractures).

The Canadian Paediatric Society has recently produced a health care guide for children and youth new to Canada.6 Guidelines are also available for the management of immigrants and refugees under surveillance for tuberculosis.7

Prevention: The primary prevention of war and the promotion of civil liberties are agendas that move through and beyond medicine. Once refugees reach Canada it is imperative that they receive care that is culturally appropriate and competent.8 To accomplish this, the preferences of displaced populations need to be incorporated into the planning and delivery of health care at the local level. Barriers to healthy settlement include poverty, unemployment, illiteracy and social isolation.

**Erica Weir** *CMAJ*

## References

1.  1. Walker P, Jaranson J. Refugee and immigrant health care. Med Clin North Am 1999;83:1103-20.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=10453265&link_type=MED&atom=%2Fcmaj%2F166%2F11%2F1441.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000081884000013&link_type=ISI) 

2.  2. Citizenship and Immigration Canada. Refugee services. Available: [www.cic.gc.ca/english/refugee](http://www.cic.gc.ca/english/refugee) (accessed 2002 Apr 25). 
    
    

3.  3. Citizenship and Immigration Canada. More than 250,000 new permanent residents in 2001 [press release]. *Canada NewsWire* 2002;Apr 17.
    
    

4.  4. Fowler N. Providing primary health care to immigrants and refugees: the North Hamilton experience. CMAJ 1998;159(4):388-91. Available: [www.cmaj.ca/cgi/reprint/159/4/388](http://www.cmaj.ca/cgi/reprint/159/4/388)
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6MzoiUERGIjtzOjExOiJqb3VybmFsQ29kZSI7czo0OiJjbWFqIjtzOjU6InJlc2lkIjtzOjk6IjE1OS80LzM4OCI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xNjYvMTEvMTQ0MS5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

5.  5. Gavagan T, Brodyaga L. Medical care for immigrants and refugees. Am Fam Physician 1998; 57: 1061-8.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=9518952&link_type=MED&atom=%2Fcmaj%2F166%2F11%2F1441.atom) 
    
    [Web of Science](http://www.cmaj.ca/lookup/external-ref?access_num=000072518600016&link_type=ISI) 

6.  6. Canadian Paediatric Society. *Children and youth new to Canada: a health care guide*. Ottawa: The Society; 1999.
    
    

7.  7. Canadian Thoracic Society, Tuberculosis Directors of Canada and Department of National Health and Welfare. Guidelines for the investigation of individuals who were place under surveillance for tuberculosis post-landing in Canada. CMAJ 1993;148(11):1957-60.
    
    [Abstract](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMToiMTQ4LzExLzE5NTciO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTY2LzExLzE0NDEuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

8.  8. Smith LS. Concept analysis: cultural competence. J Cult Divers 1998;5(1):4-10.
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=9611545&link_type=MED&atom=%2Fcmaj%2F166%2F11%2F1441.atom)