Expanding the evidence-base to offer guidance on best health care for immigrants and refugees

spottieKevin Pottie is Associate Professor of Family Medicine and Epi & Community Medicine at the University of Ottawa, as well as co-Chair of the Canadian Collaboration for Immigrant and Refugee Health, and a family physician at the Immigrant Health Clinic of Ottawa, which he helped to found. Dr Pottie will be speaking at the forthcoming North American Primary Care Research Group (NAPCRG) annual meeting.

 

My residency training in Ottawa began with a wave of refugees from El Salvador and Guatemala.  Most conflict-affected refugees - Somali, Sudanese, Congolese, Karen, Bhutanese, Colombian - come quietly and settle rapidly in our communities.  And, even in instances when the media cover the arrival of large waves of refugees, such as the Vietnamese boat people or the recent Syrian war victims, the refugees themselves settle quietly in our communities.

In the early 1990s, it felt almost revolutionary to care for refugees. There were few primary care practitioners trained and ready to lead, and commit to, ongoing care for refugees.  Learning firsthand how conflict and inequalities threaten health and security of refugees, both in Canada and with MSF internationally, has profoundly influenced my career in family medicine.  Fear of the unknown haunts newly arriving refugees. As physicians we are pushed to consider public health issues, rare tropical diseases and complex cultural differences. It's probably accurate to say that early policies and guidelines on caring for refugee populations were not based on best available evidence or health equity considerations for refugees.

Working in community health centres in Toronto, I drew energy from the strength and family commitment of undocumented or irregular migrants.  I began asking colleagues everywhere for guidelines to reduce harms and improve benefits for our health assessment and prevention approaches.  I would continue to ask for evidence based-guidelines for the next 7 years until my university department and the Public Health Agency of Canada helped us launch our Canadian evidence based migrant guidelines.

Over the last 6 years evidence-based refugee health guidelines from Canada, US, Australia have surfaced together with networks of primary care practitioners and specialists.  Our Euro Health Group is now helping develop evidence-based guidance for the European Union and European Economic Area.

Through systematic reviews and guidelines we have learned much about the health needs of persons at entry, at detention, and at community integration stages.  Early vaccination with MMR and TB screening, and basic care, are starters.  Community testing for HIV and HCV requires the building of trust and links to the heath system.  Chronic diseases, from dental caries to diabetes to iron deficiency anemia, benefit from community based care.  Mental health care is benefiting from new community based approaches and this area continues to grow. Health equity has is now a central consideration for refuges.

Systematic reviews on priority diseases aim to prevent harms and maximize benefits and serve as evidence for change.  The evidence and guidelines from refugee research is playing a role to support policy changes; for example, Ontario’s Immigrant Supplement and Health Equity Impact Assessment process. This policy development process benefits from recognizing and counting disadvantaged migrants, integrating evidence, and linking with immigrant community leaders, such as Ontario’s Local Immigration Partnerships.

Infectious disease specialists, family physicians, public health, paediatricians, psychiatrists and psychologists have all played critical roles developing refugee health in the US, Canada, Australia and now Europe.  We need to keep in mind that refugee health care is most effective when delivered in the community with links to networks of supportive specialists and to the health system.  Community based primary care has now emerged as a leader in evidence-based guidelines and refugee care.

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The North American Primary Care Research Group Annual Meeting is being held from November 12th to 16th 2016 in Colorado Springs, CO. CMAJ is a co-sponsor of the meeting.

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